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July 16, 2019

Inpatient Hospital Pre-Entitlement Claims

Pre-entitlement is a term used when a beneficiary is admitted as an inpatient prior to his/her Medicare Part A effective date.

  • For Prospective Payment System (PPS) hospitals, pre-entitlement days are not counted for utilization or for the Inpatient PPS (IPPS) Pricer.
  • For non-PPS hospitals, exempt units or Skilled Nursing Facilities (SNFs), pre-entitlement days are not counted for the cost report or for utilization.

The hospital may not bill the beneficiary or other persons for days of care preceding entitlement except for days in excess of any outlier threshold. However, total charges and units for the entire stay (except room and board) should be billed as covered and the entire stay will be paid under the appropriate MS-DRG.

Inpatient hospital admit to discharge claims with no outlier should be submitted as follows:

Example: A patient is admitted on June 25 and discharged on July 10. The patient’s Part A effective date is July 1. The claim should be submitted as follows:

  • TOB 111
  • Statement Covers Period From Date = July 1
  • Statement Covers Period Through Date = July 10
  • Admission Date = June 25
  • Utilization days = 9
  • Accommodation days/units = 9
  • Report all covered charges/units (except room and board), diagnosis codes and procedure codes from the date of admission through the date of discharge/transfer/death.

Resource: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 3External PDF, section 40

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