CMS Pub. 100-04, ch. 1, § 120.2

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.

Exact duplicates are controlled by the claims processing system through “hard coded”

edits, and may not be user-controlled. In addition, Medicare contractors cannot override

or bypass exact duplicate edits.

A. Submission of Institutional Claims

Claims or claim lines that have been determined to be an exact duplicate are rejected and

do not have appeal rights. An exact duplicate for institutional claims is a claim or claim

line that exactly matches another claim or claim line with respect to the following

elements:

• Medicare beneficiary identifier;

• Type of Bill;

• Provider Identification Number;

• From Date of Service;

• Through Date of Service;

• Total Charges (on the line or on the bill); and

• HCPCS, CPT-4, or Procedure Code modifiers.

Additional Instructions for Institutional Claims:

Whenever any of the following claim situations occur, the MAC develops procedures to

prevent duplicate payment of claims. This includes, but is not limited to:

• Outpatient payment is claimed where the date of service is totally within inpatient

dates of service at the same or another provider. Do not consider outpatient

services provided on the day of discharge within the inpatient dates of service.

• Outpatient bill is submitted for services on the day of an inpatient admission or

the day before the day of admission to the same hospital.

• Outpatient bill overlaps an inpatient admission period.

• Outpatient bill for services matches another outpatient bill with a service date for

the same revenue code at the same provider or under a different provider number.

1. History File - Paid Claims

The MACs and legacy claims administration contractors must maintain a history file

containing information about each claim processed. The file may consist of the claim or

information from it. It must contain the following minimum information:

o Medicare beneficiary identifier;

o Beneficiary name information;

o Provider identification (name or number); and

o Billing period from the claim.

Claims or claims information in the history file may be transferred to inactive files.

However, the MAC must have the facility to recall such claims or information if a claim

for the beneficiary involving the same time period is received.

2. History File - Pending Claims

Contractors must have controls to prevent a duplicate claim from being paid while two

claims are in the process within the system at the same time. This may be accomplished

through a special check of in-process claims or in the history file for paid claims. The

file should contain the same minimum information indicated in the subsections below.

The check should be performed prior to sending the claim to CWF.

3. Analysis of Patterns of Duplicate Claims

The contractors shall establish a system for continuing analysis of duplicate claims. This

includes the systematic evaluation of returned “Medicare Summary Notices” from

beneficiaries and communications from providers indicating a duplicate payment has

been made, as well as returned checks from any payee.

The contractor’s system should provide for analyzing duplicate claim receipts to

determine whether certain providers are responsible for duplicates and, if so, identify

those providers. The contractor should educate such providers to reduce the number of

duplicates they submit. Should those providers continue to submit duplicate claims, the

MAC should initiate program integrity action.

B. Claims Submitted by Physicians, Practitioners, and other Suppliers (except

DMEPOS Suppliers)

Claims or claim lines that have been determined to be exact duplicates of another claim

or claim line are denied. However, such denials may be appealed. An exact duplicate for

physician and other supplier claims submitted to a MAC or carrier is a claim or claim line

that exactly matches another claim or claim line with respect to the following elements:

• Medicare beneficiary identifier;

• Provider Number;

• From Date of Service;

• Through Date of Service;

• Type of Service;

• Procedure Code;

• Place of Service; and

• Billed Amount.

C. Claims Submitted by DMEPOS Suppliers

Claims or claim lines that have been determined to be exact duplicates of another claim

or claim line are denied. Such denials may not be appealed. An exact duplicate for

DMEPOS supplier claims submitted to a DME MAC is a claim or claim line that exactly

matches another claim or claim line with respect to the following elements:

• Medicare beneficiary identifier;

• From Date of Service;

• Through Date of Service;

• Place of service;

• HCPCS code;

• Type of Service;

• Billed Amount;

• Supplier

D. Claims Submitted by Multiple DMEPOS Suppliers

When a second DMEPOS supplier or multiple DMEPOS suppliers submit a claim during

a span date already approved for the same beneficiary for a different DMEPOS supplier,

the DME MAC shall deny the second or subsequent DMEPOS supplier’s claim as a

duplicate not a suspect duplicate when the following conditions are met:

• Same Beneficiary Medicare beneficiary identifier

• Overlapping span Date of Service (DOS) (From DOS and Through DOS)

• Same Healthcare Common Procedure Coding System (HCPCS) Code,

• Same Type of Service on the incoming claim matches a previously approved

claim in history, and

• The item is a diabetic testing supply

• Items Subject to Duplicate Editing

1. Diabetic Testing Supplies