(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 30 - Financial Liability Protections   Table of Contents  (Rev. 12423, 12- 20-23)  Transmittals for Chapter 30  10 - Financial Liability Protections (FLP) Provisions  20 - Limitation On Liability (LOL) Under 1879 Where Medicare Claims Are Denied  20.1 -   LOL Coverage Denials to Which the Limitation on Liability Applies  20.2 -  Denials When the LOL Provision Does Not Apply  20.2.1 -  Categorical Denials  30 - Determining Liability for Disallowed Claims Under 1879  30.1 -  Beneficiarys Knowledge and Liability  30.1.1 -  Other Evidence of Knowledge  30.2 -  Healthcare Provider or Supplier Knowledge and Liability  30.2.1 -  Evidence of Healthcare Provider or Supplier Knowledge  30.2.2 -  Medical Record Evidence of Healthcare Provider or Supplier Knowledge  30.2.3 -  Acceptable Standards of Practice  30.3  The Right to Appeal  30.4 -  Fraud, Abuse, Patently Unnecessary Items and Services  40 - Written Notice as Evidence of Knowledge  40.1 -  Sources of Written Notice  40.2 -  Written Notice Standards  40.2.1 -  Other Written Notice Standards  40.2.2 -  Written Notice Special Considerations   40.3 -  Medical Emergency or Otherwise Under Great Duress Situations   40.4-  Emergency Medical Treatment and Active Labor Act (EM TALA) Situations  50 -  Advance Beneficiary Notice of Non- coverage (ABN)  50.1 -  ABN Scope  50.2 -  ABN Uses   50.2.1 -  Optional ABN Uses  50.3 -  Issuance of the ABN  50.4 -  ABN Triggering Events  50.5 -  ABN Standards  50.6 -  Completing the ABN  50.7 -  Retention Requirements  50.8 -  ABN Delivery Requirements   50.8.1  Options for Delivery Other than In- Person  50.9 -  Effects of Lack of Notification, Medicare Review and Claim Adjudication  50.10 -  Using ABNs for Medical Equipment and Supplies Claims When Denials Under 1834(a)(17)(B) of the Act (Prohibition Against Unsolicited Telephone Contacts) Are Expected  50.11 -  ABNs for Medical Equipment and Supplies Claims Denied Under 1834(j)(1) of the Act (Because the Supplier Did Not Meet Supplier Number Requirements)  50.12 -  ABNs for Claims Denied in Advance Under 1834(a)(15) of the Act  50.13 -  ABN Standards for Upgraded Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)  50.14 -  ABNs for items listed in a DMEPOS Competitive Bidding Program (CBP)  50.15 -  Collection of Funds and Refunds   50.15.1 -  Physicians Services RR   50.15.2 -  DMEPOS RR Provision for Claims for Medical Equipment and Supplies   50.15.3  -  Time Limits and Penalties for Healthcare Providers and Suppliers in Making Refunds   50.15.4 -  Suppliers Right to Recover Resalable Items for Which Refund Has Been Made  50.16 -  CMS Regional Office (RO) Referral Procedures   50.17 -  ABN Special Considerations  60 - Home Health Change of Care Notice (HHCCN), Form CMS -10280  60.1 -  Background on the HHCCN  60.2 -  Scope of the HHCCN  60.3 -  Triggering Events for HHCCN/ Written Notice  60.4 -  Completing the HHCCN  60.5 -  HHCCN Delivery  70 - Skilled Nursing Facility Advance Beneficiary Notice of Non- coverage (SNF ABN)  70.1 -   SNF ABN Standards  70.2 -  Situations in Which a SNF ABN Should Be Given  70.3 - Situations in Which a SNF ABN Is Not Needed to Transfer Financial Liability to the Beneficiary  70.4 -  SNF ABN Specific Delivery Issues  70.5 -  Special Rules for SNF ABNs  70.6 -  Establishing When Beneficiary Is On Notice of Non- coverage  70.6.1 -  Source of Beneficiary Notification  80 - Hospital ABNs (Hospital- Issued Notices of Noncoverage -  HINN)  100 -  Indemnification Procedures for Claims Falling Within the Limitation on Liability Provision  100.1 -  Contractor and Social Security Office (SSO) Responsibility in Indemnification Claims  100.2 -  Conditions for Indemnification 100.3 -  Development and Documentation of Indemnification Requests  100.3.1 -  Proof of Payment  100.4 -  Beneficiary Requests Indemnification, but Had No Financial Interest in the Claim 100.5 -  Questionable Indemnification Requests Procedure  100.6 -  Determining the Amount of Indemnification 100.7 -  Notifying the Provider, Practitioner, or Supplier  100.8 -  Making Payment Under Indemnification  100.9 -  Limitation on Liability Determination Does Not Affect Medicare Exclusion 100.10 -  Exhibits  Exhibit 1 -  Letter to Provider  Exhibit 2 -  Letter to Beneficiary Who Requests Indemnification  Exhibit 3 -  Letter to Someone Other Than Beneficiary Who Requests Indemnification  Exhibit 4 -  Letter to Practitioner or Supplier (Noninstitutional Services)  Exhibit 5 -  Letter to Beneficiary Who Requests Indemnification (Noninstitutional Services)  Exhibit 6 -  Letter to Someone Other Than Beneficiary Who Requests Indemnification (Noninstitutional Services)  Exhibit 7 -  Statement of Claimant or Other Person  110 -  Contractor Instructions for Application of Limitation On Liability  110.1 -  Payment Under Limitation on Liability  110.2 -  When to Make Limitation on Liability Decisions  110.3 -  Preparation of Denial Notices  110.4 -  Bill Processing  110.5 -  Contractor Review of ABNs  110.5.1 -  General Rules  110.5.2 -  Situations in Which Contractor Review of ABNs is Indicated  110.5.3 -  Other Reasons for Contractor Request for Copies of ABNs  120 -  Contractor  Specific Instructions for Application of Limitation on Liability  120.1 -  Documentation of Notices Regarding Coverage  120.2 -  Availability of Coverage Notices to Operating Personnel  120.3 -  Applicability of Limitation on Liability Provision to Claims for Outpatient Physical Therapy Services Furnished by Clinics  120.4 -  Limitation on Liability Notices to Beneficiaries From Contractors  120.5 -  Contractor Redeterminaions or Reconsiderations in Assignment Cases Conducted at the Request of Either the Beneficiary or the Assignee  120.5.1 -  Guide Paragraphs for Contractor s to Use Where 1879 Is Applicable at Redetermination Level  130 -  A/B MAC (A) and (HHH) Specific Instructions for Application of Limitation on Liability  130.1 -  Applicability of the Limitation on Liability Provision to Claims for Ancillary, Outpatient Provider and Rural Health Clinic Services Payable Under Part B  130.1.1 -  Determining Beneficiary Liability in Claims for Ancillary and Outpatient Services  130.1.2 -  Determining Provider Liability in Claims for Ancillary and Outpatient Services  130.2 -  Prior Hospitalization and Transfer Requirements for SNF Coverage as Related to Limitation on Liability  130.3 -  Application of Limitation on Liability to SNF and Hospital Claims for Services Furnished in Noncertified or Inappropriately Certified Beds  130.4 -  Determining Liability for Services Furnished in a Noncertified SNF or Hospital Bed  140 -  Physician Refund Requirements (RR) Provision for Nonassigned Claims for Physicians Services Under 1842(l) -  Instructions for Contractor s and Physicians  140.1 -  Services Furnished Before October 1, 1987  140.2 -  Services Furnished Beginning October 1, 1987 140.3 -  Time Limits for Making Refunds  140.4 -  Situations Where a Refund Is Not Required 140.5 -  Appeal Rights  140.6 -  Processing Initial Denials  140.6.1 -  Initial Beneficiary Notices  140.6.2 -  Initial Physician Notices  140.7 -  Processing Beneficiary Requests for Appeal  140.8 -  Processing Physician Requests for Appeal  140.8.1 -  Appeal  of the Denial or Reduction in Payment  140.8.2 -  Beneficiary Given ABN and Agreed to Pay 140.8.3 -  Physician Knowledge  140.9 -  Guide Paragraphs for Inclusion in Appeal Determination  140.10 -  Physician Fails to Make Refund  140.11 -  OIG Referral Procedures  140.12 -  Imposition of Sanctions  150 -  DMEPOS Refund Requirements (RR) Provision for Claims for Medical Equipment and Supplies under 1834(a)(18), 1834(j)(4), and 1879(h) -  Instructions for Contractor s and Suppliers  150.1 -  Definition of Medical Equipment and Supplies  150.1.1 -  Unassigned Claims Denied on the Basis of the Prohibition on Unsolicited Telephone Contacts  150.1.2 -  Unassigned Claims Denied on the Basis of Not Being Reasonable and Necessary  150.1.3 -  Unassigned Claims Denied on the Basis of Failure of the Supplier to Meet Supplier Number Requirements  150.1.4 -  Assigned Claims Denied on the Basis of the Prohibition on Unsolicited Telephone Contacts  150.1.5 -  Assigned Claims Denied on the Basis of Failure of the Supplier to Meet Supplier Number Requirements  150.1.6 -  Assigned Claims Denied on the Basis of Not Being Reasonable and Necessary  150.2 -  Items and Services Furnished on an Unassigned Basis on or After January 1, 1995 150.3 -  Items and Services Furnished On an Assigned Basis On or After January 1, 1995 150.4 -  Time Limits for Making Refunds  150.5 -  Supplier Knowledge Standards for Waiver of Refund Requirement  150.5.1 -  Knowledge Standards for 1862(a)(1) Denials  150.5.2 -  Knowledge Standards for 1834(a)(15) Denials  150.5.2.1 -  Denial of Payment in Advance  150.5.2.2 -  When a Request for an Advance Determination of Coverage Is Mandatory  150.5.2.3 -  When a Request for an Advance Determination of Coverage Is Optional  150.5.2.4 -  Presumption for Constructive Notice  150.5.2.5 -  Presumption When Advance Determination was Requested  150.5.2.6 -  Presumption for Listed Overutilized Items  150.5.2.7 -  Presumption for Listed Suppliers  150.5.2.8 -  Presumption for Medical Necessity  150.5.2.9 -  Presumption About Beneficiary Knowledge  150.5.3 -  Knowledge Standards for 1834(a)(17)(B) Denials  150.5.4 -  Knowledge Standards for 1834(j)(1) Denials  150.5.5 -  Additional Knowledge Standards for All Medical Equipment and Supplies Denials  150.6 -  Advance Beneficiary Notice Standards for Waiver of Refund Requirement  150.7 -  Appeal Rights  150.8 -  Processing Initial Denials  150.9 -  Processing Beneficiary Requests for Appeal  150.10 -  Processing Supplier Requests for Appeal  150.10.1 -  Appeal  of the Denial of Payment  150.10.2 -  Beneficiary Given Advance Beneficiary Notice and Agreed to Pay 150.10.3 -  Supplier Knowledge  150.11 -  Guide Paragraphs for Inclusion in Appeal Determination 150.12 -  Supplier Fails to Make Refund  150.13 -  CMS Regional Office (RO) Referral Procedures  150.14 -  Imposition of Sanctions  150.15 -  Suppliers Right to Recover Resaleable Items for Which Refund Has Been Made  200 -  Expedited Determinations of Inpatient Hospital Discharges  200.1-   Statutory Authority 200.2 -  Scope  200.2.1 -  Exceptions  200.3 -  Important Message from Medicare (IM)  200.3.1 -  Alterations to the IM  200.3.2 -   Completing the IM  200.3.3 -  Hospital Delivery of the IM  200.3.4 -  Required Delivery Timeframes   200.3.4.1 First IM   200.3.4.2 Follow -up copy of the IM  200.3.5 -  Refusal to Sign the IM  200.3.6 -  Amending the Date of the IM  200.3.7 -  IM Delivery to Representatives  200.3.8 -  Notice Retention for the IM  200.4 -  Expedited Determination Process   200.4.1 -  Beneficiary Responsibilities