decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Program_Memos / 2001 / AB-01-97
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Article Overview
This article explains operational guidance for hospitals, physicians, carriers, and intermediary systems involved in Medicare demonstration projects. It covers claim submission and resubmission workflows, notice of admission handling, remittance and reporting requirements, and how the demonstrations interact with common billing structures and claim processing formats. The memo is relevant to hospital billing staff, physician practices, contractors, and health care coding teams supporting Medicare demonstration claims.
Why This Topic Matters
It helps readers understand the administrative and system-level requirements that affect how demonstration-related inpatient and professional claims are submitted, processed, reported, and coordinated across Medicare entities.
Article Sections
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Physician or other Part B Professional Provider
Guidance for professional providers on claims associated with the demonstration and how those claims are routed through carrier processing.
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Carrier
Carrier-side processing expectations for demonstration-related professional claims, including review and history handling.
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Special Circumstances
Situations that alter standard demonstration processing, including transfers, post-acute care, and related payment handling.
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Health Professional Shortage Area (HPSA) Bonus Payments
How the demonstration affects broader payment handling for providers in shortage areas and related claim processing support.
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Cost Reporting and Reconciliation for Hospital Payments
How payment amounts are allocated and tracked for reporting, reconciliation, and cost-reporting purposes.
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Direct Medical Education, Indirect Medical Education (IME) & Disproportionate Share (DSH)
Treatment of medical education and disproportionate share payment components under the demonstration.
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Capital Payments
How capital-related payment components are handled within the demonstration framework.
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System Specifications
Implementation requirements and processing rules for claim systems, contractor workflows, and related data handling.
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General Requirements
High-level administrative and eligibility requirements that apply across the demonstrations.
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Hospital Requirements
Hospital responsibilities for admission notice transactions, billing submission, and claim format usage.
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Intermediary Requirements
Intermediary processing, reporting, remittance, and beneficiary notice requirements tied to the demonstrations.
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Carrier Requirements
Carrier workflow, reporting, and processing requirements for professional claims and demonstration-related claim handling.
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Common Working File (CWF) Requirements
Common Working File edits, matching logic, and claim routing requirements for demonstration transactions.
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Attachment I
Lists of diagnosis-related group categories included in the demonstration attachments and the related reference tables.
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Table I A: DRGs Included in Medicare Participating Cardiovascular Centers of Excellence Demonstration
Cardiovascular-related DRG groupings referenced by the attachment.
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Table I B: DRGs Included in Medicare Participating Orthopedic Centers of Excellence Demonstration
Orthopedic-related DRG groupings referenced by the attachment.
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Attachment II
Process flow charts covering admission, discharge, professional claims, and resubmission workflows.
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Attachment III
A reporting format for weekly carrier-to-hospital reporting of demonstration claims processed as no-pay bills.
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Medicare Part B Allowance
A data dictionary entry describing a claim payment-related field used in the reporting attachment.
What You Will Learn
- How Medicare demonstration claims are organized across hospital, physician, carrier, intermediary, and CWF workflows.
- What types of operational and reporting requirements apply to hospital admission notices and claim submission formats.
- How the article frames special circumstances such as transfers, post-acute care, and shortage-area-related processing.
- What reporting and reconciliation topics are covered for payment allocation and claims history tracking.
- Which attachments and data dictionary elements support the demonstration processing guidance.
Who Should Read This
- Hospital billing departments
- Physician billing offices
- Medicare contractors and intermediaries
- Claims processing system teams
- Coding and reimbursement staff
- Health information management professionals
Codes Discussed
Modifiers Discussed
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