Medicare Claims Processing Manual Chapter 1 Guide

Name: Medicare Claims Processing Manual (Pub. 100-04)
Creator: Centers for Medicare & Medicaid Services
License: https://www.usa.gov/government-works

TL;DR

Chapter 1 of the Medicare Claims Processing Manual sets the ground rules that apply to every Medicare fee-for-service claim. It explains which contractor processes a claim, provider participation and assignment, the 12-month time limit for filing and its exceptions, what a clean claim is and how fast it must be paid, how noncovered charges are reported on institutional claims, and how long providers keep records.

Chapter 1 at a glance

Current revision: Rev. 13826; Issued June 11, 2026
Effective: July 13, 2026; Implemented July 13, 2026
Sections: 251; 24 top-level sections
Official PDF: 325 pages; clm104c01.pdf
Transmittals in history: 215; Listed at the end of the chapter
Monthly searches: 50; Google Ads, US, October 2026

What chapter 1 governs for billing

The chapter opens with formats and jurisdiction: Medicare claims are filed electronically unless an exception applies (02), and section 10 decides which A/B MAC or DME MAC receives a claim, including the rules for beneficiaries in custody and deported beneficiaries. Section 30 covers provider participation agreements and assignment, including the physician and supplier participation program and the prohibition on reassigning payment except as the law allows. Section 40 covers what happens when a provider agreement ends, and section 50 covers requests for payment, billing frequency and when an inpatient admission may be changed to outpatient status (50.3).

Section 70 is the timely filing rule that most people come here for. Claims must be filed no later than 12 months, or one calendar year, after the date of service (42 CFR 424.44). Sections 70.1 to 70.3 explain how the start and end of the period are determined, and 70.7 lists the exceptions that extend it: administrative error by Medicare or its contractor, retroactive Medicare entitlement, retroactive entitlement involving a state Medicaid agency, and retroactive disenrollment from a Medicare Advantage plan.

Section 80 governs claims processing timeliness. A clean claim cannot be paid before the payment floor: contractors wait 13 days after receipt for an electronic claim and 26 days for a paper claim, so payment can be issued no earlier than day 14 or day 27, and interest is owed when a clean claim is paid late. Section 60 tells institutional providers how to report noncovered charges, section 90 covers patients enrolled in Medicare Advantage for only part of a billing period, and section 110 sets record retention.

Sections billing teams use most

Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 1 PDF at the page where that section starts.

Key sections of Medicare Claims Processing Manual Chapter 1: General Billing Requirements
Section	CMS heading	Why it matters
10.1	A/B MACs (Part B) and DME MACs Jurisdiction of Requests for Payment	Which A/B MAC or DME MAC has jurisdiction over a Part B or DMEPOS claim.
30.3	Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims	Participation agreements and assignment for physicians, practitioners and suppliers.
50.3	When an Inpatient Admission May Be Changed to Outpatient Status	When an inpatient admission may be changed to outpatient status before discharge.
60.1	General Information on Non-covered Charges on Institutional Claims	How noncovered charges are reported on institutional claims.
70.1	Determining Start Date of Timely Filing Period--Date of Service	The start of the timely filing period, measured from the date of service.
70.7	Exceptions Allowing Extension of Time Limit	Exceptions that extend the filing limit, such as administrative error and retroactive entitlement.
80.2	Definition of Clean Claim	The definition of a clean claim and the payment floor and ceiling standards.

How chapter 1 shows up on claims and denials

A claim received more than one calendar year after the date of service is denied with reason code 29, the time limit for filing has expired. That denial is upheld on appeal unless the provider can show that one of the section 70.7 exceptions applies, so documentation of the exception (for example the retroactive entitlement notice) should accompany the resubmission. A claim that repeats one already processed is denied as an exact duplicate with reason code 18.

Coordination problems also start in this chapter. When another insurer is primary, Medicare returns reason code 22, and the claim is resubmitted with the primary payer's payment information under the Medicare Secondary Payer rules. A beneficiary who cannot be matched to Medicare records triggers reason code 31, usually a Medicare Beneficiary Identifier or name mismatch.

Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.

Remittance codes associated with Medicare Claims Processing Manual Chapter 1: General Billing Requirements
Code	Type	When it appears
29	Claim adjustment reason code	The time limit for filing has expired.
18	Claim adjustment reason code	Exact duplicate of a claim or service already processed.
22	Claim adjustment reason code	Another payer may be primary under coordination of benefits.
31	Claim adjustment reason code	Patient cannot be identified as a Medicare beneficiary.
16	Claim adjustment reason code	Claim lacks information or has a submission or billing error.

Current revision and recent transmittals

The chapter PDF posted on cms.gov is current through Rev. 13826, issued June 11, 2026, effective July 13, 2026, implemented July 13, 2026 (change request 14500). That revision changed sections 210 (Medicare Beneficiary Date of Death-Background), 210.1 (How to Correct Incorrect Dates in Medicare Records), 210.1.1 (Healthcare Provider Errors), 210.1.2 (Date of Death Submitted by Family Member or Authorized Agent), 210.1.3 (Social Security Administration (SSA) or Railroad Retirement Board (RRB) Errors). Its subject line reads: “Medicare Beneficiary Date of Death - Manual Update”.

The newest rows of the transmittal history printed at the end of the chapter (215 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.

Newest transmittals for Medicare Claims Processing Manual Chapter 1: General Billing Requirements
Revision	Issued	Subject	CR
R13826CP	June 11, 2026	Medicare Beneficiary Date of Death - Manual Update	14500
R13272CP	June 18, 2025	Updates to No Legal Obligation to Pay for or Provide Services and Examples of Application of Government Entity Exclusion (Pub. 100-02, chapter 16, sections 40 and 50.3.3 and newly created section 40.7) and Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority (Pub. 100-04, chapter 1, section 10.4)	13903
R13089CP	February 21, 2025	Manual Updates Regarding Home Health Adjustments and Skilled Nursing Facility, Home Health and Hospice Pricer Information	13955
R13026CP	December 27, 2024	Billing Instructions Related to Expedited Determinations Based on Medicare Change of Status Notifications (MCSNs)	13918
R12909CP	October 24, 2024	Corrections to Change Request (CR) 7270 - Changes to the Time Limits for Filing Medicare Fee For Service Claims	13834
R12789CP	August 15, 2024	Updates to Chapter 1 of the Medicare Claims Processing Manual (Publication (Pub.) 100-04) to Include Newly Created and Utilized Payer Only Codes	13736

Sections ordered by the date in the revision note printed under each heading.

Most recently revised sections of Medicare Claims Processing Manual Chapter 1: General Billing Requirements
Section	Heading	Revision
210	Medicare Beneficiary Date of Death-Background	Rev. 13826, June 11, 2026; effective July 13, 2026
210.1	How to Correct Incorrect Dates in Medicare Records	Rev. 13826, June 11, 2026; effective July 13, 2026
210.1.1	Healthcare Provider Errors	Rev. 13826, June 11, 2026; effective July 13, 2026
210.1.2	Date of Death Submitted by Family Member or Authorized Agent	Rev. 13826, June 11, 2026; effective July 13, 2026
210.1.3	Social Security Administration (SSA) or Railroad Retirement Board (RRB) Errors	Rev. 13826, June 11, 2026; effective July 13, 2026
10.4	Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority	Rev. 13593, January 26, 2026; effective February 26, 2026
130.5	Home Health Adjustments	Rev. 13089, February 21, 2025; effective May 22, 2025
150	Limitation of Liability Notification and Coordination With Quality Improvement Organizations (QIOs)	Rev. 13026, December 27, 2024; effective October 11, 2024

Section index

Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.

01 Foreword · p. 10 · 1 subsections

Open section 01 in the PDF
01.1 Remittance Advice Coding Used in this Manual · p. 10

02 Formats for Submitting Claims to Medicare · p. 13 · 7 subsections

Open section 02 in the PDF
02.1 Electronic Submission Requirements · p. 13
02.1.1 HIPAA Standards for Claims · p. 12
02.1.2 Where to Purchase HIPAA Standard Implementation Guides · p. 14
02.2 Paper Claims · p. 15
02.2.1 Paper Formats for Institutional Claims · p. 15
02.2.2 Paper Formats for Professional and Supplier Claims · p. 15
02.3 Remittance Advices · p. 15

10 Jurisdiction for Claims · p. 15 · 30 subsections

Open section 10 in the PDF
10.1 A/B MACs (Part B) and DME MACs Jurisdiction of Requests for Payment · p. 16
10.1.1 Payment Jurisdictions Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services · p. 17
10.1.1.1 Claims Processing Instructions for Payment Jurisdiction · p. 20
10.1.1.2 Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation · p. 24
10.1.1.3 Payment Jurisdiction for Reassigned Services · p. 26
10.1.3 Exceptions to Jurisdictional Payment · p. 26
10.1.5 Domestic Claims Processing Jurisdictions · p. 27
10.1.5.1 Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN) · p. 27
10.1.5.2 Supplier of Portable X-Ray, EKG, or Similar Portable Services
10.1.5.3 Ambulance Services Submitted to Carriers · p. 28
10.1.5.4 Independent Laboratories · p. 29
10.1.5.4.1 Cases Involving Referral Laboratory Services · p. 29
10.1.6 Railroad Retirement Beneficiary Carrier · p. 30
10.1.7 Welfare Carriers · p. 31
10.1.9 Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC · p. 31
10.1.9.1 An A/B MAC (B) Receives a Claim for Services that are in Another A/B MAC (B)'s Payment Jurisdiction · p. 32
10.1.9.2 An A/B MAC (B) Receives a Claim for Services that are in a DME MAC's Payment Jurisdiction · p. 32
10.1.9.3 A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carrier's Payment Jurisdiction · p. 33
10.1.9.4 An A/B MAC (B) Receives a Claim for an RRB Beneficiary · p. 33
10.1.9.5 An A/B MAC (B) or DME MAC Receives a Claim for a UMWA Beneficiary · p. 34
10.1.9.6 Medicare Carrier or RRB-Named Carrier to Welfare Carrier · p. 34
10.1.9.7 Protests Concerning Transfer of Requests for Payment to Carrier · p. 34
10.1.9.8 Transfer of Claims Material Between Carrier and Intermediary (FI) · p. 34
10.1.9.9 A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction · p. 35
10.2 FI Jurisdiction of Requests for Payment · p. 35
10.2.1 FI Payment for Emergency and Foreign Hospital Services · p. 36
10.3 Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider · p. 37
10.4 Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority · p. 38
10.5 Claims Processing Requirements for Deported Beneficiaries · p. 41
10.5.1 Implementation of Payment Policy for Deported Beneficiaries · p. 42

20 Provider Assignment to FIs and MACs · p. 43 · 3 subsections

Open section 20 in the PDF
20.1 FI Service to HHAs and Hospices
20.2 Provider Change of Ownership (CHOW) · p. 46
20.3 CMS No Longer Accepts Provider Requests to Change Their FI · p. 47

30 Provider Participation · p. 47 · 44 subsections

Open section 30 in the PDF
30.1 Content and Terms of Provider Participation Agreements · p. 48
30.1.1 Provider Charges to Beneficiaries · p. 48
30.1.1.1 Charges to Hold a Bed During SNF Absence · p. 49
30.1.2 Provider Refunds to Beneficiaries · p. 50
30.1.3 Provider Treatment of Beneficiaries · p. 51
30.2 Assignment of Provider's Right to Payment · p. 51
30.2.1 Exceptions to Assignment of Provider's Right to Payment - Claims Submitted to A/B MACs · p. 52
30.2.2 Background and Purpose of Reassignment Rules - Claims Submitted to B/MACs · p. 53
30.2.2.1 Reassignments by Nonphysician Suppliers - Claims · p. 56
30.2.3 Effect of Payment to Ineligible Recipient · p. 56
30.2.4 Payment to Agent - Claims Submitted to Carriers · p. 57
30.2.5 Payment to Bank · p. 58
30.2.6 Payment to Employer of Physician - Carrier Claims Only · p. 59
30.2.7 Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only · p. 60
30.2.8.2 University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers · p. 60
30.2.8.3 Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B · p. 61
30.2.9 Payment to Physician or Other Supplier for Purchased Diagnostic Tests Subject to the Anti-Markup Payment Limitation-Claims Submitted to A/B MACs (Part B) · p. 63
30.2.10 Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACs Part B · p. 66
30.2.11 Payment Under Fee-For-Time Compensation Arrangements (formerly referred to as Locum Tenens Arrangements) - Claims Submitted to A/B MACs Part B · p. 70
30.2.12 Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims · p. 74
30.2.13 Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC Part B Processed Claims · p. 75
30.2.14 Correcting Unacceptable Payment Arrangements · p. 76
30.2.14.1 Questionable Payment Arrangements · p. 79
30.2.15 Sanctions for Prohibited Payment Arrangement · p. 80
30.2.16 Prohibition of Assignments by Beneficiaries
30.3 Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims · p. 84
30.3.1 Mandatory Assignment on Carrier Claims · p. 84
30.3.1.1 Processing Claims for Services of Participating Physicians or Suppliers · p. 87
30.3.2 Nature and Effect of Assignment on Carrier Claims · p. 87
30.3.3 Physician's Right to Collect From Enrollee on Assigned Claim Submitted to Carriers · p. 89
30.3.4 Effect of Assignment Upon Rental or Purchase of Durable Medical Equipment on Claims Submitted to Carriers · p. 91
30.3.5 Effect of Assignment Upon Purchase of Cataract Glasses From Participating Physician or Supplier on Claims Submitted to Carriers · p. 92
30.3.6 Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers · p. 93
30.3.7 Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B)
30.3.8 Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers · p. 97
30.3.9 Filing Claims to a Carrier for Nonassigned Services · p. 97
30.3.10 Carrier Submitted Bills by Beneficiary · p. 98
30.3.11 Carrier Receipted Bill - Definition · p. 98
30.3.12 Carrier Annual Participation Program · p. 99
30.3.12.1 Annual Open Participation Enrollment Process · p. 104
30.3.12.1.2 Annual Medicare Physician Fee Schedule File Information · p. 119
30.3.12.2 Carrier/MACs Participation Agreement · p. 119
30.3.12.3 Carrier Rules for Limiting Charge · p. 121
30.3.13 Charges for Missed Appointments · p. 122

40 Termination of Provider Agreement · p. 123 · 15 subsections

Open section 40 in the PDF
40.1 Voluntary Termination
40.1.1 Close of Business · p. 124
40.1.2 Change of Ownership · p. 125
40.1.3 Expiration and Renewal-Nonrenewal of SNF Term Agreements · p. 126
40.2 Involuntary Terminations · p. 127
40.2.1 Processing Involuntary Terminations · p. 128
40.2.2 FI Report on Provider Deficiencies · p. 128
40.2.2.1 Subsequent Communications With Provider
40.3 Readmission to Medicare Program After Involuntary Termination · p. 129
40.3.1 Effective Date of Provider Agreement · p. 129
40.3.2 Fiscal Considerations in Provider Readmission to Medicare Program After Involuntary Termination · p. 130
40.4 Payment for Services Furnished After Termination, Expiration, or Cancellation of Provider Agreement · p. 131
40.4.1 Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions · p. 132
40.4.2 Status of Hospital or SNF After Termination, Expiration, or Cancellation of Its Agreement · p. 133
40.5 FI/Carrier/DMERC Responsibilities for Informing Providers of Changes · p. 134

50 Filing a Request for Payment With the Carrier or FI · p. 134 · 17 subsections

Open section 50 in the PDF
50.1 Request for Payment From the Carrier or FI · p. 135
50.1.1 Billing Form as Request for Payment · p. 135
50.1.2 Beneficiary Request for Payment on Provider Record - ASC X12 837 Institutional Claim Format and Form CMS-1450 · p. 135
50.1.3 Signature on the Request for Payment by Someone Other Than the Patient · p. 136
50.1.4 Request for Payment as a Claim for HI Entitlement · p. 138
50.1.5 Refusal by Patient to Request Payment Under the Program · p. 139
50.1.6 When Beneficiary Statement is Not Required for Physician/Supplier Claim · p. 140
50.1.7 Definition of a Claim for Payment
50.1.8 Establishing Date of Filing - Postmark Date - Carriers · p. 143
50.2 Frequency of Billing for Providers · p. 144
50.2.1 Inpatient Billing From Hospitals and SNFs · p. 144
50.2.2 Frequency of Billing for Providers Submitting Institutional Claims With Outpatient Services · p. 146
50.2.3 Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment · p. 150
50.2.4 Reprocess Inpatient or Hospice Claims in Sequence · p. 151
50.3 When an Inpatient Admission May Be Changed to Outpatient Status · p. 152
50.3.1 Background · p. 152
50.3.2 Policy and Billing Instructions for Condition Code 44 · p. 154

60 Provider Billing of Non-covered Charges on Institutional Claims · p. 156 · 15 subsections

Open section 60 in the PDF
60.1 General Information on Non-covered Charges on Institutional Claims · p. 156
60.1.1 Basic Payment Liability Conditions · p. 158
60.1.2 Billing Services Excluded by Statute · p. 164
60.1.3 Claims with Condition Code 21 · p. 165
60.1.3.1 Provider-liable Fully Noncovered Outpatient Claims · p. 166
60.2 Noncovered Charges on Inpatient Bills · p. 166
60.2.1 Billing for Noncovered Procedures in an Inpatient Stay · p. 167
60.3 Noncovered Charges on Institutional Demand Bills · p. 168
60.3.1 Background on Institutional Demand Bills (Condition Code 20) · p. 168
60.3.2 Inpatient and Outpatient Demand Billing Instructions · p. 169
60.4 Noncovered Charges on Outpatient Bills · p. 171
60.4.1 Outpatient Billing With an ABN (Occurrence Code 32) · p. 172
60.4.2 Line-Item Modifiers Related to Reporting of Non-covered Charges When Covered and Non-covered Services Are on the Same Outpatient Claim · p. 173
60.4.3 Liability Considerations for Bundled Services · p. 179
60.5 Coding That Results from Processing Noncovered Charges · p. 179

70 Time Limitations for Filing Part A and Part B Claims · p. 183 · 26 subsections

Open section 70 in the PDF
70.1 Determining Start Date of Timely Filing Period--Date of Service · p. 183
70.2 Definition of a Claim for Payment · p. 183
70.2.1 Appropriate Medicare Contractor · p. 184
70.2.2 Form Prescribed by CMS · p. 184
70.2.3 In Accordance with CMS Instructions · p. 184
70.2.3.1 Incomplete or Invalid Submissions · p. 185
70.2.3.2 Handling Incomplete or Invalid Submissions · p. 186
70.3 Determining End Date of Timely Filing Period—Receipt Date · p. 187
70.4 Determination of Untimely Filing and Resulting Actions · p. 188
70.5 Application to Special Claim Types · p. 188
70.6 Filing Claim Where General Time Limit Has Expired · p. 189
70.7 Exceptions Allowing Extension of Time Limit · p. 189
70.7.1 Administrative Error · p. 191
70.7.2 Retroactive Medicare Entitlement · p. 192
70.7.3 Retroactive Medicare Entitlement Involving State Medicaid Agencies · p. 193
70.7.4 Retroactive Disenrollment from a Medicare Advantage Plan or Program of All-Inclusive Care for the Elderly (PACE) Provider Organization · p. 194
70.8 Filing Request for Payment to Carriers—Medicare Part B · p. 195
70.8.1 Splitting Claims for Processing · p. 195
70.8.2 Replicating Claims for Processing · p. 198
70.8.3 Methods of Claiming Benefits for Services by Physicians and Suppliers · p. 198
70.8.4 Claims Forms CMS-1490S and CMS-1500 · p. 199
70.8.5 Photocopies · p. 200
70.8.6 Penalty for Filing Claims after One Year · p. 200
70.8.6.1 Monitoring Claims Submission Violations · p. 201
70.8.6.2 Notification Letters · p. 206
70.8.6.3 Violations That Are Not Developed For Referral · p. 207

80 Carrier and FI Claims Processing Timeliness · p. 207 · 21 subsections

Open section 80 in the PDF
80.1 Control and Counting Claims · p. 207
80.2 Definition of Clean Claim · p. 208
80.2.1 Receipt Date · p. 209
80.2.1.1 Payment Ceiling Standards · p. 210
80.2.1.2 Payment Floor Standards · p. 211
80.2.2 Interest Payment on Clean Non-PIP Claims Not Paid Timely · p. 212
80.2.2.1 Determining and Paying Interest · p. 214
80.2.2.2 Preparation of IRS Form 1099-INT · p. 215
80.3 Other Claims (other than clean) · p. 215
80.3.1 Incomplete or Invalid Claims Processing Terminology · p. 216
80.3.2 Handling Incomplete or Invalid Claims · p. 217
80.3.2.1.1 A/B MAC (B) Data Element Requirements · p. 222
80.3.2.1.2 Conditional Data Element Requirements for A/B MACs (B) and DME MACs · p. 226
80.3.2.1.3 A/B MAC (B) Specific Requirements for Certain Specialties/Services · p. 231
80.3.2.2 Consistency Edits for Institutional Claims · p. 235
80.3.3 Timeliness Standards for Processing Other-Than-Clean Claims · p. 246
80.4 Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment) · p. 247
80.5 Do Not Forward Initiative (DNF) · p. 249
80.5.1 Carrier DNF Requirements · p. 249
80.5.1.1 Reporting Requirements - Carriers · p. 251
80.6 Processing All Diagnosis Codes Reported on Claims Submitted to Carriers · p. 257

90 Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period · p. 257

Open section 90 in the PDF

91 Moral and Religious Fee for Service Claims for Medicare Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans · p. 258

Open section 91 in the PDF

100 Medicare as a Secondary Payer · p. 258

Open section 100 in the PDF

110 Provider Retention of Health Insurance Records · p. 259 · 4 subsections

Open section 110 in the PDF
110.1 Categories of Health Insurance Records to Be Retained · p. 259
110.2 Microfilming Records · p. 260
110.3 Retention Period · p. 260
110.4 Destruction of Records · p. 260

120 Detection of Duplicate Claims · p. 260 · 3 subsections

Open section 120 in the PDF
120.1 Overview · p. 261
120.2 Exact Duplicates · p. 261
120.3 Suspect Duplicates · p. 264

130 Adjustments and Late Charges · p. 265 · 18 subsections

Open section 130 in the PDF
130.1 General Rules for Submitting Adjustment Requests · p. 265
130.1.1 Adjustment Bills Involving Time Limitation for Filing Claims · p. 266
130.1.2 Claim Change Reasons · p. 267
130.1.2.1 Claim Change Reason Codes · p. 267
130.1.2.2 Edits on Claim Change Reason Codes · p. 268
130.1.2.3 Additional Edits · p. 269
130.1.3 Late Charges · p. 270
130.2 Inpatient Part A Hospital Adjustment Bills · p. 272
130.2.1 Tolerance Guidelines for Submitting Inpatient Part A Hospital · p. 273
130.3 SNF Part A Adjustments · p. 273
130.3.1 Tolerance Guides for Submitting SNF Inpatient Adjustment Requests · p. 274
130.3.2 SNF Inpatient Claim Adjustment Instructions · p. 275
130.3.3 Patient Does Not Return From SNF Leave of Absence, and Last Bill Reported Patient Status as Still Patient (30) · p. 275
130.4 Hospital and SNF Part B Adjustment Requests · p. 276
130.4.1 Guidelines for Submitting Adjustment Requests · p. 276
130.5 Home Health Adjustments · p. 276
130.6 Adjustments to Reprocess Certain Claims Denied Due to an Open Common Working File (CWF) Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record Was Subsequently Deleted or Terminated · p. 277
130.7 MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims · p. 279

140 Fiscal Intermediary (FI) Edits Affecting Multiple Bill Types · p. 279 · 3 subsections

Open section 140 in the PDF
140.1 Threshold Edit for Outpatient and Inpatient Part B Claims · p. 279
140.2 Systematic Validation of Claims Information Using Patient Assessments · p. 280
140.3 Verification Edit for Claims with OPPS Payments · p. 281

150 Limitation of Liability Notification and Coordination With Quality Improvement Organizations (QIOs) · p. 281 · 11 subsections

Open section 150 in the PDF
150.1 Limitation on Liability - Overview · p. 282
150.2 Hospital Claims Subject to Hospital Issued Notices of Noncoverage · p. 283
150.2.1 Scope of Issuance of Hospital Issued Notices of Noncoverage (HINNs) · p. 283
150.2.2 General Responsibilities of QIOs and A/B MACs (A) Related to HINNs · p. 283
150.2.3 Billing and Claims Processing Requirements Related to HINNs · p. 284
150.3 Skilled Nursing Facility (SNF), Home Health Agency (HHA), Hospice and Comprehensive Outpatient Rehabilitation Facility (CORF) Claims Subject to Expedited Determinations · p. 284
150.3.1 Scope of Issuance of Expedited Determination Notices · p. 284
150.3.2 General Responsibilities of QIOs and A/B MACs (A) Related to Expedited Determinations · p. 285
150.3.3 Billing and Claims Processing Requirements Related to Expedited Determinations · p. 286
150.4 General Responsibilities of QIOs and A/B MACs (A) Related to Expedited Determinations Based on Medicare Change of Status Notifications (MCSNs) · p. 288
150.4.1 Billing and Claims Processing Requirements Related to Expedited · p. 290

160 Identifying Institutional Providers · p. 291 · 1 subsections

Open section 160 in the PDF
160.1 Reporting of Taxonomy Codes (Institutional Providers) · p. 291

170 Payment Bases for Institutional Claims · p. 293 · 2 subsections

Open section 170 in the PDF
170.1 Services Paid on the Medicare Physician Fee Schedule (MPFS) · p. 294
170.1.1 Payments on the MPFS for Providers With Multiple Service Locations · p. 296

180 Denial of Claims Due to Violations of Physician Self-Referral Prohibition · p. 296 · 2 subsections

Open section 180 in the PDF
180.1 Background and Policy · p. 296
180.2 Denial Code · p. 297

190 Payer Only Codes Utilized by Medicare · p. 297

Open section 190 in the PDF

200 Qualified Medicare Beneficiary (QMB) · p. 304

Open section 200 in the PDF

210 Medicare Beneficiary Date of Death-Background · p. 305 · 4 subsections

Open section 210 in the PDF
210.1 How to Correct Incorrect Dates in Medicare Records · p. 306
210.1.1 Healthcare Provider Errors · p. 306
210.1.2 Date of Death Submitted by Family Member or Authorized Agent · p. 307
210.1.3 Social Security Administration (SSA) or Railroad Retirement Board (RRB) Errors · p. 307

Using this chapter in a denial or appeal

Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.

When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.

How QuickIntell works with Claims Processing Manual chapter 1

QuickRCM covers eligibility, claim readiness, denials, posting and A/R with configurable automation and human review, which is where the billing rules in this chapter are checked before a claim goes out. QuickCode supports qualified coder review of the coding and modifier questions the chapter answers.

See QuickRCM for claim readiness See QuickCode for coder review Book a meeting

Frequently asked questions: chapter 1

What is the Medicare timely filing limit?

Under chapter 1 section 70 of Pub. 100-04 and 42 CFR 424.44, a fee-for-service claim must be filed within 12 months, or one calendar year, after the date of service. Section 70.7 lists the exceptions that allow a later filing.

How soon does Medicare pay a clean claim?

Chapter 1 section 80.2.1.2 sets a payment floor: an electronic clean claim cannot be paid before the 14th day after receipt and a paper claim before the 27th day. Contractors must also pay within the payment ceiling or owe interest.

Does chapter 1 cover Medicare Secondary Payer?

Only briefly. Section 100 points to the Medicare Secondary Payer Manual (Pub. 100-05), which holds the detailed rules for when another insurer pays first.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Medicare Claims Processing Manual, Chapter 1: General Billing Requirements
Version Rev. 13826, issued 2026-06-11 · effective 2026-07-13 · file clm104c01.pdfSHA-256 cb02b00d48ef0b57…
Medicare Claims Processing Manual (Pub. 100-04)
Version 39 chapter PDFs; newest revision Rev. 13836 (chapter 14), issued 2026-06-24 · effective 2026-09-27 · file 100-04-claims-processing-manual/*.pdf (39 chapters; SHA-256 of their sha256sum listing)SHA-256 f87bc3bcd9d1570d…

Disclaimer

This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.

Medicare Claims Processing Manual Chapter 1: General Billing Requirements