Implementation of Payment Policy for Deported Medicare Beneficiaries (Rev. 943, Issued: 05-05-06)

by  Find-A-Code
July 17th, 2015

A. CWF Editing of Claims

1. An auxiliary file shall be established in the Common Working File to contain deportation status.

2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.

3. The edit will reject a claim where the beneficiary HIC number on the claim matches the HIC number on the Master Beneficiary Record and the date of service is on or after the date of deportation.

B. Carriers/DMERCs

1. Carriers and DMERCs shall deny claims for items and services when rejected by CWF.

2. Carriers and DMERCs shall refer to the CWF documentation on this subject for the error code assigned to this editing.

3. Upon receipt of an error code that is specific to this edit, carriers and DMERCs shall use reason code 96, non-covered charges, with Remark Code N126 “Social Security Records indicate that this individual has been deported. The payer does not cover items and services furnished to individuals who have been deported.”

4. When CWF rejects a claim, carriers and DMERCs shall use MSN message #16.56 “Claim denied because information received from the Social Security Administration indicates that you have been deported.” Spanish translation for 16.56 reads “La reclamación fue denegada porque la información proporcionada por la Administración del Seguro Social indica que usted ha sido deportado(a).”

5. All denials will provide appeal rights as specified in section 10.5.

C. Intermediaries/RHHIs

1. Intermediaries and RHHIs shall deny claims for items and services when rejected by CWF.

2. Intermediaries and RHHIs shall refer to the CWF documentation on this subject for the error code assigned to this editing.

3. Upon receipt of an error code that is specific to this edit, intermediaries and RHHIs shall use reason code 96, non-covered charges, with Remark Code N126 “Social Security Records indicate that this individual has been deported. The payer does not cover items and services furnished to individuals who have been deported.”

4. When CWF rejects a claim on the basis that the beneficiary was deported on the date of service(s), intermediaries and RHHIs shall use MSN message #16.56 “Claim denied because information received from the Social Security Administration indicates that you have been deported.” Spanish translation for 16.56 reads “La reclamación fue denegada porque la información proporcionada por la Administración del Seguro Social indica que usted ha sido deportado (a).

5. All denials will provide appeal rights as specified in section 10.5.

Pub 100-04 Medicare Claims Processing Manual

References:

• Pub 100-04 Medicare Claims Processing Manual