- Medicare Hospice Quick Reference Sheet
- Hospice Certifying Physician Medicare Enrollment Information
- Hospice Claim Reporting Requirements for Attending and Certifying Physicians
- 17729 Hospice Claim Edit for Certifying Physicians
- Billing Hospice Transfers
- Hospice Notice of Election Termination/Revocation (Type of Bill 8xB)
- Hospice Room and Board Denials
- Professional Services During a Patient Hospice Election
- Incarcerated or Unlawfully Present in the U.S. Claim Rejections (U538H, U538Q)
- Counting 60-Day Election Periods
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Hospice Billing Codes Chart
- Appropriate Use of Occurrence Code 27 and Occurrence Span Code 77
- Hospice Notice of Change of Ownership
- Filing an Electronic Notice of Change of Ownership (TOB 8XE)
- Hospice Change of Ownership
- Filing an Electronic Notice of Cancelation (Type of Bill 8XD)
- Filing an Electronic Notice of Transfer (Type of Bill 8XC)
- Counting 60-Day Election Periods - Leap Year
- Hospice Site of Service Codes
- Billing Hospice Physician, Nurse Practitioner and Physician Assistant Services (Related To Terminal Diagnosis)
- Hospice Visit Reporting
- The Medicare Hospice Benefit: Effects on Other Provider Types
- Counting 90-Day Election Periods - Leap Year
- Reporting Hospice Discharges, Revocations and Transfers
- Avoiding Reason Code 7C625: Appropriate Use of Remarks on Final Hospice Claims
- Hospice Claim Submission Job Aid
- Counting 90-Day Election Periods
- Hospice Quality Reporting Program
- Filing an Electronic Notice of Election (Type of Bill 8XA)
- Value-Based Insurance Design Model Hospice Benefit Component Overview
- Documentation for Hospice Transfers
- Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines
- Canceling a Hospice Notice of Election
- How to Bill When the Hospice Face-to-Face is Late from a Previous Benefit Period
- Billing Medicare for a Denial - Condition Code 21
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
Incarcerated or Unlawfully Present in the U.S. Claim Rejections (U538H, U538Q)
This stringent claim editing process helps ensure that Medicare does not make payments for services rendered to beneficiaries who are not eligible due to being unlawfully present in the U.S. or incarcerated, thus aligning with established policy guidelines.
Reason Code U538H Incarcerated Beneficiary (Patient Liable)
The term "incarcerated" refers to individuals who are in custody or under some form of confinement. This includes, but isn't limited to, those who are:
- Under arrest
- Incarcerated or imprisoned
- Escaped from confinement
- Under supervised release
- On medical furlough
- Required to reside in mental health facilities
- Required to reside in halfway houses
- Living under home detention
- Confined completely or partially under any penal statute or rule
These conditions collectively describe various ways a person might be restricted or limited in their freedom under legal or penal regulations.
Reason Code UH38Q (Patient Liable)
Alien: Unlawfully present in the U.S.
The term "alien" in this context refers to individuals who are not lawfully present in the U.S. Under the specified policy, Medicare payments cannot be made for items and services provided to an alien beneficiary if they were unlawfully present in the U.S. on the date those services were rendered. This means that Medicare will not cover the costs for healthcare services if the beneficiary is in the country without legal authorization at the time of receiving those services.
To implement the policy regarding payment restrictions for items and services furnished to unlawfully present aliens and incarcerated beneficiaries, CMS has established claim level editing. This process leverages data obtained from the SSA. The data includes the names of Medicare beneficiaries and the periods during which these beneficiaries are either:
- In federal or state custody (incarcerated)
- Unlawfully present in the United States
Here's how the process works:
- Data Comparison: The SSA provides data that contains specific information about the beneficiaries and the relevant time periods when they are either incarcerated or unlawfully present in the country.
- Claim Rejection: This information is cross-referenced with the dates of service on incoming Medicare claims. If there is any overlap between the SSA data and the dates of service, indicating that the beneficiary was in custody or unlawfully present during that time, the CWF will reject the claim.
- Notification and Denial: Rejected claims will include a trailer sent to the Medicare contractor, which details the date span during which the beneficiary was in custody or unlawfully present. Consequently, contractors will deny payment for these claims.
This stringent claim editing process helps ensure that Medicare does not make payments for services rendered to beneficiaries who are not eligible due to being unlawfully present in the U.S. or incarcerated, thus aligning with established policy guidelines.
In order for any records to be updated or corrected regarding the status of being unlawfully present or incarcerated, the patient or the patient's representative must contact the SSA to have the file updated. This is essential so that the correct information is reflected in the SSA data, which is used by the CMS for claim level editing.
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Posted 11/21/2024