CMS Pub. 100-08, ch. 11, § 11.1.3.4

(Activity Code 21010)

(Rev. 185, Issued: 01-26-07, Effective: 02-26-07, Implementation: 02-26-07)

Intermediaries shall report only the workload and costs associated with the medical

review of third party liability claims and the workload and costs associated with the

medical review of demand bills. Funding for claims processing and the appeals for third

party liability and demand bills must be funded through program management.

Intermediaries shall report the costs associated with the medical review of third party

liability claims and the medical review of demand bills in Activity Code 21010.

Intermediaries shall report the total number of claims reviewed, i.e., third party liability

claims plus claims for demand bills, in Workload 1 in CAFM II Activity Code 21010.

Intermediaries shall report the number of claims denied in whole or in part in Workload

2. Intermediaries shall report demand bills (claims) reviewed in Workload 3.

An exception to the preceding instruction may occur when the provider submits a home

health demand bill (condition code 20) type 32X, 33X, or 34X, and the beneficiary has

not selected the checkbox indicating that he or she wants Medicare to be billed on the

Home Health Advance Beneficiary Notice (HHABN). In most cases, the contractor shall

return to the provider (RTP) such claims submitted in error, except in the case of dual-eligible beneficiaries where there is a state-specific policy regarding billing Medicare.

Contractors and HHAs who serve dual-eligibles shall comply with a state-specific policy

on billing for dual-eligible beneficiaries (see CMS Pub. IOM 100-04, chapter 60, §60.5

A. for further instruction on that situation).