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pdf1a - Inpatient Hospital-Acute - Page 1
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1a - Inpatient Hospital-Acute - Page 2
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1a - Inpatient Hospital-Acute - Page 3
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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1a - Inpatient Hospital-Acute - Page 4
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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1a - Inpatient Hospital-Acute - Page 5
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 5 of 170
1a - Inpatient Hospital-Acute - Page 6
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
Page 6 of 170
1a - Inpatient Hospital-Acute - Page 7
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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1a - Inpatient Hospital-Acute - Page 8
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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1a - Inpatient Hospital-Acute - Page 9
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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1a - Inpatient Hospital-Acute - Page 10
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1a1 – Additional Days for Inpatient Hospital-Acute - Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1a1 - Additional Days for Inpatient Hospital-Acute - Page 2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1a2 - Non-Medicare Covered Stay for Inpatient Hospital-Acute - Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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CY 2025 PBP Data Entry System Screens
1a2 - Non-Medicare Covered Stay for Inpatient Hospital-Acute – Page 2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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CY 2025 PBP Data Entry System Screens
1a3 – Upgrades for Inpatient Hospital-Acute
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CY2025 PBP – Benefit Service Categories 1-10
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 3
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 4
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 5
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 6
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CY2025 PBP – Benefit Service Categories 1-10
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CY 2025 PBP Data Entry System Screens
1b - Inpatient Hospital-Psychiatric - Page 7
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b1 - Additional Days for Inpatient Hospital-Psychiatric -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b1 - Additional Days for Inpatient Hospital-Psychiatric -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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CY 2025 PBP Data Entry System Screens
1b1 - Additional Days for Inpatient Hospital-Psychiatric -Page 3
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b1 - Additional Days for Inpatient Hospital-Psychiatric - Page 4
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b2 - Non-Medicare-Covered Stay for Inpatient Hospital Psychiatric - Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
1b2 - Non-Medicare-Covered Stay for Inpatient Hospital Psychiatric - Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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2 - Skilled Nursing Facility - Page 1
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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2 - Skilled Nursing Facility - Page 2
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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2 - Skilled Nursing Facility - Page 3
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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2 - Skilled Nursing Facility - Page 4
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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2 - Skilled Nursing Facility - Page 5
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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2 - Skilled Nursing Facility - Page 6
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
2-1 - Additional Days for Skilled Nursing Facility -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
2-1 - Additional Days for Skilled Nursing Facility -Page -2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
2-1 - Additional Days for Skilled Nursing Facility - Page-3
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
2-2 - Non-Medicare-Covered Stay for Skilled Nursing Facility -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
2-2 - Non-Medicare-Covered Stay for Skilled Nursing Facility -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
CMS SENSITIVE INFORMATION - REQUIRES SPECIAL HANDLING
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CY 2025 PBP Data Entry System Screens
3 - Cardiac and Pulmonary Rehabilitation Services
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3-1 - Cardiac Rehabilitation Services -Page 1
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3-1 - Cardiac Rehabilitation Services -Page 2
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CY 2025 PBP Data Entry System Screens
3-2 - Intensive Cardiac Rehabilitation Services - Page 1
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CY 2025 PBP Data Entry System Screens
3-2 - Intensive Cardiac Rehabilitation Services - Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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3-3 - Pulmonary Rehabilitation Services - Page 1
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CY 2025 PBP Data Entry System Screens
3-3 - Pulmonary Rehabilitation Services -Page 2
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3-4 - SET for PAD Services -Page 1
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
12/29/2023
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3-4 - SET for PAD Services -Page 2
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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CY 2025 PBP Data Entry System Screens
3-1 - Additional Cardiac Rehabilitation Services - Page 1
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CY2025 PBP – Benefit Service Categories 1-10
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3-1 - Additional Cardiac Rehabilitation Services -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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CY 2025 PBP Data Entry System Screens
3-2 - Additional Intensive Cardiac Rehabilitation Services -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
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3-2 - Additional Intensive Cardiac Rehabilitation Services -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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3-3 - Additional Pulmonary Rehabilitation Services -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
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3-3 - Additional Pulmonary Rehabilitation Services -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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3-4 Additional SET for PAD Services -Page 1
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CY2025 PBP – Benefit Service Categories 1-10
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3-4 Additional SET for PAD Services -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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4a Emergency Services -Page 1
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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4a Emergency Services -Page 2
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CY 2025 PBP Data Entry System Screens
CY2025 PBP – Benefit Service Categories 1-10
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4b - Urgently Needed Services -Page 1
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CY 2025 PBP Data Entry System Screens
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CY 2025 PBP Data Entry System Screens
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4b - Urgently Needed Services -Page 3
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CY 2025 PBP Data Entry System Screens
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4c - Worldwide Emergency /Urgent Coverage -Page 1
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4c1 - Worldwide Emergency Coverage
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4c2 - Worldwide Urgent Coverage
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CY 2025 PBP Data Entry System Screens
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4c3 - Worldwide Emergency Transportation
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5 - Partial Hospitalization -Page 1
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5 - Partial Hospitalization -Page 2
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CY 2025 PBP Data Entry System Screens
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5 - Partial Hospitalization -Page 3
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CY 2025 PBP Data Entry System Screens
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6 -Home Health Services-Page 1
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CY 2025 PBP Data Entry System Screens
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6 -Home Health Services-Page 2
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6 -Home Health Services-Page 3
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6-1 Additional Hours of Care -Page 1
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6-2 Personal Care Services -Page 1
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6-2 Personal Care Services -Page 2
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7b – Chiropractic Services -Page 1
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7b1 – Routine Chiropractic Care -Page 1
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7b2 – Other Chiropractic Care -Page 1
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7c - Occupational Therapy Services -Page 1
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7c - Occupational Therapy Services -Page 3
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7d - Physician Specialist Services – Page 1
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7e - Mental Health Specialty Services -Page 1
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7e - Individual Sessions for Mental Health Specialty Services
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7e - Group Sessions for Mental Health Specialty Services
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7f - Podiatry Services -Page 1
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7f - Podiatry Services -Page 2
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7f - Podiatry Services -Routine Foot Care -Page 1
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7f - Podiatry Services -Routine Foot Care -Page 2
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7f - Podiatry Services -Routine Foot Care -Page 3
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7g - Other Health Care Professional -Page 1
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7g - Other Health Care Professional -Page 2
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7g - Other Health Care Professional -Page 3
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7h - Psychiatric Services -Page 1
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7h - Psychiatric Services -Page 2
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CY2025 PBP – Benefit Service Categories 1-10
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7hi - Individual Sessions for Psychiatric Services
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7h2 - Group Sessions for Psychiatric Services
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7i - Physical Therapy and Speech -Language Pathology Services -Page 1
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7i - Physical Therapy and Speech -Language Pathology Services -Page 2
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7i - Physical Therapy and Speech -Language Pathology Services -Page 3
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7j - Additional Telehealth Benefits -Page 1
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7j - Additional Telehealth Benefits -Page 2
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7j - Additional Telehealth Benefits -Page 3
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7k - Opioid Treatment Program Services -Page 1
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7k - Opioid Treatment Program Services -Page 2
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7k - Opioid Treatment Program Services -Page 3
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8a - Diagnostic Procedures /Tests/Lab Services -Page 1
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8a - Diagnostic Procedures /Tests/Lab Services -Page 2
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8a1 - Diagnostic Procedures /Tests -Page 1
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8a2 - Lab Services -Page 1
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8a2 - Lab Services -Page 2
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8b - Outpatient Diagnostic /Therapeutic Radiological Services -Page 1
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8b3 - Outpatient X-Ray Services -Page 1
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9a1 - Outpatient Hospital Services -Page 1
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9a2 - Observation Services -Page 1
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9b - Ambulatory Surgical Center (ASC) Services -Page 1
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9b - Ambulatory Surgical Center (ASC) Services – Page 2
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9b - Ambulatory Surgical Center (ASC) Services -Page 3
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9c - Outpatient Substance Abuse -Page 1
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9c - Outpatient Substance Abuse -Page 2
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9c - Outpatient Substance Abuse -Page 3
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9c1 - Individual Sessions for Outpatient Substance Abuse
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9c2 - Group Sessions for Outpatient Substance Abuse
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9d - Outpatient Blood Services
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9d - Three (3) pint Deductible Waived -Page 1
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9d - Three (3) pint Deductible Waived -Page 2
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10a - Ambulance Services
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10a1 - Ground Ambulance Services -Page 1
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10a1 - Ground Ambulance Services -Page-2
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10a2 - Air Ambulance Services -Page 1
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10b1 - Transportation Services -Plan Approved Health-related Location -Page 1
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10b2 - Transportation Services -Any Health-Related Locations -Page 1
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10b2 - Transportation Services -Any Health-Related Locations -Page 3
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| File Type | application/pdf |
| File Title | CY 2025 PBP Data Entry System Screens |
| Author | CMS |
| File Modified | 2023-12-14 |
| File Created | 2023-12-12 |