evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The A/B MACs (A) should take the following actions upon receipt of incomplete or invalid submissions:    If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.    If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.   If a conditional data element (a data element which is required when certain conditions exist) is not accurately entered in the appropriate field, RTP the submission to the provider of service.    If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of service of the following information:   o Beneficiarys Name;  o Medicare beneficiary identifier;  o Statement Covers Period (From -Through);  o Patient Control Number (only if submitted);  o Medical Record Number (only if submitted); and o Explanation of Errors.  NOTE: Some of the information listed above may in fact be the information missing from the submission. If this occurs, the A/B MAC (A) includes what is available.   If a submission is RTP for incomplete or invalid information, the A/B MAC (A) shall not report the submission on the MSN to the beneficiary. The notice must only be given to the provider or supplier.   Refer to the implementation guide for the current ASC X12 837 institutional claim format for specifications.  If a claim fails edits for any one of the content or size requirements, the A/B MAC (A) will RTP the submission to the provider of service.   NOTE:   The data element requirements in the implementation guide may be superseded by subsequent CMS instructions.  The CMS is continuously revising instructions to accommodate new data element requirements.
(Medicare Claims Processing Manual)
NOTE:   The data element requirements in the implementation guide may be superseded by subsequent CMS instructions.  The CMS is continuously revising instructions to accommodate new data element requirements.   The A/B MACs (A) must provide a listing of the required data elements, including a brief explanation to providers and suppliers.  A/B MACs (A) must educate providers regarding the distinction between submissions which are not considered claims, but which a re returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination.  Rejections may be corrected and re -submitted.   70.3 - Determining End Date of Timely Filing Period Receipt Date  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor.  At this point, the submission receives a perm anent receipt date that remains part of the claim record.  Once a submission (or claim) passes edits for completeness and validity described in 70.2 above, it is accepted into the Medicare claims processing system.   The receipt date has two functions. It is used for determining whether the claim was timely filed (see 70.4 below). The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary. (Se e 80 for details on determining claims processing timeliness.)   70.4 - Determination of Untimely Filing and Resulting Actions  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)
(Medicare Claims Processing Manual)
70.4 - Determination of Untimely Filing and Resulting Actions  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the From date, with the exception of the Through date for institutiona l claims that have span dates of services, as specified in 70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an initial determination.  As such, the determination that a claim was not filed timely is not subject to appeal.   Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provi der is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. In appropriate cases, suc h claims should be processed because of the spell -of-illness implications and/or in order to record the days, visits, cash and blood deductibles. The beneficiary is charged utilization days, if applicable for the type of services received.   70.5 - Application to Special Claim Types (Rev. 3537, Issued: 06- 08-16, Effective: 08 -08-16, Implementation: 08- 08-16)   Adjustments -  If a provider fails to include a particular item or service on its initial claim, an adjustment submission to include such an item(s) or service(s) is not permitted after the expiration of the time limitation for filing of the initial claim.  There is no longer timely filing period for adjustments.  There are special timeliness requirements for filing adjustment requests for inpatient services subject to a prospective payment system, if the adjustment results in a change to a higher weighted D RG.  These adjustments must be submitted within 60 days of the date of the remittance for the original claim, or the adjustment will be rejected.
(Medicare Claims Processing Manual)
 Reopenings -  However, to the extent that an adjustment bill otherwise corrects or supplements information previously submitted on a timely claim about specified services or items furnished to a specified individual, it is subject to the rules governing adm inistrative finality, rather than the time limitation for filing (see Chapter 34 on Re -openings).  These claims must be submitted with a Q in the 4th position of the Type of Bill to identify them as a Reopening.    Emergency Hospital Services and Services Outside the United States -  The time limit for claims for payment for emergency hospital services and hospital services outside the United States, whether or not the hospital has elected to bill the program, is the same as for participating hospitals.  (See 70.1 above.)  The claim for emergency hospital services and other services outside the United States will be considered timely filed if filed with any A/B MAC (A) within the time limit.    Home health Requests for Anticipated Payment (RAPs) -  Since by regulation RAPs are not claims for purposes of Title 18 of the Social Security Act, timely filing enforcement will be bypassed for any RAP for which the associated home health prospective payme nt system (HH PPS) claim could still be timely. RAPs for which the associated HH PPS claim could not still be timely will continue to be rejected, to prevent payment of RAP amounts that would be subject to recovery later.   70.6 - Filing Claim Where General Time Limit Has Expired  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.
(Medicare Claims Processing Manual)
As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.   Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in 70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.   Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no -payment bill processing instructions.) Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no -payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiarys view on these circumstances.    Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is  protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.   70.7 - Exceptions Allowing Extension of Time Limit  (Rev. 2477, Issued: 05- 25-12, Effective: 08 -27-12 Implementation: 08- 27-12)  Medicare regulations at 42 C.F.R. 424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:  (1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (S ee 70.7.1).
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(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished.  For example, at the time services were furnished the beneficiary was not entitled to Medic are.  However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).  (3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary.  For example, at t he time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare.  Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service.  The S tate Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired (See 70.7.3).  (4) Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All -inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier 6 months or more after the date the service was furnished (See 70.7.4).  The conditions for meeting each exception, and a description of how filing extensions will be calculated, are described in sections 70.7.1  70.7.4.  Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the pr ovider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database.  As explained in sections
(Medicare Claims Processing Manual)
pr ovider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database.  As explained in sections 70.7.1  70.7.4, the contractor will determine if the requirements for a particular exception are met.  However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision -making of the specific  exception request.  In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination.
(Medicare Claims Processing Manual)
70.7.1 - Administrative Error  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  Medicare regulations at 42 CFR 424.44 allow that where Medicare program error causes the failure of the provider or supplier to file a claim for payment within the time limit in 70.1 above, the time limit will be extended through the last day of the 6th calendar month following the month in which the error is rectified by notification to either the provider, supplier, or beneficiary.  In order to avoid having two extension of time triggers, contractors must notify the beneficiary and the provider or supplier in writing about the correction of the error on the same day.  Administrative error may include misrepresentation, delay, mistake, or other action of Medicare, or its contractors.  Contractors will not accept requests for extensions for such errors that extend beyond 4 years from the date of service.   The administrative error that prevents timely filing of the claim may affect the provider or supplier directly or indirectly, i.e., by preventing the beneficiary or his or her representative from filing a timely request for payment.  Situations in which fa ilure to file within the usual time limit will be considered to have been caused by administrative error include but are not limited to the following:     The failure resulted from misinformation from an employee, Medicare contractor, or agent of the Department acting within the scope of its authority, e.g., that certain services were not covered under Part A or Part B, although in fact they were covered.    The failure resulted from excessive delay by Medicare, or the Medicare contractor in furnishing information necessary for the filing of the claim.    The failure resulted from advice by an employee, Medicare contractor, or agent of the Department acting within the scope of its authority that precluded the filing of a claim until the provider or supplier receives certain information from the Medicare con tractor (e.g., a hospital following manual instructions does not file a billing for outpatient services where the services are expected to be paid for by workmens compensation; but the hospital learns after the expiration of the time limit of the ultimate  denial of workmens compensation liability).
(Medicare Claims Processing Manual)
 Any claim involving situations other than those listed above, where it appears that an extension of the time limit might be justified on the basis of administrative error, should be submitted by the appropriate Medicare claims processing contractor with a recommendation, before payment, to the appropriate CMS RO.  Contractors should consult with the appropriate RO.  ROs may in turn consult with CMS Central Office.   Where administrative error is alleged to be responsible for late filing, the necessary evidence would ordinarily include:    A statement from the beneficiary, his/her representative or the provider or supplier, depending on whom the error directly affected, as to how he/she learned of the error, and when it was corrected, and one of the following:    A written report by Medicare or the Medicare contractor describing how its error caused failure to file within the time limit; or    Copies of a CMS or Medicare contractor letter or other written notice reflecting the error, or    A written statement of an agency employee having personal knowledge of the error.   However, the statement of the beneficiary, his/her representative, or the provider or supplier is not essential if the other evidence establishes that his/her failure to file within the usual time limit resulted from administrative error, and that he/she f iled a claim within six months after the month in which he/she was notified that the error was corrected. There must be a clear and direct relationship between the administrative error and the late filing of the claim. Where the evidence is in the Medicare contractors own records, it should annotate the claims file to this effect.   If the claims processing contractor determines that a late claim should be honored because the facts support that an error or misrepresentation has caused the claim to be late, the provider, supplier, or beneficiary will have until the end of the 6th calendar month from the month in which the provider, supplier, or beneficiary received notification that the error or misrepresentation has been corrected.   70.7.2  Retroactive Medicare Entitlement  (Rev. 2477, Issued: 05- 25-12, Effective: 08 -27-12 Implementation: 08- 27-12)  The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:
(Medicare Claims Processing Manual)
The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:   (a) At the time the service was furnished the beneficiary was not entitled to Medicare.   (b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   Thus, a provider or supplier may have furnished services to an individual who was not entitled to Medicare.  More than a year later, the individual receives notification from SSA that he or she is entitled to Medicare benefits retroactive to or before the date he or she received services from the provider or supplier.  In this situation, the provider or supplier may submit a request for a filing extension to the appropriate Medicare claims processing contractor, as long as the provider or supplier submits s upporting documentation that verifies that the conditions above are met.  If the beneficiary and the provider or supplier is notified on different days about the beneficiarys retroactive Medicare entitlement, there will be two extensions of time triggers.  One extension of time trigger is when the beneficiary is first notified about the beneficiarys retroactive Medicare entitlement and the other extension of time trigger is when the provider or supplier is the first party notified of the beneficiarys retroactive Medicare entitlement. If the beneficiary is submitting the claim,  the time to file the claim is based on the day the beneficiary is first notified of the retroactive Medicare entitlement.  If the provider or supplier is submitting the claim, the time to file the claim is based on the day the provider or supplier is firs t notified of the retroactive Medicare entitlement.   Where retroactive Medicare entitlement is alleged, the provider, supplier, or beneficiary will need to provide the contractor with the following information:    an official Social Security Administration (SSA) letter notifying the beneficiary of Medicare entitlement and the effective date of the entitlement; and,    documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.
(Medicare Claims Processing Manual)
 documentation describing the service/s furnished to the beneficiary and the date of the furnished service/s.  If the provider, supplier, or beneficiary is unable to provide the contractor with an official SSA letter, the Medicare contractor shall check the Common Working File (CWF) database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiarys retroactive entitlement.  For example, if the CWF indicates a Medicare entitlement date of March 1, 2008 and a date of accretion of December 14, 2010, then the contractor may interpret the CWF da ta to mean that the beneficiary was retroactively entitled to Medicare as of March 1, 2008 and that this data was added to the CWF database on December 14, 2010.  If the contractor has any problems or concerns with respect to interpreting the CWF data, the n the contractor should consult with the appropriate CMS regional office.   If the contractor determines that both of the conditions for meeting this exception described above are met, the time to file a claim will be extended through the last day of the 6th calendar month following the month in which either the beneficiary or the provider or supplier received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   70.7.3  Retroactive Medicare Entitlement Involving State Medicaid Agencies  (Rev. 2477, Issued: 05- 25-12, Effective: 08 -27-12 Implementation: 08- 27-12)  The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:   (a) At the time the service was furnished the beneficiary was not entitled to Medicare.   (b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.   (c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.