CMS Pub. 100-04, ch. 4, § 240.4

Admissions

(Rev. 2877, Issued: 02-07-14, Effective: 10-01-13, Implementation: 04-07-14)

There may be situations when an American Indian/Alaskan Native (AI/AN) beneficiary

is admitted to an IHS/Tribal facility for social reasons. These social admissions are for

patient and family convenience and are not billable to Medicare. There are also

occasions where IHS/Tribal hospitals elect to admit patients prior to a scheduled day of

surgery, or place a patient in a room after an inpatient discharge. These services are also

considered to be social admissions as well.

For patients in a social admission status requiring outpatient services at another facility,

Medicare disallows payment for inpatient Part B ancillary services, Type of Bill (TOB)

12X during a social admission stay when there is another bill from a different facility for

an outpatient service, TOB 13X or 72X. The Common Working File (CWF) returns an

A/B crossover edit and creates an unsolicited response (IUR) in this situation.

The CWF also creates an IUR when a line item date of service on TOB 12X is equal to or

one day following the discharge date on TOB 11X for the same provider.

The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare

Part A at the time the services on TOB 12X are rendered.