evekhm/cms_iom_500 huggingface dataset:
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(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.   In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare.  After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare.  Finally, sometime af ter the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier.  If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.   In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:    documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;    documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check t he 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; see the example in section 70.7.2 above concerning the CWF for additional detail s regarding this contractor verification process); and,   documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.   If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.   70.7.4 - Retroactive Disenrollment from a Medicare Advantage plan or Program of All- inclusive Care for the Elderly (PACE) Provider Organization  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)
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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 enrolled in a Medicare Advantage (MA) plan or Program of All- inclusive Care for the Elderly (PACE) provider organization. (b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All -inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.  (c) The Medicare Advantage plan or Program of All- inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.  There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization.  And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.    In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:    prior enrollment of the beneficiary in an MA plan or PACE provider organization;    the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;    the effective date of the disenrollment; and,    the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.  If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.  70.8 - Filing Request for Payment to Carriers Medicare Part B  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)
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Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee-for-service claims.  Such claims must be filed no later than 12 months (or 1 calendar year) after the date the services were furnished.   70.8.1  Splitting Claims for Processing  (Rev. 3389, Issued: 10- 30-15, Effective: 01-01-14, Implementation: 04-04-16)   There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims. The splitting of such a claim is necessary for various reasons such as proper reco rding of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes. Split a claim for processing in the following situations:    Expenses incurred in different calendar years cannot be processed as a single claim. A separate claim is required for the expenses incurred in each calendar year;   EXCEPTION FOR DURABLE MEDICAL EQUIPMENT REGIONAL CARRIERS (DMERCs):   Expendable items (disposable items such as blood glucose test strips and PEN nutrients) that will be used in a time frame that spans two calendar years and are required to be billed with appropriately spanned from and to dates of service may be process ed on a single claim line. For these types of items, DMERCs must base pricing and deductible calculations on the from date, since that is the date when the item was furnished.    A claim other than a DMERC claim that spans two calendar years where the from date of service is untimely but the to date of service is timely should be split and processed as follows:   1. Where the number of services on the claim is evenly divisible by the number of days spanned, assume that the number of services for each day is equal. Determine the number of services per day by dividing the number of services by the number of days spanned. Then split the claim into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.
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2. Where the number of services on the claim is not evenly divisible by the number of days spanned and it is not otherwise possible to determine from the claim the dates of services, suspend and develop the claim in order to determine the dates of services. A fter determining the dates of services, split the claim accordingly into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.    A claim containing both assigned and unassigned charges. Split assigned and unassigned services from non- participating physicians/suppliers into separate assigned and unassigned claims for workload counts and processing;    Assigned claims from different physicians/suppliers (excluding group practices and persons or organizations to whom benefits may be reassigned). Process a separate claim for the services from each physician/supplier. Where the assigned claim is from a pers on or organization to which the physicians performing the services have reassigned their benefits, process all of the services as a single claim;    A claim where there is more than one beneficiary on a single claim. There can only be one beneficiary per claim; and   NOTE: Roster bills for covered immunization services furnished by mass immunizers may be submitted for multiple beneficiaries. You must create individual claims for each Medicare beneficiary based on the roster bill information.    Outpatient physical therapy services furnished on a cost basis by a physician-directed clinic cannot be processed when combined on the same claim with other charge -related services by the clinic. Process the cost related services as a separate claim.    If an unassigned claim includes services by an independent physical therapist together with other physician services, process the physical therapy services as a separate claim. Process an assigned claim from an independent physical therapist as a single cl aim.    A claim that is a duplicate of a claim previously denied is treated as a new claim if there is no indication that the claim is a resubmittal of a previous claim with additional information, or there is no indication on the second claim that the beneficiary  is protesting the previous determination.    In a claim containing services from physicians/suppliers covering more than one carrier jurisdiction, the carrier receiving the claim must split off the services to be forwarded to another contractor and count the material within the local jurisdiction as a claim. The carrier receiving the transferred material must also count it as a separate claim.
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 When services in a claim by the same physician/supplier can be identified as being both second/third opinion services and services not related to second/third opinion, the "opinion" services must be split off from the "non- opinion" services and counted as a separate claim. When one physician/supplier in an unassigned claim has provided the "opinion" service and another physician(s)/supplier(s) has provided the "non- opinion" services, the claim may not be split.    Claims containing any combination of the following types of services must be split to process each type of service as a separate claim. These services are:    --  Physical therapy by an independent practitioner, or      --  any services paid at l00 percent of reasonable charges.  (Any of these types of services may be combined on the same claim with any other type of service.)   Do not deviate from defining claims as described above. Split claims in accordance with the appropriate definition. Throughout the claims process count each of the separate claims, resulting from the split, as an individual claim.   70.8.2 - Replicating Claims for Processing  (Rev. 170, 05- 07-04)  There are no prescribed reasons other than those aforementioned for splitting claims and for counting additional claims into your workload.  However, claims are frequently split for other reasons that are dictated by the systems or the methods of processing them.  Such additional claims are labeled "Replicate Claims."  Tally and report all replicate claims (other than those aforementioned) separately.  Identify replicate claims and report them in the appropriate categories for claims.  Some examples of repl icate claims are:    Additional claims created because of a line item limitation (regardless of the methodology used for coding line items);    Extra claims created in making partial payments;    Claims created for carving out individual specialty types of services and    Extra claims created to apply special payment reductions (e.g., Gramm -Rudmann- Hollings) efficiently for applicable dates of service.   NOTE:  For budget requests and cost reports (CMS -l524, CMS -l528, CMS -l6l6, and CMS -2599), the workload must exclude the number of replicate claims produced.   70.8.3 - Methods of Claiming Benefits for Services by Physicians and Suppliers  (Rev. 170, 05- 07-04)
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70.8.3 - Methods of Claiming Benefits for Services by Physicians and Suppliers  (Rev. 170, 05- 07-04)  The method of claiming Part B benefits depends upon whether the patient is claiming payment or is assigning benefit payments to his/her source of medical treatment or services.   As a rule, beneficiaries do not submit claims for reimbursement.  However, if there is reason for a beneficiary to submit a claim for reimbursement, the beneficiary uses the CMS -1490S.  For covered services furnished on or after September 1, 1990, physicia ns and suppliers must complete and submit in accordance with SSA 1848(g)(4)(A) all Part B claims whether assigned or unassigned for beneficiaries who desire Medicare benefit payment determinations.   The physician/supplier (or the facility or organization to which the physician may reassign benefits, claims the payment.  The patient or his representative agrees to assign the benefits and the physician/supplier agreeing to the assignment accepts the Medicare reasonable charge determination as the full charge for the services.  (See 3045ff. about specific assignment procedures and the nature and effect of assignments.)   70.8.4 - Claims Forms CMS -1490S and CMS -1500 (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  A number of  prescribed claims forms have been developed for use when requesting payment for Part B Medicare services.  Many are printed and distributed nationally free of cost through CMSs Printing and Publications Branch.  (See NOTE below for exception.)   In order to maintain control over the content and format of the forms, private printing of a Government form is not routinely permitted.  However, if you or another organization wishes to independently print a prescribed claims form, the reproduction of a claims form must be in accordance with 422.527 of Title 20, Chapter III, Part 422 of the Code of Federal Regulations.  Obtain CMS approval for printing a prescribed form.  Route the written request for approval through the RO.  Include the following:    The reason or need for such reproduction;    The intended user of the form;    The proposed modifications or format changes, with printing or other specifications (such as realignment of data or line designations);
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 The reason or need for such reproduction;    The intended user of the form;    The proposed modifications or format changes, with printing or other specifications (such as realignment of data or line designations);    The type of automatic data processing machinery, if any, for which the form is designed; and   Estimates of printing quantity, cost per thousand, and annual usage.   NOTE:  This procedure does not apply to the Form CMS -1500, Health Insurance Claim Form.  A/B MACs (B), physicians and suppliers are responsible for purchasing their own forms.  This form can be bought in single, multipart snap- out sets or in continuous pin- feed format.  Medicare accepts any version.  Forms can be obtained from local printers or printed in- house as long as it follows the CMS approved specifications developed by the National Uniform Claim Committee.   The Form CMS -l490 was formerly the basic Part B claims form.  It was replaced by Form CMS -l500 for claims completed by physicians and suppliers (except ambulance suppliers), and Form CMS -l490S for claims from beneficiaries.  You must, however, continue to accept and process claims received on Form CMS -1490 form after conversion to Forms CMS -l500 and CMS -l490S.   The Form CMS -1500 (Health Insurance Claim Form) is the prescribed form for claims prepared and submitted by physicians or suppliers (except for ambulance services), whether or not the claims are assigned.  It can be purchased in any version required i.e., single sheet, snap- out, continuous, etc.  The forms described below are printed and distributed to contractors by CMS and are available in single sheets, multipart snap -out sets, or in pin- feed format.
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The forms described below are printed and distributed to contractors by CMS and are available in single sheets, multipart snap -out sets, or in pin- feed format.   The Form CMS -1490S (Patient's Request for Medical Payment) form is used only by beneficiaries (or their representatives) who complete and file their own claims.  It contains the patients comparable items of data that are on the Form CMS -1500.  When the Fo rm CMS -1490S is used, an itemized bill must be submitted with the claim.  Social Security Offices use the Form CMS -1490S when assisting beneficiaries in filing Part B Medicare claims.  For Medicare covered services received on or after September 1, 1990, the Form CMS -1490S is used by beneficiaries to submit Part B claims only if the service provider refuses to do so.  Inasmuch as the Form CMS -1490S has no provision for a diagnosis code, the diagnosis code is not required at the time of claim submission.   CMS implemented a new version of the Form CMS -1490S effective January 1, 2019. The revised form is version 01/18, OMB control number 0938- 1197. The revised form will replace the previous version of the form 01/05, OMB control number 0938- 0999.   The term, Form CMS -1490S refers to the form generically, independent of a given version.  Medicare will conduct a dual -use period (January 1, 2019 through March 31, 2019) during which Beneficiaries (or their representatives) can send Medicare claims on either the old or the revised form. When the dual -use period is over, Medicare will accept beneficiary paper claims on only the revised Form CMS -1490S, version 01/18.   The Form CMS -1556 (Prepayment Plan for Group Practices Dealing Through An A/B MAC (B)) is used by plans which, for Medicare purposes are, both Group Practice Prepayment Plans, and are paid on the basis of reasonable charges related to their costs for furni shing services to their subscribers.   70.8.5  Photocopies  (Rev. 170, 05- 07-04)
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70.8.5  Photocopies  (Rev. 170, 05- 07-04)  Some enrollees may want to keep the original itemized physician and supplier bills for income tax or complementary insurance purposes.  Photocopies of itemized bills are acceptable for Medicare deductible and payment purposes if there is no evidence of alteration.   70.8.6  Penalty for Filing Claims after One Year  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  Section 1848(g)(4) of the Social Security Act (the Act) requires that physicians and suppliers complete and submit Part B claims for medical services, equipment and supplies (furnished on or after September 1, 1990) within 12 months of the service date.  Only assigned claims submitted more than 12 months after the service date will be subject to a 10 percent reduction of the amount that would otherwise have been paid.  Payment on an assigned claim submitted by a physician or other supplier 12 months or longer after the service is furnished, shall be reduced by 10 percent from the amount that would have otherwise been paid.  On March 23, 2010, Congress passed the Patient Protection and Affordable Care Act (the Affordable Care Act).  Section 6404 of the Affordable Care Act amended sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the  Act, by reducing the maximum time period for filing Medicare Part A and Part B claim s to no more than 12 months after the date of service.  Therefore, this nullifies the 10 percent reduction requirement on physician and supplier claims submitted after 12 months from the date of service, because the claim will be denied as untimely filed; unless, an exception for the late filing is granted.  And, if an exception for late filing is granted, then the 10 percent penalty is waived.   70.8.8  Penalty for Filing Claims after One Year  (Rev. 170, 05- 07-04)
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70.8.8  Penalty for Filing Claims after One Year  (Rev. 170, 05- 07-04)  Section 1848(g)(4) of the Social Security Act requires that physicians and suppliers complete and submit Part B claims for medical services, equipment and supplies (furnished on or after September 1, 1990) within 12 months of the service date.  Only assign ed claims submitted more than 12 months after the service date will be subject to a 10 percent reduction of the amount that would otherwise have been paid.  Payment on an assigned claim submitted by a physician or other supplier 12 months or longer after t he service is furnished, shall be reduced by 10 percent from the amount that would have otherwise been paid.   70.8.8.6  Monitoring Claims Submission Violations  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  A. General   Section 1848(g)(4) of the Social Security Act requires physicians and suppliers to submit claims to Medicare carriers for services furnished on or after September 1, 1990.  It also prohibits physicians and suppliers from imposing a charge for completing and submitting a claim.  Payment for assigned services not filed within 1 year (for services on or after 9/1/90) are reduced 10 percent.  Physicians and suppliers who f ail to submit a claim or who impose a charge for completing the claim are subject to sanctions. CMS is responsible for assessing sanctions and monetary penalties for noncompliance.   Physicians and suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Physician and Supplier Program or, in the case of physician services, the Medicare beneficiary is also a recipient of State medical assistance (Medicaid) or the service is otherwise s ubject to mandatory assignment.  B. Compliance Monitoring   To ensure that providers and suppliers are enrolled in the Medicare program and submit claims in compliance with the mandatory claims submission requirements found in 1848(g)(4) of the Social Security Act, contractors shall:  1) Process beneficiary claims submitted to A/B MACs or carriers for services that are not covered by Medicare (e.g., for hearing aids, cosmetic surgery, personal comfort services, etc.; see 42 CFR 411.15 for details), in accordance with its normal processing procedures;
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2) Process beneficiary claims submitted to A/B MACs or carriers for services that are covered by Medicare and the beneficiary has submitted a complete and valid claim (Form CMS -1490S) and  all supporting documentation associated with the claim, including an itemized bill with the following information:    Date of service,   Place of service,   Description of illness or injury,   Description of each surgical or medical service or supply furnished,   Charge for each service,   The doctors or suppliers name and address,   The provider or suppliers National Provider Identifier (NPI)  The ordering & referring providers legal name and address and the National Provider Identifier (NPI) if known when the itemized bill is from: A Clinical laboratory for ordered tests An independent diagnostic imaging center for ordered imaging procedures A supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS  If the beneficiary furnishes all other information but fails to supply the provider or suppliers NPI the contractor shall not return the claim but rather look up the provider or suppliers NPI using the NPI registry.  If the contractor determines that the  provider or supplier was not a Medicare enrolled provider with a valid NPI, the contractor shall follow previously established procedures in order to process and adjudicate the claim.    3) Retain the Form -1490S and supporting documentation and manually return a copy to the beneficiary if it is for a Medicare -covered service and the claim is incomplete, does not include all required supporting documentation and/or contains invalid information.  Contractors shall also include an appropriate letter that specifically communicates all the items listed above which were missing or invalid.  In addition, the CMS-1490S and supporting documentation shall be maintained for purposes of the timely filing rules in the event that the beneficiary re-submits the claim.