Cross-Market Regulatory Atlas

Foundational claim-billing requirements for Medicare Part B FFS; baseline 837/UB-04 conformance.

UB-04 / 837I billing requirements for inpatient stays; DRG assignment, principal vs. other diagnoses, POA flags.

Physician fee schedule (PFS), RVU methodology, professional-claim coding requirements.

Defines the scope of covered Medicare benefits; medical-necessity baseline.

Binding national coverage decisions for specific procedures, devices, drugs.

When patient ≥65 and covered by employer GHP with >20 covered lives, GHP pays primary and Medicare pays secondary.

MAC / RAC / SMRC / UPIC medical-review processes; documentation requirements.

National Correct Coding Initiative bundles preventing payment for code pairs that should not be reported together.

Per-line maximum units of service that Medicare will pay for a single HCPCS / CPT code on a single date of service.

Covered entities must safeguard PHI; minimum-necessary use; patient access rights.

Administrative, physical, technical safeguards for ePHI; breach-notification requirements.

Group health plans must provide MH/SUD benefits at parity with med/surg benefits; NQTL parity testing.

Mandatory timing for adverse-benefit determinations; appeal/review rights for ESI plans.

Bans balance billing for emergency services + non-emergency at in-network facilities; IDR process for OON disputes.

Hospitals must publish standard charges + 300-shoppable-services list; payers publish negotiated rates via MRF.

HIPAA-mandated EDI transaction sets for claims (837), remittance (835), eligibility (270/271), claim status (276/277).