TN 2 (02-91)

HI 00901.005 Health Insurance Record Maintenance

A. INTRODUCTION

Three basic types of information housed in the record which must be maintained are:

  • general,

  • Part A utilization, and,

  • Part B utilization.

B. DESCRIPTION OF CHANGES

HI information is updated in two ways.

1. MBR Input

HI information is automatically transferred to the HI master tape whenever pertinent MBR data changes.

These include:

  1. changes in the:

    • claim number,

    • name,

    • Part A entitlement/Part B enrollment date, and,

  2. terminations based on:

    • termination of monthly benefits,

    • nonpayment of premiums,

    • voluntary withdrawal, and,

    • death.

2. Special Case: Death

A beneficiary"s death is also reported to the HI master tape when the Common Working File (CWF) Host site receives any claim indicating that the beneficiary died. This date of death is only shown on the HI master tape.

C. PROCESS: PART A UTILIZATION

This table describes the process involved in the maintenance of Part A utilization information.

StageDescription
1When a beneficiary receives Part A services,the provider forwards a bill to the intermediary.
2The intermediary processes the bill based upon its records of the beneficiary"s past utilization and sends the bill to its CWF Host.
3The Host site compares the data on the bill to the beneficiary utilization shown on the CWF Master File.
4If the bill is correct, the Host notifies the intermediary to make payment. If the bill is incorrect, the Host notifies the intermediary by correcting the bill (automatic adjustment) or reject (utilization reject).
5The intermediary, upon notice from the CWF Host, takes the indicated action to either pay the bill or submit a corrected bill to the CWF Host.
6The Host notifies CMS of the billing action. This updates the HI master tape and bill history maintained in CMS Central Office.

D. PROCESS: PART B UTILIZATION

This table describes the maintenance of Part B utilization information.

StageDescription
1When a beneficiary receives Part B services,the provider forwards a claim to the carrier.
2The carrier processes the claim based upon its records of the beneficiary"s past utilization and sends the claim to its CWF Host.
3The Host site compares the data on the claim to the beneficiary utilization shown on the CWF Master File.
4If the claim is correct, the Host notifies the carrier to make payment. If the claim is incorrect, the Host notifies the carrier by correcting the claim (automatic adjustment) or reject (utilization reject).
5The carrier, upon notice from the CWF Host,takes the indicated action to either pay the claim or submit a corrected claim to the CWF Host.

NOTE: A similar process is followed for Part B blood and psychiatric services for which there is an annual limitation. (See HI 00610.470 HI 00610.480.)