Body of Report

70.4 - Body of Report (Rev. 6, 08-30-02) A3-3898.4 Section B: Bill Denial Data Line 1: Bills Denied-Total - The intermediary reports all full and partial denial determinations that it made during the reporting period. It reports only denial determinations resulting in its preparing and sending a notice to the beneficiary. It counts a denial when it denies (either in full or in part) bills submitted as covered. It includes counts where it made a denial determination but found both the beneficiary and the provider to be without fault under §213 of Public Law 92-603 and, therefore, made a determination to waive liability in full. Also, it includes counts when it found only the provider to be at fault (i.e., it waived the beneficiary's liability). It does not count: • Denials of no-pay or demand bills even though the contractor sends a denial notice. • Denials of future services. • Denials made by PROs. Line 2: Bills Paid Under Waiver-Total - The intermediary reports the total number of bills on which you made a determination to waive the liability of both the beneficiary and the provider. Count determinations made at: • Initial bill processing, • Appeals process, and • Any other time such as when you reopen your initial decision. The intermediary does not count waiver determinations made by PROs. Line 2A: Initial Bills Paid Under Waiver - The intermediary reports the number of bills on which you made a decision to waive the liability of both the beneficiary and the provider during the initial adjudication of the bills. Line 3: Amount Reimbursed Under Waiver - The intermediary reports the amounts paid (to the nearest dollar) under the waiver provision for the bills reported on line 2. Do not include coinsurance amounts, charges applied toward the deductible, or reimbursement for services not under consideration with respect to the waiver provision. Where all services on a bill are paid in full (excluding the applicable deductible and coinsurance) as a combination of covered services and noncovered services paid under waiver and the exact dollar amount of the waiver payment is not available without contacting the provider, it reports an approximation of the waiver payment. In calculating this approximation, apply to total charges the proportion of waiver days to total days included on the bill, and subtract any applicable deductible or coinsurance for the waiver period. Line 3A: Amount on Initial Bills - The intermediary reports the amounts paid (to the nearest dollar) under the waiver provision for the bills reported on line 2A. Section C: Day/Visit Data Line 4: Days/Visits Processed - The intermediary reports under column 4 the total number of days (both covered and noncovered) for SNF bills shown as processed in column 4, line 1 of Form C, for the same reporting period. It reports under column 5 the number of billed visits for HHA bills shown as processed in column 5, line 1 of Form C, for the same reporting period. Line 5: Days/Visits Denied-Total - The intermediary reports under column 4 the number of SNF days denied on the bills reported on line 1. It reports under column 5 the number of HHA visits denied on the bills reported on line 1. Denied days/visits are those billed as covered which you determine to be noncovered. Line 6: Days/Visits Paid Under Waiver of Liability - The intermediary reports under column 4 the number of SNF days on the bills reported on line 2 that were paid under the waiver provision. It reports under column 5 the number of HHA visits on the bills reported on line 2 that were paid under the waiver provision. Line 6A: Days/Visits Paid Under Waiver on Initial Bills - The intermediary reports under column 4 the number of SNF days on the bills reported on line 2A that were paid under the waiver provision. It reports under column 5 the number of HHA visits on the bills reported on line 2A that were paid under the waiver provision. Section D: Demand Bill Data Line 7: Total Demand Bills - The intermediary reports under the appropriate column bills which the provider determined to be for noncovered services but which the beneficiary or his representative requested be filed in order to obtain a Medicare decision. It reports only bills identified by condition code 20. (See The Medicare Claims Processing Manual, Chapter 1, General Billing Requirements.) It reports the total number of bills processed during the reporting quarter, even if not manually reviewed. Line 7A: Full/Partial Reversals - The intermediary reports the number of demand bills on which you fully or partially reversed the provider's decision that the services were noncovered. Line 7B: Days/Visits on Reversals - The intermediary reports under column 4 the number of SNF days on the demand bills reported on line 7A. It reports under column 5 the number of HHA visits on the demand bills reported on line 7A (i.e., report days/visits for which you fully or partially reversed the provider's decision that they were noncovered). Section E: No-Pay Bill Data Line 8: Total No-Pay Bills - The intermediary reports under the appropriate column the total number of no-pay bills (excluding the demand bills reported on line 7 Section D) which are included in the total bills processed reported on line 1, page 1 of the Quarterly Supplement for the same reporting period. No-pay bills are those submitted by providers with no charges and/or covered days/visits. It does not report HHA bills where no utilization is chargeable and no payment has been made, but which you have requested only to facilitate recordkeeping processes. Line 8A: Days/Visits on No-Pay Bills - The intermediary reports under column 4 the number of SNF days on the no-pay bills reported on line 8. It reports under column 5 the number of HHA visits on the no-pay bills reported on line 8. Line 8B: MSP No-Pay Bills - The intermediary reports the number of no-pay bills included on line 8 where payment has been made in full by another insurer as primary payer.