evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Group Code: CO  CARC: 109  RARC: N104  MSN: N/A  10.1.9.2 - An A/B MAC (B) Receives a Claim for Services that are in a DME MACs Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a CMS -1500 or electronic claim for Medicare payment for items/services that are in a DME MACs payment jurisdiction, the claim shall be returned as unprocessable.   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: CO  CARC: 109  RARC: N104   MSN: N/A  10.1.9.3 - A DME MAC Receives a Claim for Services that are in an A/B MAC (B)s Payment Jurisdiction   (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local DME MAC receives a CMS -1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carriers payment jurisdiction, the claim shall be returned as unprocessable.   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: CO  CARC: 109  RARC: N104  MSN: N/A  10.1.9.4 - An A/B MAC (B) Receives a Claim for an RRB Beneficiary  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a Form CMS -1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable.
(Medicare Claims Processing Manual)
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: CO  CARC: 109  RARC: N105  MSN: N/A  NOTE :  CMS requests that when RRB receives a claim that is not for an RRB beneficiary that they return the claim to the sender and notify them that the claim must be submitted to the local contractor (Part B MAC or carrier) or DME MAC for processing.   10.1.9.5 - An A/B MAC (B) or DME MAC Receives a Claim for a UMWA Beneficiary  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS -1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.   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: CO  CARC: 109  RARC: N127  MSN: N/A  10.1.9.6 - Medicare Carrier or RRB -Named Carrier to Welfare Carrier  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  When a Medicare carrier or RRB -named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent informat ion received or developed is transferred with the claim.   This occurs only if there is a State welfare carrier and the individual is identified in the beneficiary master record as a State buy -in enrollee for that State.  For more information on the definition of a welfare carrier, refer to Pub. 100- 04, Chapter 1, section 10.1.7.
(Medicare Claims Processing Manual)
10.1.9.7 - Protests Concerning Transfer of Requests for Payment to Carrier  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  If Palmetto GBA receives a protest concerning the transfer of a request for Medicare payment to the carrier, the protest, including pertinent name and claim number(s) information, is forwarded to:   Railroad Retirement Board  Medicare Section  844 Rush Street  Chicago, IL 60611   10.1.9.8 - Transfer of Claims Material Between Carrier and Intermediary (FI)  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  If a beneficiary erroneously submits a Form CMS -1490 (beneficiary -filed claim form) to a carrier with an itemized bill for services that must be paid by the FI, the carrier forwards such claims to the FI for the necessary action. The FI will inform the provider to submit a claim once the information is received from the carrier.   If the claim covers a combination of services both within and outside the carriers jurisdiction the carrier should retain the Form CMS -1490 and any claims material needed for processing and forward a photocopy of the Form CMS -1490 and other claims materia ls to the other involved carrier(s) or FI(s). The carrier should notify the beneficiary when it transfers the claim.   The patients signature on the Form CMS -1490 satisfied the signature requirement and protects the filing date for the provider billings. (See 70.1 for time limitations for filing claims).   10.1.9.9 - A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a DME MAC receives a claim submitted on the Form CMS -1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.
(Medicare Claims Processing Manual)
When a DME MAC receives a claim submitted on the Form CMS -1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.   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: CO  CARC: 109  RARC: N104  MSN: N/A   DME MACs shall continue to follow existing procedures for misdirected beneficiary-submitted claims and electronic claims.   10.2 - FI Jurisdiction of Requests for Payment  (Rev. 1, 10- 01-03)  The FIs have jurisdiction for the following:    All Part A services (hospital, SNF, HHA, and hospice);    Most Part B services from providers that furnish Part A services; and    Part B facility services from CORFs, Renal; Dialysis Facilities, Rural Health Clinics, Religious Nonmedical Institutions, Outpatient Physical Therapy Centers, Federally Qualified Health Centers, and Community Mental Health Centers.  For example, rural health clinics may bill physician services to carriers under applicable physician provider numbers on carrier -compliant claim formats. Also, some DMEPOS may be billed by home health agencies on claims sent to RHHIs, and some physician, lab and ambulance services may be billed by some types  of providers submitting claims to FIs.   Within this general framework, specific jurisdiction among FIs is determined by which FI has received the official tie- in notice from the CMS RO. See 20 for procedures for provider nomination of its FI. Once an FI is assigned, that FI has jurisdiction for all services furnished by the provider or supplier, except those service outside the provider/suppliers scope of service. See the Medicare Claims Proces sing Manual chapters relating to the service for a description of who may bill the individual service, e.g. lab (Chapter 17) or DME (Chapter 20).   The RHHIs have jurisdiction for HHA and Hospice claims.  There is a national single FI for FQHCs.  United Government Systems processes all claims from independent FQHCs.
(Medicare Claims Processing Manual)
The RHHIs have jurisdiction for HHA and Hospice claims.  There is a national single FI for FQHCs.  United Government Systems processes all claims from independent FQHCs.   Regional RHC FIs have jurisdiction for claims from freestanding RHCs. See http://www.cms.hhs.gov/contacts/incardir.asp for a listing of RHC regional FIs. The host providers area FI has jurisdiction for provider based RHCs and FQHCs.   In addition some provider chains may elect a single FI for all providers in the chain.   A complete list of FIs and carriers and their service areas may be viewed at: http://www.cms.hhs.gov/contacts/incardir.asp.   Note that some providers and supplier under FI claims jurisdiction may also provide covered services outside the scope of the facility service, and may bill these services to the carrier.   Claims sent to the incorrect FI are returned to the provider with an instruction to bill the correct FI.   10.2.1 - FI Payment for Emergency and Foreign Hospital Services (Rev. 1, 10- 01-03)  A.  Beneficiary Services Outside United States -  Emergency Hospital Admissions   See chapter 3, for detailed information concerning beneficiary services outside the United States.  Generally, payment is made for emergency inpatient hospital services in qualified Canadian or Mexican hospitals in the following circumstances:    A Medicare beneficiary is in the United States when an emergency occurs, and a Canadian or Mexican hospital is closer to, or more accessible from, the site of the emergency than the nearest adequately equipped United States hospital that can provide emerge ncy services, or    The emergency occurred in Canada while the beneficiary is traveling between Alaska and another State without unreasonable delay and by the most direct route, and a Canadian hospital is closer to, or more accessible from, the site of the emergency than the nearest United States hospital.  For this purpose, an emergency occurring within the Canadian inland waterway between the States of Washington and Alaska is considered to have occurred in Canada.
(Medicare Claims Processing Manual)
The term United States means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, Northern Mariana Islands, American Samoa and, for purposes of services furnished on a ship, the territorial waters adjoining the land areas of the U.S.  A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government.   B.  Nonemergency Inpatient Services Furnished in Foreign Hospitals   If the beneficiary resides in the United States, and a Canadian or Mexican hospital is closer to, or more accessible from, the beneficiarys home than the nearest adequately equipped United States hospital, Medicare will pay for covered services regardless  of whether an emergency exists.   Residence means the place in the U.S. where a person has a fixed and permanent home to which he intends to return whenever he is away.  At the time such services are furnished, the Canadian or Mexican hospital must be acc redited by the JCAH or by a hospital approval program of the country in which it is located having standards essentially equivalent to those of the JCAHO.   10.3 - Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider  (Rev. 1, 10- 01-03) B3-3115  Section 1861(w)(1)  of the Act permits a hospital, critical access hospital, skilled nursing facility, home health agency, or hospice to obtain under arrangement, services for which an individual is entitled to under Medicare. Doing so discharges the liability of such indivi dual or any other person to pay for the services.  This is required in specified situations where the provider is paid under a PPS system.  Examples of this include:    While a patient is under a home health plan of care, the HHA must provide all covered and medically reasonable home health services and certain supplies (subject to consolidated billing) either directly or under arrangement.   Where a patient is a SNF inpatient, the SNF must furnish all services within the scope of the SNH benefit.    Where a patient is a hospital inpatient, the hospital must furnish certain inpatient services.    Certain services are considered included in the rural health clinic or federally funded health clinic visit.  In such cases, the supplier must look to the provider for payment and the provider will bill the FI.
(Medicare Claims Processing Manual)
 Certain services are considered included in the rural health clinic or federally funded health clinic visit.  In such cases, the supplier must look to the provider for payment and the provider will bill the FI.   In some cases, the hospital, SNF, or HHA may also choose not to arrange for additional services in this and bill for them. In some cases the provider may instead arrange for the supplier to furnish the test and to bill the carrier.  The provider may make different arrangements with different suppliers.  For example a provider may arrange with a lab supplier for the lab to bill for all outpatient lab services and make arrangements with an x-ray supplier for the provider to bill for all x ray services to inpa tients and outpatients.   Similarly the supplier may make different arrangements for services to beneficiaries for whom only Part B benefits are payable, from arrangements for beneficiaries for whom Part A benefits are payable under a PPS system.   The FIs notify carriers of contracts that the hospital, critical access hospital, skilled nursing facility, home health agency, or hospice have reported with their suppliers. The carrier should confirm the suppliers understanding of the arrangements to as sure that the supplier does not bill inappropriately.   A description of basic services for each benefit type is in the Medicare Benefit Policy Manual and also in the Medicare Claims Processing Manual chapter specific to the provider.   10.4  Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority  (Rev. 3537, Issued: 06- 08-16, Effective: 08 -08-16, Implementation: 08- 08-16)  Under Section 1862(a)(2) of the Social Security Act (the Act), the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service.  Also, under Section 1862(a)(3) of the Act, if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services.  These provisions are implemented by regulations 42 C.F.R. 411.4, 411.6, and 411.8, respectively.   The regulation at 42 CFR 411.4(b) states:
(Medicare Claims Processing Manual)
The regulation at 42 CFR 411.4(b) states:   Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required t o reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule.   Moreover, 72 FR 47405 states further that the   definition of custody is in accordance with how custody is defined by Federal courts for purposes of the habeas corpus protections of the Constitution.  For example, the term custody is not limited solely to physical confinement. (Sanders v. Freeman, 221F.3d 846, 850- 851 (6PthP Cir. 2000).) Individuals on parole, probation, bail, or supervised release may be in custody.   42 CFR 411.4(b) goes on to describe the special conditions that must be met in order for Medicare to make payment for individuals who are in custody, 42 CFR 411.4(b) states:   Payment may be made for services furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met: (1)  State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody. (2) The State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.   Exclusion from Coverage:
(Medicare Claims Processing Manual)
Exclusion from Coverage:   In accordance with the foregoing statutory and regulatory provisions, Medicare excludes from coverage items and services furnished to beneficiaries in State or local government custody under a penal statute, unless, it is determined that the State or local  government enforces a legal requirement that all prisoners/patients repay the cost of all healthcare items and services rendered while in such custody and also pursues collection efforts against such individuals in the same way, and with the same vigor, a s it pursues other debts.  CMS presumes that a State or local government that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and services.  Therefore, Medicares policy is to d eny payment for items and services furnished to beneficiaries in State or local government custody.   Implementation   CMS has established claim level editing to implement this policy using data received from the Social Security Administration (SSA).  Specifically, the data contain the names of the Medicare beneficiaries and time periods when the beneficiary is in such Sta te or local custody.  These data will be compared to the data on the incoming claims.  CWF will reject claims where the dates from the SSA file and the dates of service on the claim overlap. Any claims rejected by CWF will contain a trailer to the Medicare contractor indicating the date span covered. Contractors will, in turn, deny payment of such claims.  However, providers and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact with the use of modifier QJ (for A/B MAC (B) or DME MAC processed claims or for  outpatient claims processed by A/B MAC (A).   Appeals:   A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that, on the date of service, (1) the conditions of  411.4(b) were met, or (2) the beneficiary was not, in fact, in the custody of a State or  local government under authority of a penal statute.   A/B MAC (A)/RHHI Claims Processing Procedures
(Medicare Claims Processing Manual)
A/B MAC (A)/RHHI Claims Processing Procedures   A/B MACs (A) must deny claims for items and services rendered to beneficiaries under State or local government custody when CWF rejects the claim.  Provide appeal rights as specified above.   Providers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact on the claim by billing as follows:   For outpatient claims, providers shall append a HCPCS modifier QJ on all lines with a line item date of service during the incarceration period.   For inpatient claims where the incarceration period spans only a portion of the stay, hospitals shall identify the incarceration period by billing as non- covered all days, services and charges that overlap the incarceration period.  Non- coverage billing guidelines can be found in Pub. 100- 04, Chapter 1, Section 60.   (NOTE:  When the inpatient claim is correctly billed, the processing contractor will append the payer -only condition code 63, which will allow the claim to process for payment.  This condition code indicates that the provider has been instructed by the state or local government agency that requested the healthcare items or services provided to the patient of the State or local government entity that it pursues collection of debts incurred for furnishing such items or services with the same vigor and in the same manner as any other debt.)   A/B MAC (B)/DME MAC Claims Processing Procedures   A/B MAC (B) and DME MACs must deny claims for items and services rendered to beneficiaries when rejected by CWF. Provide appeal rights as specified above.   Physicians and other suppliers that render services to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact on the claim.  Providers should use the QJ modifier. Language approved for QJ reads:   Services/items provided to a prisoner or patient in State or local custody, however, the State or local government, as applicable, meets the requirements in 42 CFR 411.4(b).
(Medicare Claims Processing Manual)
Services/items provided to a prisoner or patient in State or local custody, however, the State or local government, as applicable, meets the requirements in 42 CFR 411.4(b).   This modifier indicates that the physician or other supplier has been instructed by the state or local government agency that requested the healthcare items or services provided to the patient that State or local law makes the prisoner or patient responsib le to repay the cost of Medical services and that it pursues collection of debts incurred for furnishing such items or services with the same vigor and in the same manner as any other debt.      10.5 - Claims Processing Requirements for Deported 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.   Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation.  Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if t here is no monthly benefit payable under Title II.  Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residin g permanently in the U.S.  Given that, a deported beneficiary is not allowed to enter the U.S. and cannot be lawfully present in the United States to receive Medicare- covered services, Medicare payment cannot be made for Part B Benefits.