evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The MAC  may receive evidence obtained and provide d by the UPIC c oncerning fraud or pot ential fraud with re spect to the  claim(s) at issu e.  If the UPIC p rovide s such evidence, it becom es part of the case file and must be  made available for inspe ction b y the appellant prior to the  reconside ration.  Evi dence of this nature  is to  be evaluated to de termine issues such as wh ether, in c onjunc tion with oth er credible  evidence, the services in que stion w ere actually provide d or were provided as bille d.  NOTE:  See 300.3 for additional informa tion regarding fraud and abuse  investigations.   280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Where there is a subst antial basis for determinin g tha t an item or service either was not f urnished or  was not furnishe d as billed, the  MAC  may deny or down -code payment, as appropriate.  The  reviewer must e nsure that the case file clearly documents the  evidence that formed the  basis for the determination.  Appeal r ights after such a determination re main the  same as they would f or any other unfavorable decision.  I f the MAC  has reason to be lieve or evidence to suppor t that items or  services w ere not furnishe d or were not furnishe d as bille d, it sha ll send a copy of the  decision to its UPIC .    280.4 - Responsibilities of Adjudicators  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
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280.4 - Responsibilities of Adjudicators  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  If, during the course of the redetermination, the  reviewer susp ects a civil or  criminal law viol ation, the  reviewer shall render a decision onl y on the  coverage or payment issu es raised by the  redetermination request.  Althoug h the  reviewer cannot m ake a determination of  civil or cr iminal fraud, h e/she may still d eny or reduce payment if he/she believes that the items or s ervices a t issue  were not re ndered, or were not rendered a s bille d (as discussed above) .  In making this d etermination, the  reviewer may conside r all available evidence that is in cluded in the  case fil e, including w itness testimo ny, medical recor ds, and evidence compile d through a fra ud inve stigation, a s discussed above .  (See 310.4.B  below.)   In addition to denying the claims b ecause  the services were not re ndered as bille d, if the reviewer suspects f raud, he /she shall forward information r egarding the potential civil or  criminal viol ation to the  UPIC .  For further discussion on M edicare fraud issue s, refer to the  Medicare Program Integrity Manual, IOM 100- 08, Chapt er 4.  280.5 - Requests to Suspend the Appeals Process  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  The MAC  does not h ave the author ity to suspe nd re determinations a t the request of the Office of the Inspector  General  (OIG) or the Department of Justice (DOJ) without a pproval and di rection from C MS central office (CO).  If the OIG or DOJ  submits a  request to susp end a r edetermination, the  MAC  shall first bring that request to the  attention of  CO through the RO.
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280.6 - Continuing Appeals of Providers, Physicians, or Other Suppliers Who are Under Fraud or Abuse Investigations  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  Reviewers shall continue adjudicating the appeals of Medicare claims submitted by a provider, physician, or other supplier who is being or has been investigated, indicted, or convicted for fraud or abuse on other Medicare claims, or who is on Medicare paym ent suspension, unless the MAC has been informed that the provider, physician, or other supplier has agreed, as part of a settlement with the Government, or as the result of a prosecution, to withdraw the appealed claims or to waive the right to appeal the  subject claim(s).  If it has received notice of such a settlement, the MAC shall dismiss the appeal based on the fact that the appellant has waived his/her/its right to an appeal, and/or agreed to withdraw appeal of these claims as part of a settlement ag reement with the Government.  The MAC places a copy of the settlement document or other evidence of a settlement in the file.  A reviewer shall remain neutral in the adjudication of claims that involve a provider, physician, or other supplier who is being or has been investigated, indicted or convicted of fraud or abuse.   280.7 - Appeals of Claims Involving Excluded Providers, Physicians, or Other Suppliers  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  The appeals process remains in eff ect for all claims with s ervice dates prior to the  effective  date of exclusion. An e xcluded provider , physician, or suppli er, or the  beneficiary may appeal such claims.  I n addition, if t he billing pri vileges of a pro vider, phy sician, or s upplier are revoked retroactively, and the  contractor re opens pr eviously paid c laims to ass ess an o verpayment against the  exclude d par ty, the  excluded party  (or the beneficiary) may  appeal the  revised initial d etermination and ove rpayment unde r the claims appeal pro cess (42 CFR part 405 subpart I ).
(Medicare Claims Processing Manual)
NOTE:  A pro vider or su pplier's app eal of a r evocation or de nial of bil ling p rivileges is pro cessed in accordanc e with the  procedur es set forth in 42 C FR part 405 subpart H  and 42 C FR part 498 ( see also, I OM 100-08, C hapter  15, 15.25) . The contra ctor is bound by the  terms of the  revocation a ction unl ess billing privileges are r einstate d und er the enrollm ent appe als pro cess.    290 - Guidelines for Writing Appeals Correspondence  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The guidelines in this section are to be used when preparing appeals correspondence, which includes redeterminations decisions and inquiries about the status of appeals.  These shall be handled as expeditiously as possible without lowering the quality of t he response.  General instructions on responding to beneficiary and provider/supplier communications are found in CMS Medicare Pub. 100- 09.  All other CMS -issued instructions on correspondence guidelines apply as well, including instructions on corresponde nce letterhead requirements.   290.1 - General Guidelines  (Rev. 2729, Issued: 06-21 -13, Effective: 07 -23-13, Implementation: 07 -23-13)  MACs sh all prepare appeals c orrespond ence so the  appellant can easily understand both the reason w hy any of the services w ere not c overed or could not be  fully reimbur sed, and wha t action the  appellant can take if the appellant dis agrees with th at decision.  In addition, the g uidelines listed here should be  follow ed to the  extent possibl e:   Keep the  language as simple  as possibl e;   Do not use  abbreviations or  jargon;   Choose  a positive  rather than a negative tone , whenever possibl e.  Avoid w ords or phra ses that empha size what cannot be  done by the MAC  or the appellant;   If possibl e, avoid one  sentence paragraphs, une ven spacing be tween paragraphs, e tc.;
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 If possibl e, avoid one  sentence paragraphs, une ven spacing be tween paragraphs, e tc.;   Apolog ize when appropriate, e.g., if the response  is late.  How ever, do not a polog ize for enforcing Medicare guidelines that may be adverse to the  appellants claim;   Summ arize the question bef ore providing a  response; and,   Use correct sp elling, grammar , and punc tuation.  290.2 - Letter Format  (Rev. 4278, Issued: 04 -12-19, Effective: 06 -13-19, Implementation: 06- 13-19)  Appeals c orresponde nce shall follow the  instructions issu ed by CMS for MAC  written correspon dence letterhead re quirements unl ess otherwise instructed and/or  agreed to b y CMS.  In addition, observe the following information:    Num erical d ates must not be  used (i.e., inst ead o f 6/16/13, use  June 16, 201 3), except when included in a table;    Type/font si ze must be  12 point or large r (all respons es are to be processed using a  font si ze of 12 and a font style of Univ ersal or Times New Roman or similar style for the ease of reading by the beneficiary and the provider) ;   When the  subj ect ma tter is lengthy or compli cated, bull et points should be  used to c larify, if possibl e;   For long letters, headings should be  used to break i t up (e .g., DECISION, BACKGR OUN D, R ATIONA LE);   If procedure codes are cited, the  actual name of the procedu re must be  associated with the  code;   Span dates may not be  used for 1 da y of service; and   The MAC  should no t use all capit al letters.  Letters that contain all capital letters appear impersonal and comput er generated.  Refer to 300.5 f or instructions on how to ha ndle cases involving multiple  beneficiaries, inc luding overpayment cases involving multiple  beneficiaries.
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Refer to 300.5 f or instructions on how to ha ndle cases involving multiple  beneficiaries, inc luding overpayment cases involving multiple  beneficiaries.  290.3 - How to Establish Reading Level  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The MMA requires that appeals correspondence be written in a manner calculated to be understood by beneficiaries.  MACs shall write appeals correspondence that is understandable to beneficiaries.  The purpose of this section is to provide some guidance to MACs on writing letters that are easy for beneficiaries to understand.  To achieve this goal, MACs shall:  (1) Write in plain English/plain language with a clear, simple, conversational writing style with good communication of key points.   (2) Get reading levels of letters as low as you can without losing important content or distorting the meaning and without sounding condescending to the reader.   NOTE:  This requirement does not apply to providers.  MACs can use a cover sheet for the beneficiary, when sending a copy of the decision.   290.3.1 - Writing in Plain Language  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The following are some tips to help MACs  to write letters in plain language:   Include definitions or explain terms you must use that are not familiar with your intended audience.    Use heading, subheadings, or other devices to signal what's coming next.  Labels for sections, headings, and subheading should be clear and informative to the intended audience.    Write in an active voice and in a conversational style.  For example, conversational style uses contractions (I'd instead of I would) and informal vocabulary (find out instead of determine).    Use a friendly and positive tone.
(Medicare Claims Processing Manual)
 Write in an active voice and in a conversational style.  For example, conversational style uses contractions (I'd instead of I would) and informal vocabulary (find out instead of determine).    Use a friendly and positive tone.    Use words that are familiar to your intended audience.  Shorter words tend to be more common, and they are generally preferable.  For example, use doctor instead of physician.  Pay back instead of reimburse.  Can get instead of eligible.  There are excepti ons.  For example, access is a short word, but it is health care jargon that is hard for many consumers to understand.  Organization is a five -syllable word, but is probably familiar to most readers.    When a term is best known to your intended audience by its acronym, use the acronym and spell out the word that it represents in parenthesis with the letters that form the acronym in bold.  For example: PCP (Primary C are P rovider).    Be on alert for words that are abstract or vague, or that may mean different things to different people.  Replace these words with more specific words to be sure your readers understand the key messages.   Keep your sentences simple and direct.  Most should be reasonably short; about eight to ten words per sentence for most sentences.  When sentences are long, the main point gets lost in all the words.  Active voice makes the style more direct.    Vary the length of your sentences.  Somewhat longer, natural -sounding sentences of about 12 to 15 words can effectively break up the choppy effect of using many short sentences.    Paragraphs should be relatively short.  Short paragraphs are more inviting to your reader and give the visual appearance of being easier to read.    Use simpler words rather than technical terms whenever you can without losing the content or distorting the meaning.  Sometimes it's important to use a technical term, such as the words mammogram, or cholesterol.    Appearance should be appealing at first glance.  Pages should be uncluttered with generous margins and plenty of white space.   The graphic design should use contrast, indentation, bullets, and other devices to signal the main points and make the text easier to skim.   Use a large type and spacing between lines.
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 The graphic design should use contrast, indentation, bullets, and other devices to signal the main points and make the text easier to skim.   Use a large type and spacing between lines.   290.4 - Required Elements in Appeals Correspondence  (Rev. 2926, Issued: 04- 11-14, Effective: 07 -14-14, Implementation: 07- 14-14)  The following should be  used in a ll appeals c orresponde nce:   The name of the beneficiary/provider /physician/suppli er to whom the  letter is addressed rather than Dear Sir/Madam;"   Corresponde nce is id entified by either the date on w ritten corresponde nce or the d ate the written correspondence was received;   The name of the provide r, physician or suppli er as well as the date(s) of service;   When appropriate, an explanation in l etters to be neficiaries, explaining  why he/she is being sent a letter if the appeal came from the  provider , physician or other suppli er;   The appeal determination/decision is pl aced in the  beginning of the letter;   Explicit rationale that describes why the items or  services a t issue  do not  meet M edicare guidelines.  M erely stating that an item or service is not m edically reasona ble and ne cessa ry unde r 1862( a)(1) or not m edically reasonable and necessa ry unde r Medicare guidelines does not pr ovide  any rationale. The rationale should inc lude a description of  the logic that led to the decision, re ferences used to suppor t the decision, a nd other information th at is re levant to suppor t the decision in the  case;   When the  appeals c orresponde nce includes Me dicare statutory citations, t hey must be  related to the decision in l aymans terms.  The  statutory cite is liste d as a parenthe tical at the end of the sentence.  For example, inst ead of  beginning a sentence with,  1879 of  the Social Security Act states that..., the sentence should st art with  Under Medicare law, suppliers must...( 1879 of  the Social Security Act);
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 Whenever the person is to recei ve some  further respons e, such as an MSN (if available), an estima ted time frame as to wh en he/she will recei ve it is p rovide d;   Telephone  numbe r on a ll correspond ence for addition al que stions;    What, if anything, must be  done  next, and by whom;   As appropriate, the results of any consult ations with pr ofession al medical staff;   When applicable, a statement advising the appellant that upon w ritten request the MAC  will provide  them copies of regulations, st atutes, and guidelines used in m aking the determination;   For appeals, if  the redetermination is p artially or whol ly favorable, an explanation a bout w hy the new determination is di fferent fro m the  previous de termination; a nd   The corresponde nce must be written in a  clear manner and with a  custom er- friendly tone.  300 - Disclosure of Information  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  300.1 - General Information  (Rev. 3549, Issued: 06- 24-16, Effective: 07 -26-16, Implementation: 07- 26-16)  The basis for policy governing the disclosure and confidentiality of information collected by the contractor is 1106 of the Act, the Departments Public Information regulations, as well as the Privacy Act, and the Freedom of Information Act.  In general, all information relating to an individual is confidential except as provided by regulation.  In the interest of an appellants right to due process, there are situations where information may be disclosed.  The CMS regulations implementing 1106 of the Act can be found at 42 CFR Part 401, Subpart B . (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 6.)
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In addition, 1106 in title XI of the Act provides penalties for violation of the provisions concerning confidentiality of information.  Activities prohibited under the provisions of the Act include, but are not limited to, making false and fraudulent statements, fraudulent  concealment of evidence affecting payment benefits, false impersonation of another individual, misuse or conversion of payments for use of another, and improper disclosure of confidential information. (See the Medicare Program Integrity Manual 100- 08.)  300.2 - Disclosure of Information to Third Parties  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  If a beneficiary wishes to have his/her information disclosed to a third party without appointing that individual as a representative, this can be accomplished by the beneficiary or third party providing written authorization to the MAC for the release of the information.  The written authorization must contain a signature of the beneficiary and an explanation of the type of information the beneficiary agrees to release to the individual.  An example of this type of situation is where a beneficiary has aske d a Member of Congress for assistance with his/her appeal.  In this case, it may be necessary for the Member of Congress to receive the decision; however the Member of Congress does not wish to accept the responsibility associated with being the beneficiar y's appointed representative or the beneficiary does not wish to appoint the Member of Congress as his/her representative.  See 310.1 for more information on requests for redetermination submitted by Members of Congress.  If the beneficiary wishes to appoint a representative, MACs should refer to 270.  300.3 - Fraud and Abuse Investigations  (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06- 13-19)
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Any and all evidence used by the A/B MAC (A), (B), (HHH), or DME MAC  to arr ive at a determination or  decision sha ll be pl aced in the  appeals c ase file (copies are acceptabl e).  Information in the  case  file shall be made available to an appellant upon re quest.  Th erefore, the MAC  shall be aware that information pl aced in the case file is accessible  to an appellant.  The  UPIC sh all also under stand tha t the MAC  may not c onsid er any evidence that has not been m ade a part of the case  file.  The UPIC a nd the  MAC  shall therefore exercise  discretion whe n deciding whe ther to pl ace any of the following information into the  appeals cas e file:   The impetus be hind a  fraud and abuse inve stigation;   The name of the beneficiary or any other person lodg ing the compl aint th at triggers the fraud and abuse inve stigation;   Notes or transcripts of  beneficiary interviews resulting from a  fraud and abuse inv estigation;   Records or  information c ompil ed for law enforcement pur poses dur ing a fraud and abuse investigation; or   The name of a confidential source( s) when confidentiality has been promised by CMS in re turn for coope ration in a  fraud and abuse inve stigation.  Where the MAC  relies upon a ny of the above  information in or der to deny a claim or  to re nder a less than fully favorable determination or  decision, the n an appellant ha s a due process right to re view this information.  If information is ke pt out of  an appeals case file for confidentiality reasons, it  may not be  relied upon t o ma ke a coverage decis ion or de ny or reduce pa yment.  300.4 - Medical Consultants Used  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)
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300.4 - Medical Consultants Used  (Rev. 1274, Issued: 06- 29-07, Effective: 07 -01-07, Implementation: 10- 01-07)  The parties are entitled to know the identity and qualifications of any consultant whose evidence the MAC used to support the initial claim determination or the redetermination.  If the MAC uses a consultant, it shall include the identity and qualifications of the consultant in the file for possible use by the ALJ, and for the appellants use upon request.  This applies to both external medical consultants and internal staff used to review the claim.  An example of this would be the name and title of the me dical consultant.   300.5 - Appeal Decision  Involving Multiple Bene ficiaries (Rev. 4278, Issued: 04- 12-19, Effective: 06 -13-19, Implementation: 06 -13-19)  A. Appeals of  Overpayments Involving Multiple  Beneficiaries with a Single Account  Receivable   If an app ellant submits a r equest for re determination that in volves an o verpayment with a single a ccount receivable for c laims in volving multiple  beneficiaries, the  MAC shall issue  one decision l etter to the  appellant that in cludes info rmation sp ecific  to the  claims for e ach beneficiary.  The summa ry of fa cts, coverage, payment and liability  decisions for e ach beneficiarys claim(s) may be included as a s eparate attachment to the  deci sion letter. Sin ce ea ch beneficiary is a party  to the  appeal, subj ect to the  exception in 300.5.C  below, the MAC shall s end each beneficiary a copy of th eir own determination w ithout compromising the  privacy of othe r beneficiaries in the  appeal.  (Refer to I OM, 100 -06, M edicare Finan cial Manag ement M anual,  Chapter 6, section 460.1, for inst ructions on how  to count r equests that in volve multiple  beneficiaries).  B. Appeals Involving Claims of  Multiple Beneficiaries, Ot her than Overpayments with a Single Account  Receivable
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B. Appeals Involving Claims of  Multiple Beneficiaries, Ot her than Overpayments with a Single Account  Receivable  If a party  files a request for re determination that in volves claims of multiple  beneficiaries that do not comprise  an o verpayment with a single  account r eceivable, the MAC may  process the app eal by  issuing a separate decision l etter for e ach beneficiary's claim(s) (i.e., as a split appe al), or the  MAC may  issue  a single  letter with atta chments for e ach separate c laim, w hichever is more  efficient.  Exampl e:  If a suppli er submits a single  appeal request involving unr elated claims for various be neficiaries that w ere denied on pr epayment review or through pr epayment edits, the MAC may  process the  appeal as a split and issue  separate l etters to the  suppli er-appellant, or the  MAC may  issue a single  letter with attachments for e ach claim.  I n either case, the be neficiary, as a party  to the appeal, must r eceive a copy of the decision l etter that p ertains to his or he r claims.   Exampl e:  If a suppli er submits a single  appeal request involving c laims r eviewed by a r ecovery auditor on a postpa yment basis, r esulting in ove rpayments (not e xtrapolat ed) processe d as s eparate a ccounts r eceivable, the MAC may  issue  either a single  deci sion l etter to the appe llant w ith atta chments for e ach claim, or separate decision l etters, w hichever is more e fficient.  T he beneficiary, as a party  to the  appeal, must r eceive a copy of t he decision l etter that p ertains to his or he r claims, subj ect to the  except ion not ed in 300.5.C  below.  C. Exception  to S ending Decision  Letters to B eneficiaries in Overpayment Cases