CMS Pub. 100-04, ch. 30, § 140.7

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.

Where a beneficiary requests an appeal of the initial denial or reduction in payment, the

contractor will process the appeal in the normal fashion except that, where the appeal

results in a reversal to full or partial payment, the contractor will include the following

special paragraph in the appeal notice sent to the beneficiary:

The doctor who furnished this service has been informed of this decision

and advised that he/she may collect (his/her full charge for the service/up

to the maximum amount he/she is allowed by law to charge under

Medicare for the less extensive service for which payment has been

made).

If the reversal is for the less extensive service, the contractor will incorporate in the

notice the following:

You could have avoided paying $_______, the difference between the

maximum amount the doctor is allowed to charge and the amount

Medicare approved for the lesser service, if the claim had been assigned.

The contractor will send the physician who furnished the service a separate notice which

clearly identifies the service for which full or partial payment is being made (i.e.,

includes the patient’s name, Medicare beneficiary identifier, a description of the service

billed by procedure code, date and place of service, and amount of the charge. Where

only partial payment is being made, the contractor will clearly indicate the less extensive

service for which payment has been made). The contractor will include the following

language:

You were previously advised that Medicare payment could not be made for this

service. However, after reviewing this claim, we have determined that payment

may be made (for a less extensive service). Therefore, if you have already

refunded the amounts you collected from the beneficiary for this service, you may

recollect (these amounts/any amounts which do not exceed your maximum

allowable actual charge (MAAC) for the less extensive service for which payment

has been made).