CMS Pub. 100-04, ch. 3, § 170.3

RNCHI Specialty Workload

(Rev. 2654, Issued: 02-08-13, Effective: 05-09-13, Implementation, 05-09-13)

Upon submission of a claim for RNHCI services, the contractor ensures that the

submission contains the complete set of required data elements according to the

instructions in §170.2. The specialty contractor ensures that the submission does not

contain data that is invalid, internally inconsistent or is not otherwise submitted in error.

If the submission is not found to be consistent with CMS instructions, it is returned to the

RNHCI for correction.

Once the claim is found to satisfy CMS instructions, the contractor ensures the claim is

not a duplicate of previously paid RNHCI services or does not demonstrate grounds for

Medicare denial for any other reason. If the claim appears appropriate for payment based

on the specialty contractors initial processing, the claim is submitted to the CMS Common

Working File (CWF) for approval.

The CWF system compares the claim submitted by the contractor to the eligibility and

utilization data for the beneficiary that received the services. The CWF ensures the

beneficiary is eligible for Part A for the dates of service (since RNHCI services are

exclusively a Part A benefit) and the beneficiary has utilization days remaining in their

current inpatient spell of illness. The CWF also compares the RNHCI claim to the

beneficiary’s file of RNHCI elections and claims. If CWF does not identify any error

conditions on the RNHCI claim, an approval message is returned to the specialty

contractor.

An RNHCI claim may be rejected by CWF if:

• No RNHCI election period is present for the dates of service of the claim;

• The RNHCI election period to which the claim would apply has been revoked (see

section 180 for procedures that lead to revocation of the election);

• The RNHCI election period to which the claim would apply has been cancelled; or

• The service dates on the claim overlap previously paid claims for RNCHI services

or other inpatient services that were processed by a Medicare contractor other than

the specialty contractor.

Claims rejected for these reasons may not be corrected and returned by the RNHCI. If the

error condition can be resolved (for instance, by the resubmission of an election period

cancelled in error), the RNHCI may submit a new original claim for the services.

Upon receipt of payment approval or rejection from CWF, the contractor may then

process the claim to completion. RNHCI claims are paid a daily interim rate as

established for each RNHCI provider under TEFRA payment rules (see Pub. 15-2,

Provider Reimbursement Manual, chapter 30). The contractor makes RNHCI payments

subject to the inpatient hospital cash deductible when applicable and, if services are for the

61st through 90th day of a benefit period or are for lifetime reserve days, subject to

coinsurance (see Pub. 100-01, Medicare General Information, Eligibility and Entitlement

Manual, Chapter 3, Sections 10.1 and 10.2).