evekhm/cms_iom_500 huggingface dataset:
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An audit of Medicare payments by the Office of Inspector General identified a vulnerability for the Medicare trust fund with respect to this issue.  The study identified improper payments for beneficiaries, who, on the date of service on the claim, had bee n deported.  To address this vulnerability, CMS is establishing claim level editing using data from the Social Security Administration (SSA).  Specifically, the data contains the name and Medicare beneficiary identifier of the Medicare beneficiary and the month the deportation is effective.  CWF will reject claims where the effective date on the Master Beneficiary Record is equal to or greater than the date of service on the claim. All claims rejected by CWF shall be denied by the respective A/B MAC (B), DME MAC, A/B MAC (HHH) or A/B MAC (A) that submi tted the claim to CWF.   Policy:   Medicare payment shall not be made for an item or service furnished to an individual that has been deported from the United States.  Appeals:  A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis of the deportation status at the time the item or service was furnished.        10.5.1 - Implementation of Payment Policy for Deported Medicare Beneficiaries  (Rev. 4201, Issued: 01 -18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A.  CWF Editing of Claims   1. An auxiliary file shall be established in the Common Working File to contain deportation status.  2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.   3. The edit will reject a claim where the Medicare beneficiary identifier on the claim matches the Medicare beneficiary identifier on the Master Beneficiary Record and the date of service is on or after the date of deportation.   B.  Contractors Actions
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B.  Contractors Actions   Medicare contractors shall deny claims for items and services when rejected by CWF.  The contractor shall refer to the CWF documentation on this subject for the error code assigned to this editing.  All denials will provide appeal rights as specified in section 10.5.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: PR CARC: 96  RARC: N126  MSN: 16.56  20 - Provider Assignment to FIs and MACs  (Rev. 1707; Issued:  03-27- 09; Effective:  04 -027-09; Implementation:  04-27-09)   A. The Process of Moving Providers from FIs to MACs   1. The General Case   An existing Medicare provider with a claims history will remain in its current workload assignment.   As each MAC contract is awarded, the new MAC will take over workload from the carriers and FIs that serviced the state(s) in the given MAC jurisdiction.  The Part A and Part B workload segments for each of the states in the given MAC jurisdiction will be moved one-by-one in the 12 months following the final award.  The specific requirements associated with workload transfers will be directed through formal CMS transmittals.   A new provider (also known as an initial enrollment) will be assigned to the FI or MAC that covers the state where the provider is located, unless the assignment is directed to a non-geographic workload by 20B below.  A special exception exists for a Multi -Provider Complex/Sub-Unit relationship (ref: 42 CFR 483.5(b)).  An initial enrollment for a sub-unit will be assigned to the FI or MAC that currently serves the existing parent hospital  even if the parent hospital is not presently billing in accordance with the geographic assignment rule.  Each such case is fact-specific and will be treated on an individual basis.   2. Out of Jurisdiction Providers  An out-of-jurisdiction provider (OJP) is a provider that is not currently assigned to the A/B MAC or FI in accordance with B.1-5 below (including the geographic assignment rule.)  For example, an individual, freestanding provider located in Maine, but currently assigned to the Wisconsin FI, would be an OJP.
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Many legacy Part A workload segments may include a number of OJPs.  Examples of how an OJP may have been assigned to the given Part A segment include:  a. Individual provider nominations.  (Note MMA 911 repealed the provider nomination provisions of the Act.);   b. Chains being granted single FI status; and  c. Legacy -world regional and national FIs for specific provider types such as FQHCs, RHCs, and ESRD facilities.   New MACs will initially service some OJPs until CMS undertakes the final reassignment of all OJPs to their destination MACs based on the geographic assignment rule and its exceptions.   CMS will start the overall transfer of OJPs to their final destination MACs after all 15 A/B MACs have been implemented.  Each move will be dependent on the then- current implementation status of the systems that support the cost report audit, claims proces sing, and provider enrollment functions at the departure and destination MACs.  Some providers will need to submit or update their Medicare enrollment record before being reassigned.   B. The Settled MAC Environment   The settled MAC environment refers to the period after all OJPs have been moved to their destination MACs.    1. Home Health & Hospice   All home health and hospice (HH&H) providers will be assigned to the MAC contracted by CMS to administer HH&H claims for the geographic locale in which the provider is physically located.    2. Durable Medical Equipment   Each supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) will submit claims to the DME MAC contracted by CMS to administer DMEPOS claims for the geographic locale in which the beneficiary permanently resides.    3. Qualified Railroad Retirement Beneficiaries Entitled to Medicare   Physicians and other suppliers (except for DMEPOS suppliers) will continue to enroll with and bill the contractor designated by the Railroad Retirement Board (under Section 1842(g) of The Act) for Part B services furnished to these beneficiaries.  Supplier s of DMEPOS will bill the DME MACs.    4. Specialty Providers and Demonstrations
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4. Specialty Providers and Demonstrations   Specialty providers, and providers involved with certain demonstrations, will submit claims to a specific MAC designated by CMS.  Examples of specialty providers and their corresponding MACs are:  Specialty Service  MAC Jurisdiction  Centralized Billing for Mass Immunizers  4 Indian Health Services/Federally Recognized Tribal Providers  (Refer to Chapter 19 of this manual.)  4 Low Vision Demonstration 5, 10, 11, 13, and 14 Veterans Affairs Medicare Equivalent Remittance Advice Project  4 Home Health Third Party Liability Demonstration Project  14 Independent Organ Procurement Organizations  10 Religious Non -medical Health Care Institution (RNHCI)  10 Histocompatibility Lab  10   5. The Geographic-Assignment Rule  Medicare providers, physicians, and suppliers will generally be assigned to the A/B MAC that covers the state where the provider is located.  This includes FQHCs, RHCs, and ESRD facilities.   An exception exists for qualified chain providers (QCPs).  A QCP may request that its member providers be serviced by a single A/B MAC - specifically, the A/B MAC whose jurisdiction includes the QCPs home office.  See 42 CFR 421.404 for QCP criteria and additional information.  A few providers that meet the provider-based criteria of 42 CFR 413.65 may present an additional exception to the geographic-assignment rule.  Provider- based entities (other than HH+H providers) will be assigned to the MAC contracted by CMS to administer claims for the Medicare benefit category applicable to the providers covered services for the geographic locale in which the main (parent) provider is physically located.  20.1 - FI Service to HHAs and Hospices  (Rev. 1, 10-01-03) A2-2807.B  Under 42 CFR 421.117, CMS is authorized to designate RHHIs to service HHAs and hospices. This provision was implemented through the designation of regional FIs to service all HHAs and hospices. See http://www.cms.hhs.gov/contacts/incardir.asp for RHHI jurisdictions.
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An HHA or hospice chain may request to be served under an arrangement involving a lead FI serving its home office and regional FIs serving the individual facilities of the chain.  Alternatively, a HHA or hospice chain may request to be served by a single designated regional intermediary.  In either case, CMS does not grant requests automatically but rather requires the provider to demonstrate that the requested arrangement would be consistent with effective and efficient administration of the Medicare program.   For provider-based HHAs and hospices, audits, cost report settlements and other fiscal functions (such as setting interim payment rates) are performed by the FI serving the parent provider.  The claims processing activities are performed by the designated RHHI for the provider.  20.2 - Provider Change of Ownership (CHOW)  (Rev. 861, Issued:  02- 17-06; Effective:  10 -01-05; Implementation:  03 -17-06)  Providers (as defined in 1861(u)  of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners.  They are also required to inform CMS on how they will organize the new entity and when the change will take place.  A terminating cost report will be required from the seller owner in all CHOWs for certification purposes.  There are five types of changes that can occur:   1.   A CHOW in accordance with 42 CFR 489.18;  2.   Changes in the ownership structure to an existing provider that do not constitute a CHOW;   3.   A new owner who purchases a participating provider but elects not to accept the automatic assignment of the existing provider agreement, thus avoiding the old owners Medicare liabilities;   4.   An existing provider who acquires another existing provider (acquisition/merger); and   5.   Two or more existing providers who are totally reorganizing and becoming a new provider (consolidation).
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4.   An existing provider who acquires another existing provider (acquisition/merger); and   5.   Two or more existing providers who are totally reorganizing and becoming a new provider (consolidation).  Providers that undergo a change of ownership will usually continue with the same FI that served the previous owner.  However, if the prospective owner does not wish to accept the automatic assignment of the existing provider agreement, this means that the existing provider agreement is terminated effective with the CHOW date.  The regional office must be notified in writing of the CHOW per instructions contained in section 3210.5 of the State Operations Manual. The prospective owner provides a notice 45 -days in advance of the CHOW to the CMS/RO to allow for the orderly transfer of any beneficiaries that are patients of the provider.  All reasonable steps must be taken to ensure that beneficiaries under the care of the provider are aware of the prospective termination of the agreement.  There may be a period when the facility is not participating and beneficiaries must have sufficient time and opportunity to make other arrangement for care prior to the CHOW date.   After the CHOW has taken place, the RO acknowledges the refusal to accept assignment in a letter to the new owner, with copies to the State Agency (SA) and the FI.  The RO completes a form CMS -2007 with the date the agreement is no longer in effect, noting that the termination is due to the new owners refusal to accept assignment of the provider agreement.   If the new owner refuses to accept assignment and also wishes to participate in the Medicare program, the RO will first process the refusal as indicated above and then treat the new owner as it would any new applicant to the program.  The RO will obtain and process the application documents, have the SA perform an initial survey and if all the requirements for participation are met, assign an effective date of participation.  The earliest possible effective date for the applicant is the date that the RO det ermines that all Federal requirements are met.  Once this is completed, a new provider agreement with a new provider number will be issued to the new owner.  The provider will be assigned to the local FI.   See chapter 10, of the Medicare Program Integrity Manual, for complete requirements for completion of Form CMS -855 in change of ownership situations.
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See chapter 10, of the Medicare Program Integrity Manual, for complete requirements for completion of Form CMS -855 in change of ownership situations.   20.3 - CMS No Longer Accepts Provider Requests to Change Their FI  (Rev. 2876, Issued: 02- 07-14, Effective: 03 -07-14, Implementation: 03- 07-14)  Medicare providers will no longer be able to request a change of FI, they must remain with the FI to which they have been assigned.   30 - Provider Participation  (Rev. 1, 10- 01-03) A2-2810   The RO uses the provider tie -in notice, Form CMS -2007 (see the CMS forms page at http://www.cms.hhs.gov/forms/ ), as an official notification to the FI of a change in its list of providers. The RO completes and transmits a Form CMS -2007 to the home office of the FI in each of the following circumstances:    A provider is certified for participation in the program,   A provider is issued a notice of termination,    A change of FI is authorized (including changes between Blue Cross plans or between FI processing facilities, i.e., any changes involving a change in the FI number), or    To correct information previously furnished the FI.  Part I of the Form CMS -2007, Identifying Information, identifies the provider and is always completed.   Part II, New Provider Certification, is completed where the provider is certified (including certifications required because of a change of ownership).   Part III, Change of FI, is completed where a change of FI has been authorized.  Part IV, Terminations, is completed in all termination actions.   Part V, Remarks, will be used for additional clarifying information.  The FI must promptly notify the RO of any information found to be incorrect. The RO will issue a corrected Form CMS -2007.   30.1 - Content and Terms of Provider Participation Agreements  (Rev. 1, 10- 01-03) A2-2840, RHC -320
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30.1 - Content and Terms of Provider Participation Agreements  (Rev. 1, 10- 01-03) A2-2840, RHC -320  In the agreement/attestation statement signed by a provider serviced by an FI, the provider agrees to maintain its compliance with all of the conditions for certification in 42 CFR 491.  If a provider fails to maintain compliance with one or more of the conditions, it must promptly report this (usually within 30 days of the failure) to the responsible CMS office or official.  Failure to report promptly may be a cause for termination of the providers agreement.   30.1.1 - Provider Charges to Beneficiaries  (Rev. 2921, Issued: 04- 04-14, Effective: 05 -05-14, Implementation: 05- 05-14)  In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiarys behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for which the benefici ary would have been entitled to have payment made had the provider filed a request for payment (see 50).  The provider may bill the beneficiary for the following items:    Part A deductible;    Part B deductible;    First 3 pints of blood, which is called the blood deductible (if there is a charge for blood or the blood is not replaced);    Part B coinsurance;    Part A coinsurance; or    Services that are not Medicare covered services. See Chapter 30 for related requirements.   SNFs may not require, request, or accept a deposit or other payment from a Medicare beneficiary as a condition for admission, continued care, or other provision of services, except as follows:    A SNF may request and accept payment for a Part A deductible and coinsurance amount on or after the day to which it applies.   A SNF may request and accept payment for a Part B deductible and coinsurance amount at the time of or after the provision of the service to which it applies.   A SNF may not request or accept advance payment of Medicare deductible and coinsurance amounts.
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 A SNF may not request or accept advance payment of Medicare deductible and coinsurance amounts.   A SNF may require, request, or accept a deposit or other payment for services if it is clear that the services are not covered by Medicare and proper notice is provided. See Chapter 30 for instructions about ABNs and demand bills.   SNFs, but not hospitals, may bill the beneficiary for holding a bed during a leave of absence if the requirements in 30.1.1.1 are met.  30.1.1.1 - Charges to Hold a Bed During SNF Absence  (Rev. 4001, Issued: 03- 16-18, Effective: 06 - 19- 18, Implementation: 06- 19-18)  Charges to the beneficiary for admission or readmission are not allowable.  However, when temporarily leaving a SNF, a resident can choose to make bed- hold payments to the SNF.   Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the facility and has established residence in a particular living space within it.  Similarly, bed -hold payments are distinguishable from payments for readmission, in that the latter compensate the facility merely for agreeing in advance to allow a departing resident to reenter the facility upon return, while bed -hold payments represent remuneration for the privilege of actually maintaining the residents personal effects in the particular living space that the resident has temporarily vacated.   One indicator that post -admission payments do, in fact, represent permissible bed- hold charges related to maintaining personal effects in a particular living space (rather than a prohibited charge for the act of readmission itself) would be that the charge s are calculated on the basis of a per diem bed -hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility.
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Under 1819(c)(1)(B)(iii) of the Act and 42 CFR 483.10(g)(17) -(18), the facility must inform residents in advance of their option to make bed- hold payments, as well as the amount of the facilitys charge.  For these optional payments, the facility should m ake clear that the resident must affirmatively elect to make them prior to being billed.  A facility cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the residents departure from the facility.   30.1.2 - Provider Refunds to Beneficiaries  (Rev. 1, 10- 01-03) RHC- 322  In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.   Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable because of the deductible and coinsurance requirements.   Amounts are considered to have been incorrectly collected because the provider believed the beneficiary was not entitled to Medicare benefits but:    The beneficiary was later determined to have been entitled to Medicare benefits;    The beneficiarys entitlement period fell within the time the providers agreement with CMS was in effect; and    Such amounts exceed the beneficiarys deductible, coinsurance or non covered services liability.     30.1.3 - Provider Treatment of Beneficiaries  (Rev.4163, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12- 04-18)
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30.1.3 - Provider Treatment of Beneficiaries  (Rev.4163, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12- 04-18)  In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment.  The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment.  If the provider does not furnish treatment for certain illnesses and conditions to patients who are not Medicare beneficiaries, it need not furnish such treatment to Medicare beneficiaries in order to participate in the Medicare program.  It may not, however, refuse to furnish treatment for certain ill nesses or conditions to Medicare beneficiaries if it furnishes such treatment to others.  Failure to abide by this rule is a cause for termination of the providers agreement to participate in the Medicare program (see the regulations at 42 CFR 489.53(a)(2), and also see Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 5, 10.2).  30.2 - Assignment of Providers Right to Payment  (Rev. 1, 10-01-03) A3-3488, A3-3703.1, B3-3060  Except as provided in 30.2.1, FIs pay benefits due a provider only to the provider.  Carriers may pay assigned benefits only to the physician, practitioner, or supplier who furnished the service.  They do not pay the benefits to any other person or organization under an assignment or reassignment, power of attorney, or under any other arrangement in which the other person or organization receives the payment directly.  For this purpose, assigned benefits include, in addition to the benefits usually encompassed by this term, benefits payable after the death of the enrollee to the physician or other supplier on the basis of his agreement to accept the reasonable charge as the full charge.  A power of attorney for this purpose means a written authorization by a principal to an agent:   To receive in the agents own name amounts due the principal;  To negotiate checks payable to the principal; or  To receive in any other manner direct payment of amounts due the principal.