Limitation of Liability

100.5 – Section D – Limitation of Liability (Rev. 45, 05-28-04) Section D concerns requests involving limitation of liability determinations in Part A reconsiderations, Part B reviews and Part B hearings. To include a claim in lines 79-82, you must have originally denied it or reduced it for medical necessity or custodial care reasons. Lines 80-82 are mutually exclusive; i.e., a claim meeting the above conditions may be counted on only one of three lines. Therefore, ensure that the sum of the number of the claims recorded on each of these lines equals the total number of claims considered for limitation of liability during the period as reported on line 79. The counts in lines 79-82 reflect counts of claims. Report cases corresponding to the claims counted in Section A, as appropriate. If a claim is considered for limitation of liability at the initial claim level, do not count it at the review or hearing level unless you change the limitation of liability decision. Categorize claims for the columns shown in Section D according to the adjudication level at which limitation of liability is considered or granted. If you make several different limitation of liability decisions on the same claim, use the highest numbered line (out of 80-82) on the report that applies to that claim. Count the claim only once. For example, if you waive both the beneficiary and provider liability on any part of the claim, count the claim on line 82. Line 79. Total Number Considered.--Show, under the appropriate columns, the number of claims, meeting the conditions above, for which limitation of liability was considered during the month. Line 80. No. Considered - Not Waived.--Show, under the appropriate columns the number of claims that meet the conditions above, on which limitation of liability was considered, but was not granted to the beneficiary. This also includes cases where only provider liability is waived. Line 81. No. Waived - Ben. Only.--Show, under the appropriate columns, the numbers of claims that meet the conditions above, where the liability of only the beneficiary was limited. Line 82. No. Waived - Ben. and Prov.--Show, under the appropriate columns, the numbers of claims where the liability of both the beneficiary and provider was limited. Line 83. Amount Awarded.--For cases included in line 82, show the amount of the submitted charges for services where liability was limited (including noncovered services where liability of the beneficiary and provider are limited). Show charges prior to application of the deductible and coinsurance. Round results to nearest dollar.