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CMS Regulatory Manuals

The Centers for Medicare and Medicaid Services (CMS) publishes a series of manuals on its website that contain regulatory guidance on a number if topics.

Below we have linked some of the more relevant manuals (divided into chapters). Since these link directly to the CMS site, when content gets updated the changes will be reflected here.  

CMS Manuals

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Medicare General Information, Eligibility, and Entitlement

.weight800 {font-weight:800 } Chapter 1 -
General Overview
Rev. 94, 10-16-2015

  • General Program Benefits
  • Administration of the Medicare Program - Introduction
  • Federal Government Administration of the Health Insurance Program
  • Role of A/B MACs (A) and (HHH)
  • Role of A/B MACs (B)
  • Background and Responsibilities of the Peer Review Organization (PROs)
  • Institutional Planning and Budgeting
  • CMS Managed Modules for Software Programs and Pricing/Coding Files

.weight800 {font-weight:800 } Chapter 2 -
Hospital Insurance & Supplementary Medical Insurance
Rev. 124, 05-17-2019

  • Hospital Insurance Entitlement
  • Hospital Insurance Obtained by Premium Payment
  • End of Coverage for Hospital Insurance
  • Supplementary Medical Insurance
  • Identifying the patient’s health Insurance Record using the “Medicare Card”
  • Medicare Part C, Medicar+Choice

.weight800 {font-weight:800 } Chapter 3 -
Deductibles, Coinsurance Amounts, and Payment Limitations
Rev. 129, 11-22-2019

  • Hospital Insurance (Part A)
  • Supplementary Medical Insurance (SMI) (Part B)
  • Outpatient Mental Health Treatment Limitation
  • Limitation on Physical Therapy, Occupational Therapy and Speech-Language Pathology Services

.weight800 {font-weight:800 } Chapter 5 -
Definitions
Rev. 120, 11-02-2018

  • Provider and Related Definitions
  • Hospital Defined
  • Skilled Nursing Facility Defined
  • Religious Nonmedical Health Care Institution Defined
  • Home Health Agency Defined
  • Hospice
  • Physician Defined
  • Health Maintenance Organizations (HMOs) Defined
  • Other Definitions

Medicare Benefit Policy Manual:

.weight800 {font-weight:800 } Chapter 1 -
Inpatient Hospital Services Covered Under Part A
(Rev. 234, 03-10-2017)

  • Covered Inpatient Hospital Services Covered Under Part A
  • Nursing and Other Services
  • Drugs and Biologicals
  • Supplies, Appliances, and Equipment
  • Other Diagnostic or Therapeutic Items or Services
  • Inpatient Services in Connection With Dental Services
  • Health Care Associated With Pregnancy
  • Termination of Pregnancy
  • Treatment for Infertility
  • Inpatient Rehabilitation Facility (IRF) Services
  • Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
  • Religious Nonmedical Health Care Institution (RNHCI) Services

.weight800 {font-weight:800 } Chapter 2 -
Inpatient Psychiatric Hospital Services
(Rev. 253, 12-14-2018)

  • Inpatient Psychiatric Facility Services
  • Admission Requirements
  • Medical Records Requirements
  • Personnel Requirements
  • Psychological Services
  • Social Services
  • Therapeutic Activities
  • Benefit Limits in Psychiatric Hospitals
  • Benefits Exhaust

.weight800 {font-weight:800 } Chapter 3 -
Duration of Covered Inpatient Services
(Rev. 261; Issued: 10-04-2019)

  • Benefit Period (Spell of Illness)
  • Inpatient Benefit Days
  • Inpatient Days counting towards Benefit Maximums

.weight800 {font-weight:800 } Chapter 4 -
Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation
(Rev. 1, 10-01-2003)

  • Inpatient Psychiatric Benefit Days Reduction
  • Days of Admission, Discharge, and Leave
  • Reduction for Psychiatric Services in General Hospitals
  • Determining Days Available
  • Inpatient Psychiatric Hospital Services - Lifetime Limitation

.weight800 {font-weight:800 } Chapter 5 -
Lifetime Reserve Days
(Rev. 257, 03-01-2019)

  • Summary of Provision
  • When Payment Will Be Made for Reserve Days
  • Election Not to Use Lifetime Reserve Days
  • Content of Election

.weight800 {font-weight:800 } Chapter 6 -
Hospital Services Covered Under Part B
(Rev. 267, 02-04-2020)

  • Medical and Other Health Services Furnished to Inpatients of Participating Hospitals
  • Outpatient Hospital Services
  • Drugs and Biologicals
  • Other Covered Services and Items
  • Sleep Disorder Clinics
  • Intermittent Peritoneal Dialysis Services
  • Outpatient Hospital Psychiatric Services
  • Rental and Purchase of Durable Medical Equipment
  • Services of Interns And Residents

.weight800 {font-weight:800 } Chapter 7 -
Home Health Services
(Rev. 265, 01-10-2020)

  • Home Health Prospective Payment System (HH PPS)
  • Conditions To Be Met for Coverage of Home Health Services
  • Conditions Patient Must Meet to Qualify for Coverage of Home Health Services
  • Covered Services Under a Qualifying Home Health Plan of Care
  • Coverage of Other Home Health
  • Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B)
  • Duration of Home Health Services
  • Specific Exclusions From Coverage as Home Health Services
  • Medical and Other Health Services Furnished by Home Health Agencies
  • Physician Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA)
  • Use of Telehealth in Delivery of Home Health Services

.weight800 {font-weight:800 } Chapter 8 -
Coverage of Extended Care (SNF) Services Under Hospital Insurance
(Rev. 261; Issued: 10-04-2019)

  • Requirements – General
  • Prior Hospitalization and Transfer Requirements
  • Skilled Nursing Facility Level of Care – General
  • Physician Certification and Recertification f or Extended Care Services
  • Covered Extended Care Services
  • Covered Extended Care Days
  • Medical and Other Health Services Furnished to SNF Patients

.weight800 {font-weight:800 } Chapter 9 -
Coverage of Hospice Services Under Hospital Insurance
(Rev. 246, 09-14-2018 )

  • Requirements – General
  • Certification and Election Requirements
  • Coinsurance
  • Benefit Coverage
  • Limitation on Liability for Certain Hospice Coverage Denials
  • Provision of Hospice Services to Medicare/Veteran’s Eligible Beneficiaries
  • Hospice Contracts with An Entity for Services not Considered Hospice Services
  • Hospice Pre-Election Evaluation and Counseling Services
  • Caps and Limitations on Hospice Payments

.weight800 {font-weight:800 } Chapter 10 -
Ambulance Services
(Rev. 243, 04-13-2018)

  • Ambulance Service
  • Coverage Guidelines for Ambulance Service Claims
  • Implementation of the Ambulance Fee Schedule

.weight800 {font-weight:800 } Chapter 11 -
End Stage Renal Disease (ESRD)
(Rev. 257, 03-01-2019)

  • Definitions Relating to ESRD
  • Renal Dialysis Items and Services
  • Home Dialysis
  • Other Services
  • ESRD Prospective Payment System (PPS) Base Rate
  • ESRD PPS Case-Mix Adjustments
  • ESRD PPS Transition Period
  • Bad Debts
  • Medicare as a Secondary Payer
  • Definitions Relating to ESRD
  • Renal Dialysis Items and Services
  • Home Dialysis
  • Other Services
  • ESRD Prospective Payment System (PPS) Base Rate
  • ESRD PPS Case-Mix Adjustments
  • ESRD PPS Transition Period80 - Bad Debts
  • Medicare as a Secondary Payer
  • Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury (AKI)
  • Transplantation

.weight800 {font-weight:800 } Chapter 12 -
Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
(Rev. 255, 01-25-2019)

  • Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare
  • Required and Optional CORF Services
  • Rules for Provision of Services
  • Specific CORF Services

.weight800 {font-weight:800 } Chapter 13 -
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
(Rev. 263, 12-20-2019)

  • RHC and FQHC General Information, Location Requirements, Staffing Requirements, Visits, Services, Payment Rate, Cost Reports
  • Non RHC/FQHC Services
  • RHC and FQHC Charges, Coinsurance, Deductible, and Waivers
  • Commingling
  • Physician Services
  • Services and Supplies Furnished “Incident to” Physician’s Services
  • Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services
  • Services and Supplies Furnished Incident to NP, PA, and CNM Services
  • Clinical Psychologist and Clinical Social Worker Services
  • Services and Supplies Incident to CP Services
  • Mental Health Visits
  • Physical Therapy, Occupational Therapy, and Speech Language Pathology Services
  • Visiting Nursing Services
  • Telehealth Services
  • Hospice Services
  • Preventive Health Services
  • Care Management Services
  • Virtual Communication Services

.weight800 {font-weight:800 } Chapter 14 -
Medical Devices
(Rev. 198, 11- 06-2014)

  • Coverage of Medical Devices
  • Food and Drug Administration (FDA)-Approved Investigational Device Exemption (IDE) Studies
  • Hospital Institutional Review Board (IRB) Approved Non-significant Risk Devices
  • Services Related to and Required as a Result of Services Which are Not Covered under Medicare

.weight800 {font-weight:800 } Chapter 15 -
Covered Medical and Other Health Services
(Rev. 259, 07-12-2019)

  • Supplementary Medical Insurance (SMI) Provisions
  • When Part B Expenses Are Incurred
  • Physician Services
  • Effect of Beneficiary Agreements Not to Use Medicare Coverage
  • Drugs and Biologicals
  • Services and Supplies
  • Sleep Disorder Clinics
  • Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • X -Ray, Radium, and Radioactive Isotope Therapy
  • Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
  • Durable Medical Equipment – General
  • Prosthetic Devices
  • Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
  • Therapeutic Shoes for Individuals with Diabetes
  • Dental Services
  • Clinical Psychologist Services
  • Clinical Social Worker (CSW) Services
  • Nurse-Midwife (CNM) Services
  • Physician Assistant (PA) Services
  • Nurse Practitioner (NP) Services
  • Clinical Nurse Specialist (CNS) Services
  • Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) under Medical Insurance
  • Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
  • Chiropractic Services – General
  • Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities
  • Ambulatory Surgical Center Services
  • Telehealth Services
  • Preventive and Screening Services
  • Foot Care
  • Diabetes Self-Management Training Services
  • Kidney Disease Patient Education Services

.weight800 {font-weight:800 } Chapter 16 -
General Exclusions From Coverage
(Rev. 198, 11-06-2014)

  • General Exclusions from Coverage
  • Services Not Reasonable and Necessary
  • Foot Care
  • No Legal Obligation to Pay for or Provide Services
  • Items and Services Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments
  • Services Not Provided Within United States
  • Services Resulting from War
  • Personal Comfort Items
  • Routine Services and Appliances
  • Hearing Aids and Auditory Implants
  • Custodial Care
  • Cosmetic Surgery
  • Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household
  • Dental Services Exclusion
  • Services Reimbursable Under Automobile, No Fault, Any Liability Insurance or Workers’ Compensation
  • Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider
  • Services Related to and Required as a Result of Services Which Are Not Covered under Medicare

Medicare Managed Care Manual:

.weight800 {font-weight:800 } Chapter 1 -
General Provisions
(Rev. 125, 02-10-2017) )

  • Legislative History
  • Types of Medicare Advantage (MA) Plans
  • Other MA Plans
  • Medicare Cost Plans and Health Care Prepayment Plans (HCPP)

.weight800 {font-weight:800 } Chapter 2 -
Medicare Advantage Enrollment and Disenrollment
(Rev. 08-15-2023)

  • Definitions
  • Eligibility for Enrollment in MA Plans
  • Election Periods and Effective Dates
  • Enrollment Procedures
  • Disenrollment Procedures
  • Post-Enrollment Activities
  • Appendices & Exhibits

.weight800 {font-weight:800 } Chapter 4 -
Benefits and Beneficiary Protections
(Rev. 121, Issued: 04-22-2016)

  • Introduction
  • Ambulance, Emergency, Urgently Needed and Post-Stabilization
  • Supplemental Benefits
  • Over-the-Counter (OTC) Benefits
  • Cost-sharing Guidance
  • Meaningful Difference
  • Non-Renewal Based on Low Enrollment
  • Value-Added Items and Services (VAIS)
  • National and Local Coverage Determinations
  • Rewards and Incentives
  • Access to and Availability of Services
  • Coordination of Medicare Benefits with Employer/Union Group
  • Medicare Secondary Payer (MSP) Procedures
  • Service Area
  • Benefits during Disasters and Catastrophic Events
  • Beneficiary Protections Related to Plan-Directed Care
  • Balance Billing
  • Information on Advance Directives
  • Part C Explanation of Benefits (EOB)
  • Educating and Enrolling Members in Medicaid and Medicare Savings

Chapter 9 -
Employer/Union Sponsored Group Health Plans
(Rev. 111, 05-03-2013) .weight800 {font-weight:800 }

  • Introduction
  • Benefit Design Requirement Waivers
  • Enrollment Requirement Waivers
  • Service Area Requirement Waivers
  • Marketing Requirement Waivers
  • Waivers Only Applicable to Direct Contract EGWPs
  • Appendices

.weight800 {font-weight:800 } Chapter 10 -
MA Organization Compliance with State Law and Preemption by Federal Law
(Rev. 103, 11-04-2011 )

  • Introduction
  • State Licensure Requirement
  • Federal Preemption of State Law
  • Medicare Secondary Payer (MSP) Rules
  • State Premium Taxes or Other Fees Imposed on Federal Payment to MA Organizations
  • Examples of Federal Preemption Scenario

.weight800 {font-weight:800 } Chapter 11 -
Medicare Advantage Application Procedures and Contract Requirements
(Rev. 83, 04-25-2007)

  • Definitions
  • General Medicare Advantage Application and Contract Provisions
  • Minimum Enrollment Requirements for MA Organizations
  • Term and Effective Date of an MA Contract
  • Contracting Prohibitions Under the Medicare Advantage (MA) Program
  • MA Contract Renewal
  • Contract Nonrenewal
  • Contract Terminations
  • Modification or Termination of an MA Contract by Mutual Consent
  • MA Contract Provisions
  • MA Organization Relationship with Related Entities, Contractors, Subcontractors, First-Tier and Downstream Entities
  • Compliance with Other Laws and Regulations
  • Certification of Data That Determine Payment Requirements
  • Special Rules for Religious Fraternal Benefit (RFB) Societies

.weight800 {font-weight:800 } Chapter 14 -
Contract Determinations and Appeals
(Rev. 122, 05-27-2016)

  • Contract Determinations
  • Hearings
  • Review by the CMS Administrator
  • Reopening of Contract Determination or Decision of a Hearing Officer or the CMS Administrator

.weight800 {font-weight:800 } Chapter 16a -
Private Fee-for-Service (PFFS) Plans
(Rev. 99, Issued: 05-27-2011)

  • Introduction
  • General Requirements
  • Access to Services
  • Provider Types: Direct-Contracting, Deemed-Contracting, and Non-Contracting
  • PFFS Terms and Conditions of Payment for Deemed Providers
  • Variations in Payment Rates to Providers
  • PFFS Payment Rules for Providers and Cost Sharing Rules for Members
  • Balance Billing Rules
  • Prohibition on Prior Authorization, Prior Notification, and Referrals
  • Written Advance Organization Determinations
  • Prompt Payment Requirements
  • Timing Filing Requirement
  • Provider Payment Dispute Resolution Process
  • Requirement for PFFS Plans to Provide an Explanation of Benefits to Members
  • Requirement for PFFS Plans to have a Quality Improvement Program
  • PFFS Crosswalk Options

.weight800 {font-weight:800 } Chapter 16b -
Special Needs Plans
(Rev. 123, Issued: 08-19-2016 )

  • Introduction
  • Description of SNP Types
  • Application, Approval, and Service Area Expansion Requirements
  • Enrollment Requirements
  • Renewal Options and Crosswalks
  • Marketing
  • Covered Benefits
  • Quality Improvement

.weight800 {font-weight:800 } Chapter 17 (Subchapter D) -
Medicare Cost Plan Enrollment and Disenrollment Instructions
(Rev. 38, 10-31-2003)

  • Definitions
  • Eligibility for Enrollment in a Medicare Cost Plan
  • Enrollment Periods and Effective Date of Enrollment
  • Enrollment Procedures
  • Disenrollments
  • Post-Enrollment/Disenrollment Activities
  • Exhibits

.weight800 {font-weight:800 } Chapter 17 (Subchapter F) -
Benefits and Beneficiary Protections
(Rev. 77, 10-28-2005)

  • General Requirements
  • Requirements of Specific Benefits
  • Hospice
  • Financial Responsibility
  • Out-of-Area, Out-of-Network and Extended Absence
  • Cost Employer Group Health Plans (EGHP)
  • Medicare Secondary Payer
  • National Coverage Determinations and Legislative Changes in Benefits
  • Discrimination Against Beneficiaries Prohibited
  • Disclosure Requirements
  • Confidentiality and Records
  • Availability, Accessibility, and Continuity
  • Information on Advance Directives

.weight800 {font-weight:800 } Chapter 21 -
Compliance Program Guidelines
(Rev. 110, 01-11-2013)

Note: this is also listed as “Chapter 9 of the Prescription Drug Benefit Manual”

  • Introduction
  • Definitions
  • Overview of Mandatory Compliance Program
  • Sponsor Accountability for and Oversight of FDRs
  • Elements of an Effective Compliance Program
  • Appendices

Medicare Prescription Drug Benefits Manual:

.weight800 {font-weight:800 } Chapter 3 -
Eligibility, Enrollment and Disenrollment
(Rev. 07-31-2018)

  • Definitions
  • Eligibility for Enrollment in a Part D Plan
  • Enrollment and Disenrollment Periods and Effective Dates
  • Enrollment Procedures
  • Disenrollment Procedures
  • Post-Enrollment Activities
  • Appendices & Exhibits

.weight800 {font-weight:800 } Chapter 4 -
Creditable Coverage Period Determination and the Late Enrollment Penalty
(In effect: 04-01-2010)

  • Process for Making a Creditable Coverage Period Determination
  • Attestation of Creditable Prescription Drug Coverage
  • Reporting Creditable Coverage Period Determinations to CMS
  • CMS Calculating & Reporting LEP to Part D Sponsors
  • Notification to Beneficiaries of the Late Enrollment Penalty
  • Billing, Collecting, and Refunding the LEP
  • LEP Consideration Process
  • Information Retention Requirements
  • Appendices
  • Exhibits

.weight800 {font-weight:800 } Chapter 5 -
Benefits and Beneficiary Protections
(Rev. 14, 09-30-2011)

  • Benefits and Beneficiary Protections
  • Requirements Related to Qualified Prescription Drug Coverage
  • Incurred/ “True Out-of-Pocket” (TrOOP) Costs
  • Prescription Drug Plan Service Areas
  • Access to Covered Part D Drugs

.weight800 {font-weight:800 } Chapter 6 -
Part D Drugs and Formulary Requirements
(Rev. 18, 01-15-2016)

  • Definition of a Part D Drug
  • Part D Exclusions
  • Formulary Requirements
  • Appendices

.weight800 {font-weight:800 } Chapter 7 -
Medication Therapy Management and Quality Improvement Program
(Rev. 11, 02-19-2010)

  • Medication Therapy Management and Quality Improvement Program
  • Quality Assurance Requirements
  • Medication Therapy Management Program (MTMP)
  • Consumer Satisfaction Surveys
  • Electronic Prescription Program (E-prescribing)
  • Drug Utilization Management Program
  • Part D Complaints Processing
  • Appendices

.weight800 {font-weight:800 } Chapter 9 -
Compliance Program Guidelines
(Rev. 16, 01-11-2013)

Note: this is also listed as “Chapter 21 of the Managed Care Manual”

  • Introduction
  • Definitions
  • Overview of Mandatory Compliance Program
  • Sponsor Accountability for and Oversight of FDRs
  • Elements of an Effective Compliance Program
  • Appendices

.weight800 {font-weight:800 } Chapter 12 -
Employer/Union Sponsored Group Health Plans
(Rev.6, 11-07-2008)

  • Introduction
  • Approved Employer/Union Sponsored Group Health Plan Waivers
  • Appendices

.weight800 {font-weight:800 } Chapter 13 -
Premium and Cost-Sharing Subsidies for Low-Income Individual
(Rev. 14, 10-01-2018)

  • Introduction
  • Definitions
  • Eligibility Requirements
  • Eligibility Determinations
  • Premium Subsidy
  • Cost-Sharing Subsidy
  • Part D Sponsor Responsibilities When Administrating the Low – In-come Subsidy
  • Application of Low-Income Subsidy to Employer Group Waivers Plans
  • Enhanced Allotment for Low-Income Residents of the Territories
  • Appendices

.weight800 {font-weight:800 } Chapter 14 -
Coordination of Benefits
(Rev. 17, 08-23-2013)

  • Introduction
  • Overview
  • CMS Requirements
  • Beneficiary Requirements
  • Part D Sponsor Requirements
  • Coordination of Benefit Activities of Non-Part D Payers
  • Appendices

Medicare Marketing Manual:

.weight800 {font-weight:800 } Medicare Marketing Guidelines
(Issued: 07/20/2017)

  • Introduction
  • Materials Not Subject To Marketing Review
  • Plan/Part D Sponsor Responsibilities
  • General Marketing Requirements
  • Disclaimer Requirements
  • Required Documents
  • Outreach, Marketing and Educational Events, and Sales Activities
  • Telephonic Activities and Scripts
  • The Marketing Review Process
  • Part D Sponsor Websites and Social/Electronic Media
  • Promotional Activities, Rewards, and Incentives
  • Marketing and Sales Oversight and Responsibilities
  • Employer/Union Health Plans
  • Use of Medicare Mark for Part D Sponsors
  • Allowable Use of Medicare Beneficiary Information Obtained from CMS
  • Appendices

.weight800 {font-weight:800 } Medicare Communications and Marketing Guidelines (MCMG)
(Issued: 10/05/2018)  

  • Introduction
  • Communications and Marketing Definitions
  • General Communication Requirements
  • General Marketing Requirements
  • Outreach Activities
  • Activities in Healthcare Settings
  • Websites and Social/Electronic Media
  • Call Centers
  • Tracking, Submission, and Review Process
  • Required Materials
  • Agent/Broker Activities, Oversight, and Compensation Requirements
  • Use of Medicare Beneficiary Information obtained from CMS
  • Appendices

Medicare Secondary Payer (MSP) Manual:

.weight800 {font-weight:800 } Chapter 1 -
Background and Overview
(Rev. 125, 03-22-2019)

  • General Provisions
  • Definitions
  • Beneficiary’s Rights and Responsibility
  • Effect of GHP’s Payments on Deductible, Coinsurance and Utilization
  • Rules Defining Employees Covered by GHP’s and LGHP’s
  • Aggregation Rules Applicable to Determine the Employer Size
  • Prohibitions Applicable to Employers offering GHP Coverage
  • Actions Resulting from GHP or LGHP Nonperformance
  • Referral to the Regional Office
  • Federal Government’s Right to Sue and Collect Double

.weight800 {font-weight:800 } Chapter 2 -
MSP Provisions
(Rev. 118, 04-28-2016)

  • Medicare Secondary Payer Provisions for Working Aged Individuals
  • Medicare Secondary Payer Provisions for End-Stage Renal Disease (ESRD) Beneficiaries
  • Medicare Secondary Payer Provision for Disabled Beneficiaries
  • Liability Insurance
  • Workers' Compensation (WC)
  • No-Fault Insurance
  • Interest on MSP Recovery Claims

.weight800 {font-weight:800 } Chapter 3 -
MSP Provider, Physician, and Other Supplier Billing Requirements
(Rev. 125, 03-22-2019)

  • General
  • Obtain Information From Patient or Representative at Admission or Start of Care
  • Provider, Physician, and Other Supplier Billing
  • Completing the Form CMS-1450 in MSP Situations by Providers of Service

.weight800 {font-weight:800 } Chapter 4 -
Coordination of Benefits Contractor (COBC) Requirements
(Rev. 125, 03-22-2019)

  • Overview and General Responsibilities
  • CMS IEQ Responsibilities
  • IRS/SSA/CMS Data Match
  • The Coordination of Benefits Contractor (COBC) Discontinues Dissemination of the Right of Recovery Letters
  • Exception for Small Employers in Multi-Employer Group Health Plans (GHPs)

.weight800 {font-weight:800 } Chapter 5 -
Contractor Prepayment Processing Requirements
(Rev. 125, 03-22-2019)

  • Coordination with the Benefits Coordination & Recovery Center (BCRC)
  • Sources That May Identify Other Insurance Coverage
  • Develop Claims for Medicare Secondary Benefits
  • FI and Carrier Claim Processing Rules
  • MSP Pay Modules to Calculate Medicare Secondary Payment Amount
  • MSP Reports
  • Hospital Review Protocol for Medicare Secondary Payer

.weight800 {font-weight:800 } Chapter 6 -
Medicare Secondary Payer (MSP) CWF Process
(Rev. 76, 11-19-2010)

  • General Information
  • MSP Maintenance Transaction Record Processing
  • CWF, MSP Auxiliary File30.1 -Integrity of MSP Data
  • MSP Claim Processing
  • Special CWF Processes
  • Use of Inter-Contractor Notices (ICNs) and CWF for Development Conditional Payment Amount
  • Converting Health Insurance Portability and Accountability Act (HIPAA) Individual Relationship Codes to Common Working File (CWF) Medicare Secondary Payer(MSP) Patient Relationship Codes

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