Medicare rule pack
Every finding cites a published rule
Medicare comes first because its rules are public: each finding can link to the CMS or Medicare Administrative Contractor page it comes from, with its effective date. Each rule is drafted from the policy text with the exact quote; every rule is flag-only, and a billing or coding expert agrees each one before it runs.
| Rule | What it checks | Source | Needs | State |
|---|---|---|---|---|
| Medicare ID | The Medicare Beneficiary Identifier is present and in a valid format | CMS MBI format | Order | Approved |
| Diagnosis present and billable | An ICD-10-CM code is on the order and is billable in the current code set | ICD-10-CM FY2027 | Order | Approved |
| Not screening-only | The order isn't billed on a screening diagnosis alone where screening isn't covered | CMS coverage rules | Order | Approved |
| Ordering provider enrolled | The ordering provider has an individual NPI and is enrolled to order for Medicare | CMS Order and Referring file | Order | Approved |
| Lab NCDs | The diagnosis supports the test under the national coverage determinations for lab tests | CMS lab NCD code files, Oct 2026 | CPT codes, diagnosis | Draft |
| Units per day | Units per code per day stay within the medically unlikely edit | CMS MUE, quarterly | CPT units | Draft |
| Plan type | Medicare entered but the patient is on Medicare Advantage; Medigap billed as primary | Eligibility response, card on the scan | Scan, eligibility | In build |
| Commercial plan, Medicare age | A commercial plan billed for a patient of Medicare age | Payer rules | Order | Draft |
| Urine drug testing | No standing orders, drugs named, frequency limits, diagnosis codes not pre-printed by the lab | LCD L35006 | Scan, history | Planned |
| Vitamins | Screening not covered; vitamin D, B12 and folate limited to 3 a year | LCD L34914 | History | Planned |
| Signature | The order's signature or documented intent to order is present where the rule requires it | CMS and contractor guidance | Scan | Approved |
| ABN needed | The test is likely not covered for this diagnosis, so an ABN is needed | Derived from the rules above | All of the above | Planned |
| Timely filing | The claim can still be filed within 12 months of the date of service | CMS timely filing rule | Collection date | Planned |
States: Approved rules are written and signed off; some run once their data source is connected (the signature rule needs scan reads). Draft rules are written and waiting on data or review. Rule files are refreshed each quarter, when CMS publishes new NCD and MUE files.
Eligibility findings
What the payer's own answer adds
Each eligibility check is read for the order's date of service.
| Finding | Grade | Fix owner |
|---|---|---|
| Part B not active on the date of service | Likely denial | Accessioning |
| Medicare entered; patient enrolled in Medicare Advantage | Fix before billing | Accessioning |
| Another insurer pays before Medicare | Fix before billing | Accessioning |
| Member ID, name or date of birth doesn't match | Fix before billing | Accessioning |
| Other coverage not entered | Fix before billing | Accessioning |
| Preventive test before its next eligible date | ABN needed or Likely denial | Clinic, client services |
| QMB patient: never bill the patient for coinsurance or deductible | Note | Billing |
| Hospice election active: tests for the terminal condition go to the hospice | Review | Billing |
| Payer or check unavailable | Unverified | Retried automatically |