CMS Pub. 100-04, ch. 1, § 80.4

Standard to Continue PIP (Periodic Interim Payment)

(Rev. 4201, Issued: 01-18-19, Effective: 02-19-19, Implementation: 02-19-19)

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.

A. General

To remain on PIP, providers, (with the exception of HHAs that do not receive PIP with

the advent of PPS mandated by law on October 1, 2000), must submit 85 percent of their

bills timely and accurately. Timely and accurately means that 85 percent of its bills

(excluding those listed below) are submitted within 30 days of discharge and pass front-end edits for consistency and completeness. A bill is not considered received unless it

can pass FI edits. FIs must accumulate statistics on inpatient and SNF billing

performance for each PIP provider to monitor whether it meets this requirement. These

instructions do not effect bi-weekly payments for pass-throughs (Medicare Provider

Reimbursement Manual, (PRM) §2405.2) and for adjustments to indirect cost for medical

education (PRM §2405.3).

The evaluation for timeliness of billing should be consistent with the frequency for

monitoring the payment amounts under the PIP program. Thus, for non-PPS hospitals

and SNFs the evaluation process is scheduled at 3-month intervals and PPS providers are

evaluated every 4 months. The evaluation includes data from the entire 3- or 4-month

period. In determining whether a provider submitted its bills within 30 days of discharge

or through date on interim bills, count the date from Form CMS-1450 FL6 (through date)

to the date received by the FI. If the provider does not meet the criteria, discontinue PIP

immediately. The periodic performance report that is provided in accordance with

subsection B will constitute advance notice before discontinuing PIP.

Exclude the following:

• MSP cases (value codes 12-16);

• Any special situation identified by the provider or FI that is documented as

beyond provider control. Exclusions must be approved by the RO; and

• Bills that have not passed FI front-end edits for acceptance. (Such bills are

counted only when acceptable to the shared system edit processes.)

The FIs must accumulate statistics monthly and summarize them for the entire evaluation

period.

B. Procedure for Measuring and Reporting to Hospitals and SNFs

The FIs accumulate a record for each bill that passes front-end edits. Bills must be

counted in the month received regardless of the discharge month. No later than 10 workdays after the end of the month, FIs furnish a report to each hospital/SNF. For the month

indicating the following:

• The total number of bills received;

• The number not excluded as described in section A;

• The number not excluded received in 30 days or less;

• The percentage not excluded received in 30 days or less.

Also, for providers that fail to meet the standard, furnish individual case identification of

claims that were not billed within 30 days of discharge. List only claims that are not

excluded and are identified in subsection A. The report must be furnished in electronic

media, unless the FI determines a paper listing would be cheaper to process. If electronic

media is used, use the following record format. Determine the physical characteristics of

the file.

Fld Description Psn. Picture Just From Thru

1 Provider Number 6 X(6) L 001 006

2 Blank 3 X(3) 007 009

3 Blank 1 X 010

4 Medicare beneficiary

identifier

12 X(12) L 011 022

5 Blank 1 X 023

6 Beneficiary Surname 6 X(6) L 024 029

7 Blank 1 X 030

8 Patient Control Number 17 X(17) L 031 047

9 Blank 1 X 048

10 From Date 6 9(6) 049 054

11 Blank 1 X 055

12 Discharge or Thru Date 6 9(6) 056 061

13 Blank 1 X 062

14 Date Bill Received 6 9(6) 063 068

15 Blank 1 X 069

16 Days Elapsed 4 9(4) R 070 073

If sub-provider identification is used, positions 7, 8, and 9 may be utilized.

C. Reinstatement of PIP

Do not reinstate PIP for a provider until it meets all criteria in PRM §§2405.1.B and 2407

and has met the requirements in subsection A for timeliness and accuracy for six

consecutive months.

D. New Request for PIP

Evaluate new requests for PIP as in subsections A and B. At least three months

experience is required for new requests, (except for new providers with less experience).

E. Hospitals on 100 Percent PRO Prepayment Review

The 30-day requirements for submitting bills to FIs are not applicable. The RO makes

determinations of timely and accurate bill submission by hospitals for which the PRO

reviews 100 percent of the discharges before payment. However, other standards remain

applicable for retaining PIP in such cases. See PRM §§2405.1.B and 2407 for the

requirements.