CMS Pub. 100-05, ch. 5, § 70.5.3

Admissions Questionnaire and Procedures

A - Admissions Procedures

1 When is other payer information solicited? (During billing or during admission?)

2 Describe the process followed to solicit MSP information.

3 Do admissions staff receive training on soliciting MSP information? If so, describe

the training. Do you think the staff understands the admissions questions well

enough to solicit information and/or explain to beneficiaries?

4 Is MSP information obtained primarily from the patient, Medicare Common

Working File, or in some other way?

B – Questionnaire

1 Are the admissions questionnaire data solicited through an online query (i.e. are the

admissions questions asked and responses retained online) or through the X12

270/271 transaction?

2 Do you re-administer the questionnaire each time the patient is admitted? (It should

be administered once per admission.)

3 Do you require the beneficiary's signature on the questionnaire? (No signature is

required, and the hospital should be informed, if necessary.)

4 Are there written hospital policies, instructions or procedures concerning soliciting

primary plan information? (Request copies for review.)

5 How long are admission questionnaires, or copies of the X12 270/271 transaction,

retained, either online, in files, or both? (Requirements are found at §70.3.)