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CMS Division of Institutional Claims Processing

CMS Division of Institutional Claims Processing 2025

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The document outlines the Change Request Process for the Health Insurance Prospective Payment System (HIPPS) Code Set managed by the CMS Division of Institutional Claims Processing. It details the responsibilities of the division in creating and maintaining HIPPS codes, the frequency of updates, and the procedure for submitting change requests. The process includes requirements for request submissions, CMS review procedures, and communication of decisions regarding code changes. The document emphasizes the importance of ensuring no duplication of codes and assessing potential impacts on other payers and systems.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is an institutional provider CMS?

An institutional provider refers to a hospital, a critical care facility, a skilled nursing facility, a home health agency or hospice or another similar institution providing services to Medicare beneficiaries.

Who is the organization that processes Medicare claims for CMS?

Coordination of Benefits Overview The Medicare Administrative Contractors, (MACs), intermediaries, and carriers are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.

What is the difference between CMS 1500 and 837?

What are the 837P and Form CMS-1500? The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed.

What is an example of an institutional claim?

Any surgical operation is another example of an institutional claim. The operating room, anesthetic, drugs, and any other supplies required during the treatment will be claimed by the hospital or healthcare provider.

What is the difference between institutional claims and professional claims?

The fundamental difference between professional billing and institutional billing is that professional billing is limited to the services provided by a physician or multiple physicians, whereas institutional covers all the charges related to interventions administrative charges during the patients stay in a hospital

What does CMS consider a provider?

A Medicare provider is a facility, supplier, physician, or other individual or organization that furnishes health care services. Under Medicaid, a provider is an individual, group, or agency that provides a covered Medicaid service to a Medicaid enrollee.

What is the difference between a provider and a supplier in CMS?

The term suppliers includes those who furnish goods and services used in care and treatment. Medicaid terminology, by contrast, uses provider generically to include all health care vendors. (See 42 CFR 431.107(a) and 433.37.) Medicare providers and suppliers are defined at 42 CFR 498.2.

CMS Division of Institutional Claims Processing 2025

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