CMS Pub. 100-05, ch. 5, § 70.5.4

1 Does the hospital bill for all bill types?

2 Are all claims electronically billed?

3 Is the information pertaining to a payer primary to Medicare contained on the

admission questionnaire, the X12 270/271 transaction, or in an online database,

available in its entirety to the billing department? (The billing department must be

made aware of a payer primary to Medicare, e.g., working aged, ESRD, liability

insurance.)

4 Do circumstances arise where the billing department obtains information directly

from the patient? How is it obtained? Is the regular admissions form used to obtain

the information in these situations?

5 Where there is the possibility of payment by a Federal government grant program,

how does the hospital bill Medicare? (Determine whether the hospital bills both the

grant program and Medicare, or only Medicare.)

6 How does the hospital bill the Department of Labor where the services are covered

by the Federal Black Lung (BL) program? (The hospital should bill the black lung

program first.)

7 Does the hospital have the ability to track workers' compensation (WC) cases on

succeeding visits to the hospital or the outpatient department? Describe the tracking

mechanism. How does the hospital bill for the succeeding visits? (Many times

individuals may have to return to the hospital for additional medical services as a

result of a WC occurrence.)

8 Does the hospital bill more than one primary insurer simultaneously? (Providers are

prohibited from billing more than one insurer for primary payment. Reviewer

should request a credit balance report for this aspect of the review.)

9 Where the patient is in the ESRD coordination period and an employer has paid in

part, or should pay for the services, does the hospital show the name, group number

of the insurer, proper value code, and proper amount on the bill?

10 What is the hospital's policy on submission of no-pay bills?

11 Where a GHP or LGHP is the primary payer because the beneficiary is either

working aged or disabled, or is involved in a no-fault or liability case, does the

hospital show the name, group number of the insurer, proper value code, and proper

amount on the bill?