CMS Pub. 100-06, ch. 6, § 330.3

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.

This solicits the reasons for overpayments in which a determination was made during the quarter

that an overpayment had been made to, or on behalf of, the beneficiary. The data include both the

number of claims on which beneficiary-recoverable overpayments were discovered and the

amount of overpayment (not over-allowance) involved.

Where more than one cause of overpayment exists, the carrier reports the claim and dollar amount

of the overpayment on only one of the lines 14 through 23 according to the principal reason for

overpayment. The principal reason is that which involves the greatest dollar amount.

The number of claims and amounts of beneficiary overpayments for reasons 14 through 23

combined should equal the number of claims and amount reported in Section A on line 4.

Line 14. Beneficiary Not Entitled - The carrier enters under the appropriate columns the number

and dollar amount of overpayments which resulted because payments were made to, or on behalf

of, a beneficiary for services rendered during a period of non-entitlement or for claims processed

under the wrong Medicare beneficiary identifier. (See Medicare Carrier Quality Assurance

Handbook §290.1).

Line 15. Services Not Covered - The carrier enters the number and dollar amount of

overpayments which resulted because payments were made for non-covered services other than

medically unnecessary services. (See Medicare Carrier Quality Assurance Handbook §290.2).

Line 16. Charge Exceeded Reasonable Charge - The carrier enters under the appropriate

columns the number and dollar amount of overpayments which resulted when improper charges,

higher than the reasonable charge amount, were allowed. (See Medicare Carrier Quality

Assurance Handbook §290.3).

Line 17. Payment Made to Wrong Payee - The carrier enters under the appropriate columns the

number and dollar amount of overpayments which resulted when a person other than the proper

payee received the payment (e.g., the beneficiary is paid on an assigned claim). It reports duplicate

payments made to the wrong payee in line 18 instead of here.

Line 18. Duplicate Payment - The carrier enters under the appropriate columns the number and

dollar amount of overpayments which occurred when payment was made to, or on behalf of, the

beneficiary more than once for the same service.

Line 19. Medically Unnecessary Services - The carrier enters under the appropriate columns the

number and dollar amount of overpayments discovered which arose because of payments for

services later determined to be medically unnecessary.

Line 20. Services Not Rendered - The carrier enters under the appropriate columns the number

and dollar amount of overpayments discovered which arose because of payments for services not

actually rendered. It includes claims which involve forgery or fraudulent billing for noncovered

services and other identified program abuses.

Line 21. Medicare Secondary Payor - The carrier enters under the appropriate columns the

number and dollar amounts of overpayments which arose because Medicare is secondary to prime

insurers (e.g., Department of Labor, BL, WC, VA, auto, medical or no fault, liability, EGHP under

the working aged or ESRD provision or LGHP under the disabled provision).

Line 22. Documentation/Coding/Data Entry - The carrier enters under the appropriate columns

the number and dollar amount of overpayments which resulted from:

• Insufficient documentation to support the payment action. (This could involve a claims

processor's failure to resolve questions concerning entitlement, coverage, utilization, or

reasonable charge)

• Incorrect or incomplete coding; and

• Errors in the transferring of data from an external document into a machine readable form,

including errors in keypunching and other methods for data entry. (See Medicare Carrier

Quality Assurance Handbook §§210.5-210.6).

NOTE: If a documentation/coding data entry error results in an overpayment which may be

categorized into any of lines 14 - 21, the carrier uses one of lines 14 - 21 instead of using line 22.

Line 23. Other - The carrier enters under the appropriate columns the number and dollar amount

of overpayments discovered which are not specifically provided for in lines 14-22 above.