CMS Pub. 100-04, ch. 2, § 10.5

Hospital Stay Information for Determining Deductible and Benefit

Period Status

(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC Implementation: 02-16-16; ASC X12: 02-16-16)

If it has been determined that Medicare is the primary payer, the hospital or SNF must

determine if the patient has been an inpatient in any hospital or SNF, including swing bed

stays, during the prior 60 days. If so, the hospital or SNF must determine the admission

and discharge dates and the number of days of hospitalization or skilled nursing (as

applicable) the patient used in the current benefit period. The admission and discharge

dates must be reported on the claim, and the number of days of hospitalization or skilled

nursing (as applicable) must be used to calculate the hospital insurance copayment and

the number of days remaining in the benefit period.

If the patient indicates he/she was not an inpatient within the last 60 days, the hospital

applies the inpatient deductible to the current stay if it is a covered hospital admission.

The A/B MAC (A) determines the accuracy of the claim data after receipt of the claim.

The remittance advice received from the A/B MAC (A) reflects the amount of deductible

(hospital claims) and coinsurance (hospital and SNF claims) applied. If this amount is

different from what was billed, the hospital/SNF must correct the records accordingly.