CMS Pub. 100-06, ch. 6, § 360.5

B3-13410.5

ASSIGNED CASES

To include an assigned claim in lines 68-71, the carrier must have originally denied it or reduced it

as "not reasonable and necessary" under §1862(a)(1) of the Act. (see The Medicare Claims

Processing Manual, Chapter X, Limitation on Liability)

Lines 69-71 are mutually exclusive i.e., a claim meeting the above condition may be counted on

only one of the three lines. Therefore, the carrier ensures that the sum of the number of claims

recorded on each of these lines equals the total number of assigned claims considered for

limitation of liability during the period reported on line 68.

The counts in lines 69-71 reflect counts of claims at the initial claim (column 1), review (column

2), and hearing levels (column 3) (as defined in MCM-3, §§3000-3000.2), not review or hearing

requests. The carrier reports cases corresponding to the claims counted here in Section A also, as

appropriate. If a claim is considered for limitation of liability at the initial claim level, the carrier

does not count it at the or hearing level unless it changes the limitation of liability decision.

It categorizes claims for columns shown in Section D according to the adjudication level at which

limitation of liability is considered or granted. If it makes several different limitation of liability

decisions on the same claim, it uses the highest numbered line on the report that applies to that

claim. It counts the claim only once. For instance, if it waives liability for both the beneficiary and

provider liability on any part of the claim, it counts the claim only on line 71.

Line 68. Total Number Considered - The carrier reports, under the appropriate columns, the

number of assigned claims meeting the conditions above for which limitation of liability was

considered during the month.

Line 69. Considered - Not Waived - The carrier reports under the appropriate columns the

number of assigned claims meeting the conditions above on which limitation of liability was

considered but was not granted to the beneficiary.

Line 70. Waived - Bene. Only - The carrier shows, under the appropriate columns, the number of

assigned claims meeting the conditions above on which it granted limitation of liability to only the

beneficiary.

Line 71. Waived - Bene. and Prov. - The carrier reports, under the appropriate columns, the

numbers of assigned claims where it granted limitation of liability during the reporting month to

both the beneficiary and provider.

Line 72. Amount Awarded - For cases included in line 71, the carrier shows the amount of

allowed charges for services (including noncovered services) where limitation of liability is

granted to the beneficiary and provider. It shows charges after reasonable charge reductions, but

prior to application of deductible and coinsurance amounts, rounding results to the nearest dollar.

UNASSIGNED CASES

This section applies to claims where waiver of a provider's liability to make refund to the

beneficiary on unassigned claims for those services found to be not reasonable or necessary is

considered under “Limitation on Liability”. See The Medicare Claims Processing Manual,

Chapter X, Limitation on Liability.

Line 73. Total Number Considered - The carrier reports, under the appropriate columns, the

number of unassigned claims that meet the conditions of §7330 for which limitation of liability

was considered during the month.

Line 74. Phys. Refund Waived - The carrier reports, under the appropriate columns, the number

of unassigned claims that meet the requirements of §7330 on which it waived the liability of the

provider to refund to the beneficiary the amount disallowed as not reasonable and necessary.

Line 75. Phys. Refund Upheld - The carrier reports, under the appropriate columns, the number

of unassigned claims that meet the requirements of The Medicare Claims Processing Manual,

Chapter X, Limitation on Liability chapter, on which it required the physician to refund the

amount disallowed.