evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
a. Preliminary education equal to the requirements for graduation from an accredited high school or other secondary school;    b. Graduation from a college of chiropractic approved by the State's chiropractic examiners that included the completion of a course of study covering a period of not less than 3 school years of 6 months each year in actual continuous attendance covering adequate course of study in the subjects of anatomy, physiology, symptomatology and diagnosis, hygiene and sanitation, chemistry, histology, pathology, and principles and practice of chiropractic, including clinical instruction in vertebral palpation, nerve tracing and adjusting; and   c. Passage of an examination prescribed by the State's chiropractic examiners covering the subjects listed in subsection b.  2. After June 30, 1974 - Individuals commencing their studies in a chiropractic college after June 30, 1974, must meet all of the following additional requirements:    a. Satisfactory completion of 2 years of pre -chiropractic study at the college level;    b. Satisfactory completion of a 4- year course of 8 months each year (instead of a 3-year course of 6 months each year) at a college or school of chiropractic that includes not less than 4,000 hours in the scientific and chiropractic courses specified in subsection 1.b, plus courses in the use and effect of X -ray and chiropractic analysis; and   c. The practitioner must be over 21 years of age.   70.7 - Interns and Residents  (Rev. 1, 09- 11-02)  A.  General   For Medicare purposes, the terms "interns" and "residents" include physicians participating in approved graduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital setting; e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools.  Where a senior resident has a staff or faculty appointment or is designated, for example, a "fellow," it does not change the resident's status for the purposes of Medicare coverage and payment.  As a general rule, services of interns and residents are paid as provider services by the A/B MAC (A).   B.  Services Furnished by Interns and Residents Within the Scope of an Approved Training Program
(Medicare General Information, Eligibility, and Entitlement)
B.  Services Furnished by Interns and Residents Within the Scope of an Approved Training Program   Medical and surgical services furnished by interns and residents within the scope of their training program are covered as provider services.  Effective with services furnished on or after July 1, 1987, this includes services furnished in a setting which i s not part of the provider where a hospital has agreed to incur all or substantially all of the costs of training in the nonprovider facility.  The Medicare A/B MAC (A) is required to notify the A/B MAC (B) of such agreements.  Where the provider does not incur all or substantially all of the training costs and the services are performed by a licensed physician, the services are payable on a fee schedule basis by the A/B MAC (B).  Prior to July 1, 1987, the covered services of interns and residents were pai d by the A/B MAC (B) on a reasonable charge basis as physician services if furnished by a licensed physician off the provider premises regardless of who incurred the training costs.  C.  Services Furnished by Interns and Residents Outside the Scope of an Approved Training Program -Moonlighting   Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed outside the facility where they have their training program, are covered as physicians' services and paid on a fee schedule or reasonable charge basis where the requirements in the first 2 bullets below are met.  Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed in an outpatient department or emergency room of the hospital where they have their training program, are covered as physicians' services and paid on a fee schedule or reasonable charge basis where the following criteria are met:   The services are identifiable physicians' services, the nature of which requires performance by a physician in person and which contributes to the diagnosis or treatment of the patient's condition;   The intern or resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed; and    The services performed can be separately identified from those services that are required as part of the training program.  When these criteria are met, the services are considered to have been furnished by the individuals in their capacity as physicians and not in their capacity as interns and residents.
(Medicare General Information, Eligibility, and Entitlement)
When these criteria are met, the services are considered to have been furnished by the individuals in their capacity as physicians and not in their capacity as interns and residents.   80 - Health Maintenance Organizations (HMOs) Defined  (Rev. 1, 09- 11-02)  An HMO for Medicare purposes is a public or private organization that provides, either directly or through arrangement with others, comprehensive health services to enrolled members.  An HMO must service those who live within a specified service area.  It must provide services based on a predetermined periodic rate or periodic per capita rate basis without regard to the frequency or extent of covered services it furnishes.  An HMO must also meet other statutory requirements.   An HMO's service area is a geographic area in which a full range of its services are offered to its members.  This geographic area differs from an HMO's enrollment area since it may include locations outside its service area where it offers less than its f ull range of services.  (For example, an HMO may cover house calls in emergencies in its service area but not for members who live outside the service area.)   Section 1876 of the Act allows a Medicare beneficiary eligible for Part A and Part B, or Part B only, to choose to have covered items and services furnished through a Medicare qualified HMO.  An HMO enters into a contract with the Secretary in order to par ticipate under Medicare.   90 - Other Definitions  (Rev. 1, 09- 11-02)  NOTE:  We anticipate adding to this section as we find the need to define other terms.   90.1 - Supplier Defined  (Rev. 1, 09- 11-02)  The term supplier means an entity that is qualified to furnish health services covered by Medicare, other than providers, physicians, and practitioners.   The following suppliers must meet the conditions in order to receive Medicare payment: ambulatory surgical centers (ASCs), independent physical therapists, mammography facilities, DMEPOS suppliers, independent occupational therapists, clinical laboratories , portable X -ray suppliers, dialysis facilities, rural health clinics, and Federally -qualified health centers.
(Medicare General Information, Eligibility, and Entitlement)
An ASC is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. It enters into an agreement with CMS to do so.  An ASC is either independent (i.e., not a part of a provider of services or any ot her facility), or operated by a hospital (i.e., under the common ownership, licensure, or control of a hospital).   A DME supplier is an entity that furnishes DME and has a number assigned by the National Supplier Clearinghouse.  90.2 - Laboratory Defined  (Rev. 1, 09- 11-02)  Laboratory means a facility for the biological, microbiological, serological, chemical, immuno -hematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impa irment of, or the assessment of the health of, human beings.  These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body.  Facilities only collecting or pre paring specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories.  90.3 - Practitioners Defined  (Rev. 1, 09- 11-02)  Practitioners except for physicians are health professionals who may deliver covered Medicare services if the services are incident to a physician's service or if there is specific authorization in the law.  The following practitioners may deliver services  without direct physician supervision: nurse practitioners and physician assistants in rural health clinics, designated manpower shortage area or HMOs, qualified clinical psychologists, clinical social workers, certified nurse midwives, and certified regis tered nurse anesthetists.   90.4 - Group Practice Defined  (Rev. 1, 09-11-02)  A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not- for-profit corporation, faculty practice plan, or similar association:   In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, faci lities, equipment, and personnel;
(Medicare General Information, Eligibility, and Entitlement)
 For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;   In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and    Which meets such other standards as the Secretary may impose by regulation to implement 1877(h)(4) of the Social Security Act.  The group practice definition also applies to health care practitioners.   Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI
(Medicare General Information, Eligibility, and Entitlement)
of the Social Security Act.  The group practice definition also applies to health care practitioners.   Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI   12/21/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update  01/01/2024 13496  R120GI  11/02/2018  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)  12/04/2018  11004  R114GI  03/16/2018  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512  R101GI  09/16/2016  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748  R58GI  03/06/2009  Disclosure of Physician Ownership in Hospitals  06/08/2009  6306  R42GI  11/09/2006  Swing bed Hospital Updates  12/11/2006  5114  R35GI  02/10/2006  Revisions to Instructions for Contractors Other Than the Religious Nonmedical Health Care Institution (RNHCI) Specialty Contractor Regarding Claims for Beneficiaries with RNHCI Elections  05/11/2006  4218  R28GI  08/12/2005  Conforming Changes for Change Request 3648 for Pub. 100 -01 09/12/2005  3912  R19GI  03/11/2005  Definition of Home Health Agency  N/A 3698  R18GI  03/04/2005  Billing for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2005  3681  R01MGI  09/11/2002  Initial Publication of Manual  NA NA  Back to top of Chapter
(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 6 - Disclosure of Information   Table of Contents  (Rev. 123, 05- 10-19) (Rev. 124, 05- 17-19)   Transmittals for Chapter 6
(Medicare General Information, Eligibility, and Entitlement)
10 - The Privacy Act of 1974 10.1 -  Disclosure of Information 10.2 -  Procedures for Handling Requests  10.3 -  Processing Freedom of Information (FOI) Requests  10.4 -  Reporting FOI Activity  20 - Case Numbering  21 - Fees for Information (Contractors)  21.1 -  Fees  21.2 -  Billing of Fees and Charges  21.3 -  Requests Fulfilled Without Remittance  30 - Disclosure of Program Materials (Contractors) 30.1 -  Manuals, PMs, and Other CMS Materials  30.2 -  Internal Guidelines  40 - Disclosure of Information about Identifiable Beneficiaries (Contractors)  40.1 -  Prohibition Against Disclosure  40.2 -  The Authority for Disclosure  50 - Disclosure Necessary for Proper Administration of the Health Insurance Program  60 -  Disclosure of Information 70 - Disclosure of Information after the Death of a Beneficiary (Contractors)  80 - Disclosure to Third Parties for Other than Program Purposes (Contractors)  80.1 -  Release for Title XVIII Claims Info rmation for Complementary Insurance Purposes (Contractors)  90 - Matching MAC Health Insurance  100 -  Disclosure to State Agencies or to Contractors Acting for State Agencies Administering Programs Receiving Gra nts in Aid (Contractors)  100.1 -  Information That May Be Disclosed and Authorization Required 100.2 -  Procedures for Supplying Title XVIII Information to State Agencies  100.3 -  Disclosure to Title V and Title XIX Agencies of Information Indicating Unprofessional or Unethical Practices by Physicians and Other Practitioners  100.4 -  Disclosure to Title XIX Agencies of Physician Charge Information  100.5 -  Electronic Reporting of Crossover Claims  110 -  Disclosure to Peer Review Organizations (PROs)  120 -  Disclosure to the Internal Revenue Service (Contractors)  130 -  Disclosure to the Office for the Civilian Health and Medical Program of the Uniformed Services (TRICARE) by Contractors  130.1 -  General  130.2 -  Type of Information  130.3 -  Proc edures for Release  140 -  Disclosure of Information About Providers and Suppliers by CMS  140.1 -  Disclosure Necessary for Proper Administrative of the Medicare Program (CMS) 140.2 -  Disclosure of Medicare Reports  140.3 -  Disclosure of Information About Named Physicians and Other Suppliers of Service (RO's)  140.4 -  Disclosure of Names of Providers, Physicians, and Suppliers of Servic es 140.4.1 -  Names of Providers Terminated from Program Participation (A/B MACs (B) ) or DME MACs  140.4.2 -  Names of Providers, Suppliers, and
(Medicare General Information, Eligibility, and Entitlement)
Physicians, and Suppliers of Servic es 140.4.1 -  Names of Providers Terminated from Program Participation (A/B MACs (B) ) or DME MACs  140.4.2 -  Names of Providers, Suppliers, and Physicians Found Guilty of Fraud (CMS) 140.4.3 -  Names of Physicians on Second Opinion Lists (Contractors)  140.4.4 -  Referral to State Licensing Boards, Medical Review Boards, and Professional Societies  140.4.5 -  Disclosure of Med icare Statistics  150 -  Disclosure of Reports About Named Contractors  150.1 -  Disclosure by ROs of Annual Reports of Contractors Performance (RCP)  150.2 -  Disclosure of Medicare Audit Reports to the Press and Public (Audit Agency)  160 -  Disclosure of Statistics (CMS or Contractors)  160.1 -  Information That the Contractor May Disclose  160.2 -  Information That May Be Released Upon Authorization by the Regional Office  170 -  Disclosure of Health Insurance Information by Providers  170.1 -  Disclosure of Health Insurance Information to a Beneficiary or in Connection With a Claim 170.2 -  Disclosure to Contractors  170.3 -  Disclosure to Third parties for Proper Administration of the Health Insurance Program  170.4 -  Disclosure to Third Parties  for Other Than program Purposes  170.5 -  Disclosure of Claims Payment Information in Alcohol and Drug Abuse Cases  170.6 -  Disclosure of Itemized Statement to an Individual for Any Item or Service Provided 180 -  Cost to a Provider That Requests Information Available to the Public  190 -  The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule  200 -  Removal of Medicare Number from Reimburseme nt Checks  Exhibit A -  Freedom of Information Act Request  Exhibit B -  Summary Sheet for the CMS Monthly FOIA Report  Exhibit C -  Invoice of Fees for FOIA Services  Exhibit E -  Medicare Authorization to Disclose Personal Health Information Form and Information to Help You Fill Out the Medicare Authorization to Disclose Personal Health Information Form
(Medicare General Information, Eligibility, and Entitlement)
10 - The Privacy Act of 1974 (Rev. 1, 09- 11-02)  A. General   The purpose of the Privacy Act of 1974 is to provide safeguards for individuals against an invasion of privacy by Federal agencies.  Among other things, Federal agencies are required to permit an i ndividual to:    Determine what records pertaining to the individual are collected, used, or disseminated by such agencies;    Prevent records pertaining to the individual obtained by Federal agencies for a specific purpose from being used for another purpose without the individual's consent; and    Gain access to information pertaining to the individual in Federal agency records, and to correct such records when appropriate.   Contractors considered to be Federal agencies for purposes of administering the Privacy Act must comply with its provisions.  Contractors must:    Inform each individual from whom information is requested of their rights under the Privacy Act;    Describe the method of accessing an individual's records;    Prepare a method of accounting for  disclosures; and    Devise a method of reviewing records at the request of individuals and making corrections if appropriate.  Additional information concerning Medicare privacy policies can be accessed on the CMS Web site under the Privacy Policy link at the bottom of the web page.   B. Definition of "Individual"   "Individual" means a living person on whom CMS has any personal (as opposed to business) information.  "Individual" does not include so- called persons such as sole proprietorships, partnerships, or corporations.  Except for disclosure of and access to medical information about minors, a parent or legal guardian of a minor, or a legal guardian of someone the court has declared incompetent, has the same rights as the individual to the individual's re cords.  No one may act on behalf of an individual who has not been declared incompetent by a court or gain access to his/her records under the Privacy Act without the individual's written consent.  C. Physicians' and Suppliers' Rights to Access Under the P rivacy Act
(Medicare General Information, Eligibility, and Entitlement)
C. Physicians' and Suppliers' Rights to Access Under the P rivacy Act   Providers, physicians, and suppliers as business entities do not have access to business information about themselves under the Privacy Act, since the Privacy Act concerns individuals only.  However, a physician or other supplier who is also an individual has the same access rights as any other individual to personal information maintained about themselves.  Purely business information which is retrievable by the physician's unique identifier is not subject to the Privacy Act, but it may be disc losed to the physician to the extent that we would not deny the physician the information under the Freedom of Information Act (FOIA).   D. Informing Individuals of Rights   The contractor must inform the individual of his/her rights under the Privacy Act when it solicits any information directly from the beneficiary in connection with a Medicare claim.  This would usually be a result of the failure of the individual or provider to furnish all the information required on a claims form.  When information is collected by telephone, the contractor will give the individual a brief oral explanation.  When information is requested by mail a written notice is used.   E. Method of Accessing Individual Records -  General   The law requires that an agency must inform an individual, upon request, whether a system of records contains a record pertaining to the individual, permit the individual to review such record and to be accompanied for the purpose of reviewing the record by a person of his or her choice.  Further, the individual is permitted to obtain a copy of such record in a comprehensible form at a reasonable cost.  There is a charge of 10 cents per page with all fees under $25 waived.  There is no charge for searching; nor is there a charge for a copy furnished as a means of permitting an individual access to their records.   Each requester shall be asked for proof of identity as well as such general information as is necessary to determine where and how to look for records about the data subject Within 10 working da ys of receiving a request, the contractor must decide whether to release the records.  The requested information must be furnished within 30 working days unless good cause exists.  An example of "good cause" would be an inactive record filed in a records center that cannot be obtained within 30 days.  The requester should be told of the delay and given an approximate date to expect the information.
(Medicare General Information, Eligibility, and Entitlement)
If an individual's request for information concerning themselves is not in the contractor's files, the contra ctor should advise the individual that it does not have the information and, if available elsewhere, that it is forwarding the request to the office which has it.  The contractor should furnish any requested information available if the request cannot be satisfied in full.  The contractor should identify requests under the Privacy Act that require referral to CMS for data in central office systems.  As required by the Privacy Act, the contractor should send the request for processing, along with a copy of t he interim response, to the systems manager listed in the Annual Publication:  Systems of Records.   F. Methods of Accessing Individual Medical Records   The official responsible for the records, or their designated medical officer, may disclose medical info rmation directly to the individual if the official determines, based on review of the medical evidence, that such disclosure is not likely to have an adverse effect.  In such cases the responsible official will give the requested information to the individual and annotate the record to show that the disclosure was made.   If the responsible official determines that direct disclosure of the medical record would be likely to have an adverse effect on the individual or does not consider themselves qualified to make such a determination, the official will disclose the medical information to the representative designated in writing by the individual.  The representative must be a medical professional (licensed medical practitioner or nurse) who would be willing to review the record and discuss it with the individual.  The contractor will retain a record showing the reason for its determination and a copy of the correspondence transmitting the information to the individual or to his/her medical representative.   If there is sensitive medical information in the records and the individual refuses to name a medical professional or cannot afford the fee for the service, or if the designated medical professional refuses to serve, the contractor will refer the file to the C MS regional office.   G. Disclosure of Medical Information Relating to Minors