CMS Pub. 100-04, ch. 3, § 170.1.3

Elections, revocations and cancellations of elections may be submitted to the contractor

via the paper Form CMS-1450 or via the contractor’s Direct Data Entry (DDE) system.

Election transactions are not covered transaction under the Health Insurance Portability

and Accountability Act of 1996 (HIPAA) and therefore the HIPAA standard claim

transaction is not required. Additionally, the HIPAA standard claim transaction (ASC

X12 837 institutional claim format) does not support the data requirements of these

transactions.

This section gives detailed information only for items required for the notice of election

and related transactions. The RHNCI does not need to complete items not listed.

Provider Name, Address, and Telephone Number

Required - The minimum entry is the RNHCI’s name, city, State, and ZIP code. The post

office box number or street name and number may be included. The State may be

abbreviated using standard post office abbreviations. Five- or 9-digit ZIP codes are

acceptable. The RNHCI uses the information to reconcile provider number discrepancies.

Phone and/or FAX numbers are desirable.

Type of Bill

Required - The RNHCI enters the 3-digit numeric type of bill code. The first digit

identifies the type of facility. The second digit classifies the type of care. The third digit

(commonly referred to as a “frequency” code) indicates in this instance the nature of the

election related transaction.

The RNHCI enters type of bill 41A, 41B, or 41D as appropriate.

Valid codes for RNHCI elections:

1st Digit - Type of Facility

4- Religious Nonmedical Health Care Institution

2nd Digit - Classification (Special Facility)

1- Inpatient (Part A)

3rd Digit - Frequency

A - RNHCI election notice

B - RNHCI revocation notice

D - Cancellation

The RNHCI submits type of bill 41D to the specialty contractor as a cancellation of a

previously submitted notice of election or notice of revocation, when it was submitted in

error. In situations where the RNHCI is correcting a previously submitted date, they

submit a new type of bill 41A to the contractor for processing.

Patient’s Name

Required - The RNHCI enters the patient’s name with the surname first, first name, and

middle initial, if any.

Patient’s Address

Required - The RNHCI enters the patient’s full mailing address including street name and

number, post office box number or RFD, city, State, and ZIP code.

Patient’s Birth Date

Required - (If available) The RNHCI enters the month, day, and year of birth. If the date

of birth cannot be obtained after a reasonable effort, the field will be zero-filled.

Patient’s Sex

Required - The RNHCI enters an “M” for male or an “F” for female.

Admission Date

Required - The RNHCI enters the date of the election, revocation or cancellation. In no

instance should the date be prior to July 1, 2000.

National Provider Identifier

Required - The RNHCI enters their National Provider Identifier (NPI). During Medicare

processing, the NPI is matched to the RHNCI’s CMS Certification Number (CCN).

RNHCI CCNs are composed of a 2-digit state code and a 4-digit provider identifier in the

range 1990-99.

Insured’s Name

Required - The RNHCI enters the beneficiary’s name on line A if Medicare is the primary

payer. The RNHCI enters the name as on the beneficiary’s Medicare card. If Medicare is

the secondary payer, the RNHCI enters the beneficiary’s name on line B or C, as

applicable, and enters the insured’s name on line A.

Insured’s Unique Identification

Required - On the same lettered line (A, B, or C) that corresponds to the line on which

Medicare payer information is, the RNHCI enters the patient’s HICN. The RNHCI enters

the number as it appears on the patient’s Medicare Card, Social Security Award

Certificate, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice,

etc., or as reported by the Social Security Office.