Completing the CMS-838

20.2 - Completing the CMS-838 (Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The CMS-838 consists of a certification page and a detail page. An officer (the Chief Financial Officer or Chief Executive Officer) or the Administrator of your facility must sign and date the certification page. Even if no Medicare credit balances are shown in your records for the reporting quarter, you must still have the form signed and submitted to your FI in attestation of this fact. Only a signed certification page needs to be submitted if your facility has no Medicare credit balances as of the last day of the reporting quarter. An electronic file (or hard copy) of the certification page is available from the CMS web site (e.g., www.cms.hhs.gov/forms) or your FI. The detail page requires specific information on each credit balance on a claim-by-claim basis. This page provides space to address 17 claims, but you may add additional lines or reproduce the form as many times as necessary to accommodate all of the credit balances that you have reported. An electronic file (or hard copy) of the detail page is also available from the CMS Web site or your FI. You may submit the detail page(s) on a diskette/CD or by secure electronic transmission to your FI as long as the transmission method and format are acceptable to your FI. Segregate Part A credit balances from Part B credit balances by reporting them on separate detail pages. NOTE: Part B pertains only to services you provide which are billed to your FI. It does not pertain to physician and supplier services billed to carriers. Begin completing the CMS-838 by providing the information required in the heading area of the detail page(s) as follows: • The full name of the facility; • The facility's provider number (if there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number); • The month, day and year of the reporting quarter, e.g., 12/31/02; • An "A" if the report page(s) reflects Medicare Part A credit balances, or a "B" if it reflects Part B credit balances; • The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3);and • The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data. Complete the data fields for each Medicare credit balance by providing the following information (when a credit balance is the result of a duplicate Medicare primary payment, report the data pertaining to the most recently paid claim): Column 1 - The last name and first initial of the Medicare Beneficiary, (e.g., Doe, J.) Column 2 - The Medicare beneficiary identifier of the Medicare Beneficiary. Column 3 - The multiple-digit Internal Control Number (ICN) assigned by Medicare when the claim is processed. Column 4 - The 3-digit number explaining the type of bill, e.g., 111 - inpatient, 131 - outpatient, 831 - same day surgery. (See the section(s) for the Uniform Billing instructions in the applicable provider manual.) Columns 5/6 - The month, day and year the beneficiary was admitted and discharged, if an inpatient claim; or "From" and "Through" dates (date service(s) were rendered), if an outpatient service. Numerically indicate the admission (From) and discharge (Through) date (e.g., 1/1/02). Column 7 - The month, day and year (e.g., 1/1/02) the claim was paid. If a credit balance is caused by a duplicate Medicare payment, ensure the paid date and ICN number correspond to the most recent payment. Column 8 - An "O" if the claim is for an open Medicare cost reporting period, or a "C" if the claim pertains to a closed cost reporting period. (An open cost report is one where an NPR has not yet been issued. Do not consider a cost report open if it was reopened for a specific issue such as graduate medical education or malpractice insurance.) Column 9 - The amount of the Medicare credit balance that was determined from your patient/accounting records. Column 10 - The amount of the Medicare credit balance identified in column 9 being repaid with the submission of the report. (As discussed below, repay Medicare credit balances at the time you submit the CMS-838 to your FI.) Column 11 - Choose one of the following: A "C" when you submit a check with the CMS-838 to repay the credit balance amount shown in column 9; An "A" if a claim adjustment is being submitted in hard copy (e.g., adjustment bill in UB-92 format) with the CMS-838; A “Z” if payment is being made by a combination of check and hard copy adjustment bill with the CMS-838; or An “X” if an adjustment bill has already been submitted electronically or by hard copy. Column 12 - The amount of the Medicare credit balance that remains outstanding (column 9 minus column 10). Show a zero (“0”) if you made full payment with the CMS-838 or a claim adjustment has been submitted and has been fully processed to recoup the Credit Balance. Column 13 - The reason for the Medicare credit balance by entering a “1" if it is the result of duplicate Medicare payments, a "2" for a primary payment by another insurer or a "3" for "other reasons". Provide an explanation on the detail page for each credit balance with a “3”. Column 14 - The Value Code to which the primary payment relates, using the appropriate two digit code as follows: (This column is completed only if the credit balance was caused by a payment when Medicare was not the primary payer. If more than one code applies, enter the code applicable to the payer with the largest liability. For code description, see the section(s) in the applicable provider manual for the listed codes.) 12 - Working Aged 13 - End Stage Renal Disease 14 - Auto No Fault 15 - Workers' Compensation 16 - Other Government Program 41 - Black Lung 42 - Department of Veterans Affairs (VA) 43 – Disability 44 – Conditional Payment 47 - Liability Column 15 - The name and billing address of the primary insurer identified in column 14. NOTE: Once a credit balance is reported on the CMS-838, it is not to be reported on a subsequent period report.