CMS Pub. 100-04, ch. 32, § 350.11.7

Lawfully Present in the United States

(Rev. 3287, Issued: 06-30-15, Effective: 04-21-15, Implementation: 04-21-15)

Medicare payment may not be made for items and services furnished to an alien beneficiary who was not lawfully

present in the United States on the date of service.

The CWF must establish an auxiliary file based on enrollment data contained in the Enrollment Data Base maintained by

the Centers for Medicare & Medicaid Services in order to appropriately edit the claims specifically associated with alien

beneficiaries. The auxiliary file will be the basis for an edit that rejects claims for a beneficiary that was not lawfully

present in the U.S. on the date of service. MACs and DMACs must deny claims for items and services, rejected by

CWF on the basis that the beneficiary was not lawfully present in the U.S. on the date of service. MACs and DMACs

must refer to the CWF documentation on this subject for the error code MSN Message 5.7, assigned to this editing.

Upon receipt of an error code MSN Message 5.7, A/B MACs, DME MACs, and A/B MACs (HHH) must deny the claim

and use reason code (CARC) 177 – “Patient has not met the required eligibility requirements.” When CWF rejects a

claim, MACs and DMACs must use MSN message 5.7, “Medicare payment may not be made for the item or service

because, on the date of service, you were not lawfully present in the United States.” 5.7, Medicare no puede pagar por

este artículo o servicio porque, en la fecha en que lo recibió, usted no estaba legalmente en los Estados Unidos.

A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that the

beneficiary was lawfully present in the United States on the date of service. In addition, this same information must be

published in your next regularly scheduled bulletin. If you have a listserv that targets the affected provider communities,

you must use it to notify subscribers that information “Medicare Services for Alien Beneficiaries Lawfully present the

United States” is available on your Web site.

NOTE: Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA),

codified at 8 U.S.C. §1611, prohibits aliens who are not “qualified aliens” from receiving Federal public

benefits including Medicare.

However, Section 5561 of the Balanced Budget Act of 1997 (BBA) amended Section 401 of the PRWORA to create a

Medicare exemption to the prohibition on eligibility for non-qualified alien beneficiaries, who are lawfully present in the

United States and who meet certain other conditions. Specifically, payment may be made for services furnished to an

alien who is lawfully present in the United States (and provided that with respect to benefits payable under Part A of

Title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], who was authorized to be employed with respect to any

wages attributable to employment which are counted for purposes of eligibility for Medicare benefits). The definition

for “lawfully present in the United States” is found at 8 CFR 1.3.