Inpatient Hospital Pre-Entitlement Claims

Published 10/26/2020

One of the top Provider Contact Center (PCC) Frequently Asked Questions (FAQs) for July 2019 – September 2019 is related to inpatient hospital pre-entitlement claims.

Question: Where can I find information regarding billing services rendered prior to Medicare Part A entitlement (pre-entitlement)?

Answer: If the patient was inpatient and then received Medicare entitlement, you would bill the claim with the original admission date, with the “From” and “Through” dates on the claim being the dates of Medicare entitlement.

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:
    Form Locator (FL) Description Billing Instruction
Form Locator (FL)
Description
Billing Instruction
 
FL 4
Type of Bill (TOB)
111
FL 6
Statement Covers Period From Date
Medicare Part A effective date
FL 6
Statement Covers Period Through Date
End date of the inpatient stay
FL 12
Admission Date
Date the patient was admitted
FL 39-41
Value Codes:
  • 80 – Covered days
  • 81 – Non-covered days
  • 82 – Coinsurance days
  • 83 – Lifetime reserve days
Utilization days = number of days for the Statement Covers Period
FL 42-48
Charges
  • Accommodation days (room and board) = number of days for Statement Covers Period
  • Report covered charges/units (except room and board) from the date of admission through the date of discharge/transfer/death
FL 67
Diagnosis Codes
All ICD-10-CM diagnosis codes from the date of admission through the date of discharge/transfer/death
FL 74
Procedure Codes
All ICD-10-PCS procedure codes from the date of admission through the date of discharge/transfer/death

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 Internet-Only Manual 100-4, Chapter 3, Section 40 (PDF).


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