evekhm/cms_iom_500 huggingface dataset:
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 For swing- bed determinations.  The Preadmission/Admission HINN (HINN 1) should be given.   NOTE:   An ABN, Form CMS -R-131 may be required if a SNF has been acting as a supplier of Part B services or supplies outside a physicians plan of care.  See Section 50 of this manual, as applicable.    70.4 - SNF ABN Specific Delivery Issues  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)    When completing and delivering the SNF ABN, SNFs must meet the written notice standards in 50.6 and 50.7 of this chapter, unless otherwise specified.  Failure to provide a proper SNF ABN in situations where a physician has ordered the extended care item or service may result  in the SNF being held financially liable under the LOL provisions, where such provisions apply.  SNFs may also be sanctioned for violating the conditions of participation ( 42 CFR 483.10) regarding resident (beneficiary) rights.   NOTE:  The SNF ABN is not a replacement for, but is in addition to, the required UR entity notices .  The SNF ABN protects the SNF from liability in the event the beneficiary, for some reason, does not receive the UR entity notice.                      70.5 - Special Rules for SNF ABNs  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   A.  Collection from Beneficiary
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A.  Collection from Beneficiary   When a SNF ABN is properly executed and given timely to a beneficiary and Medicare denies payment on the related claim, the SNF must wait for the beneficiary to receive a Medicare Summary Notice (MSN) before it can collect payment on the related claim.  Medicare does not limit the a mount that the SNF may collect from the beneficiary in such a situation.  A beneficiarys agreement to be personally and fully responsible for payment means that the beneficiary agrees to pay out of pocket or through any other insurance that the benefici ary may have, e.g., through employer group health plan coverage, through Medicaid, or through some other Federal or non- Federal payment source.   NOTE:   The beneficiary may request a demand bill at any point in her or his care.   B.  Unbundling Prohibition  The SNF ABNs may not be used to shift financial liability to a beneficiary in the case of services for which full payment is bundled into other payments; that is, where the beneficiary would otherwise not be financially liable for payment for an extended c are item or service because Medicare made a bundled payment.  Using a SNF ABN to collect from a beneficiary where full payment is made on a bundled basis would constitute double billing.  A SNF ABN may be used to shift financial liability to a beneficiary in the case of extended care items or services for which partial payment is bundled into other payments; that is, where part of the cost is not included in the bundled payment made by Medicare.   C.  Acceptance or Rejection of SNF ABN   These instructions are to assist the Medicare contractor in advising SNFs with respect to their responsibilities in advising beneficiaries with respect to their rights and protections and in dealing with complaints from beneficiaries, or authorized represe ntatives, about the lack of notice or defective notice.  The SNF should:
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 Answer inquiries from a beneficiary regarding the basis for the SNFs, the UR entitys, the QIOs, or the Medicare contractors assessment that extended care items or services may not be covered and, if requested by the beneficiary, the SNF must give the beneficiary access to medical record information or other documents upon which these entities  based their assessment, to the extent permissible or required under applicable state law.   NOTE:   Where state law prohibits such direct disclosure, the SNF should advise a beneficiary who has requested access to such information how to obtain that information from the SNF once a demand bill has been submitted.    Respond timely, accurately, and completely to a beneficiary who requests information about the extent of the beneficiarys personal financial liability.    Timely submit additional information to the Medicare contractor, if a beneficiary or a physician provides that additional information with respect to Medicare coverage of the subject extended care items or services.   70.6 - Establishing When Beneficiary Is On Notice of Non -coverage  (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   If the beneficiary has previously been informed in writing that similar or reasonably comparable extended care items or services were non -covered and it was clear that the beneficiary knew that the circumstances were the same, the beneficiary is liable.  With this exception, the beneficiary is presumed not to have known, nor to have been expected to know, that the extended care items or services are not covered unless, or until, s/he receives notification from an appropriate source.   70.6.1 - Source of Beneficiary Notification   (Rev.: 4198; Issued: 01- 11-19; Effective: 04 -30-18; Implementation: 04 -30-18)   Written Notification must be given by one of the following sources:   A.  The SNF that is furnishing non- covered extended care items or services.   Examples:    On or before the day of admission, the SNF furnishes to the beneficiary a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is non-covered; or
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 During the inpatient stay, the SNF timely furnishes to the beneficiary a SNF ABN notifying the beneficiary that the covered extended care item(s) or service(s) will no longer be covered.   B.  The UR entity of the SNF that is furnishing non- covered extended care items or services.   Example:    The UR entity timely furnishes to the beneficiary a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is no longer covered.   C.  The QIO or Medicare contractor.   Example:    The QIO, where a beneficiary is in a swing bed, timely furnishes to the beneficiary, a SNF ABN notifying the beneficiary that the extended care item(s) or service(s) is not covered or the item(s) or service(s) is no longer covered.  NOTE:   This occurs after the beneficiary receives a HINN 1 (Preadmission/Admission HINN) and after the QIOs decision of the non -coverage.    The Medicare contractor sends the beneficiary her or his first notification of non-coverage (e.g., the MSN).      70.7  70.13 New sections to be added     80 - Hospital ABNs (Hospital-Issued Notices of Noncoverage - HINN)  (Rev. 594, Issued: 06- 24-05, Effective: 07 -01-05, Implementation: 07- 01-05)  Instructions for the Hospital ABN have been retracted. Instructions related to HINNs have been relocated as follows:    Instructions regarding HINNs are found in this instruction, CR 3903, which precedes the placement of full instructions in Chapter 30.   Instructions regarding hospital billing for cases involving QIO review will be relocated to a new section in Chapter 1 of this manual in the near future. Current procedures should not change in the interim.   Related instructions for QIOs can be found in the Medicare Quality Improvement Organization Manual, Publication 100- 10, Chapter 7.  100 - Indemnification Procedures for Claims Falling Within the Limitation on Liability Provision  (Rev. 1, 10- 01-03)
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100 - Indemnification Procedures for Claims Falling Within the Limitation on Liability Provision  (Rev. 1, 10- 01-03)  Section 1879(b) of the Act provides that when a provider, practitioner, or supplier is held liable for the payment of expenses incurred by a beneficiary for noncovered items or services and such provider, practitioner, or supplier requests and receives payment from the beneficiary or any person(s) who assumed financial responsibility for payment of expenses, the Medicare program indemnifies the beneficiary or other person(s).   Further, any such indemnification payments are considered overpayments to the provider, practitioner, or supplier.   A provider, practitioner, or supplier who is determined liable may not seek payment from a third party payer. (See 30.2.B .)  100.1 - Contractor and Social Security Office (SSO) Responsibility in Indemnification Claims  (Rev. 1, 10- 01-03)  The contractor, SSO, RO, or central office may receive requests or inquiries concerning indemnification. However, a beneficiary or person(s) who made payment on behalf of the beneficiary to a liable provider usually visits his/her nearest SSO or deals dire ctly with the contractor to file a request for indemnification.   Those offices are responsible for assisting beneficiaries or any person(s) in filing claims for indemnification.   100.2 - Conditions for Indemnification  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A beneficiary or any person(s) who assumed financial responsibility for payment is indemnified for claims filed if all of the following conditions are met:    The contractor has determined that the beneficiary is without liability under authority of 1879 of the Act for items and services furnished by a provider, practitioner, or supplier;    The contractor or the QIO has determined that the provider, practitioner, or supplier is liable under 1879 for the items and services furnished to the beneficiary. A provider, practitioner, or supplier is considered to have knowledge that payment will n ot be made under Medicare for items or services in a particular claim where the following evidence is established regarding the provider, practitioner, or supplier;
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(1) Evidence that a provider, practitioner, or supplier knew, or could reasonably be expected to have known, of exclusion of items or services   o General notice to the medical community regarding exclusion of certain items or services: e.g., colonic irrigation, acupuncture.   o General notice to the medical community that services exceeding certain frequencies would be denied or subject to additional review, e.g., vitamin B12 injections, or nursing home visits more frequent than once a month.  o Written notice to the particular provider, practitioner, or supplier that a type of service or item would be noncovered in all or certain circumstances.   A distinction must be maintained between coverage rules that specify that a type of service or item would be not reasonable or necessary in all or certain circumstances, and utilization guidelines the contractor established to identify excessive services. Any written policies or other internal edits that are disclosed to a provider, practitioner, or supplier would not be considered as a notice of exclusion, since they are used for referring claims for further development rather than as rules to make a con tractor coverage decision.   In addition to instances when the Medicare program has given notice, the allegation of a provider, practitioner, or supplier is not accepted without further verification in situations of potential program abuse involving a pattern of unnecessary services b y a provider, practitioner, or supplier to a number of beneficiaries. When a provider, practitioner, or supplier frequently renders unnecessary services, i.e., services that significantly exceed the frequency with which the general medical community render s them, it is reasonable to expect the provider, practitioner, or supplier to know that such a pattern deviates from the standard practice.   (2) Evidence that provider, practitioner, or supplier did not have knowledge of exclusion of services.   In contrast to subsection 1, there may be situations where an assumption can be made that neither the beneficiary nor the provider, practitioner, or supplier had knowledge of exclusion, and liability can be limited by the reviewer without a statement by either party. In the following situations, further development would not be necessary:
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a. The service is for a type of treatment that can be rendered only by a physician, but the contractor has not previously denied payment for the treatment, and it is not unreasonable that a particular physician might consider the treatment appropriate. In order to determine whether the services are reasonable and necessary, the contractor requests its physician consultant or CMS to advise whether the services are covered. This is a case for which there are no general coverage guidelines for the services; the contractor has not advised either the physician or the medical community regarding the coverage of the servic es; and the contractor is uncertain without expert consultation. In such a case, it may be presumed that neither the beneficiary nor the physician could have known that the services would be noncovered.   b. The item or service is ordinarily covered, but a question is raised as to whether it is reasonable and necessary in treatment of a particular diagnosis. Neither the provider, practitioner, or supplier nor the medical community has been advised that the item or service is not covered for that diagnosis. The case requires a determination by the contractors medical consultant or is referred to CMS for guidance. As in example (a), the liability of both parties should be limited.   c. The provider, practitioner, or supplier is newly arrived in the contractor service area, and the contractor has not yet communicated to the provider, practitioner, or supplier information in an existing general notice that the item or service is not cov ered, always or under certain circumstances.   NOTE:   If any provider, practitioner, or supplier could reasonably be expected, by virtue of normal medical knowledge, to know that the service was unneeded, the presumption suggested in the above examples would not apply.   The requester for indemnification has paid the provider, /practitioner or supplier all or some of the charges for items and services for which the beneficiarys liability has been waived under 1879 of the Act; and    The requester seeks indemnification by filing a written statement prior to the end of the sixth month following:   o The month in which payment was made to the provider, practitioner or supplier; or
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 The requester seeks indemnification by filing a written statement prior to the end of the sixth month following:   o The month in which payment was made to the provider, practitioner or supplier; or   o The month in which the contractor advised the beneficiary that the beneficiary was not liable for the noncovered items or services, whichever is later.   The contractor extends the six month time limit if good cause is shown. The contractor uses the principles for determining good cause outlined in Chapter 29, Appeals of Claim Decisions.   100.3 - Development and Documentation of Indemnification Requests  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  When the contractor receives a request or inquiry concerning indemnification directly from the beneficiary or the beneficiarys authorized representative, it must obtain the following information and documentation:    Identifying information sufficient for the contractor to locate the claim(s) for noncovered items or services for which payment has been made to the provider, practitioner, or supplier by the beneficiary or other person and for which the liability of the  beneficiary was limited. Ordinarily, the initial MSN or appeal determination suffices.    A statement on Form SSA -795, Statement of Claimant or Other Person, (see 100.10, Exhibit 4 ) to the effect that the requester paid the provider, practitioner, or supplier all or some of the charges for the noncovered items or services for which the beneficiarys liability was limited. The statement must specify the amount the requester has paid the provider, practitioner, or supplier. If the requester submits this information in a letter, the letter serves as the signed statement.   100.3.1 - Proof of Payment  (Rev. 1, 10- 01-03)  The following types of documentation are sufficient to establish that payment was made in the amount alleged:    An itemized bill from the provider, practitioner, or supplier reflecting the items and services for which the provider, practitioner, or supplier has been found liable and has received payment along with the payers cancelled check, money order receipt, or statement of receipt from the provider, physician, or supplier;
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 A summary bill from the provider, practitioner, or supplier which pertains to the items and services for which the provider, practitioner, or supplier has been found liable and has collected from the beneficiary or other person along with the payers cancelled check, money order receipt, or a statement of receipt from the provider, practitioner, or supplier showing the same total amount;    The payers cancelled check, money order receipt, or the statement of receipt from the provider, practitioner, or supplier if the contractors records reflect the provider, practitioner, or suppliers charges for the items and services for which the provider, practitioner, or supplier has been found liable and these equal the total of the amount paid; or    If the requester alleges that the provider, practitioner, or supplier did not furnish an itemized bill or a receipted statement and no other proof of payment is available, the contractor obtains a statement on Form SSA -795 to this effect from all parties involved, including the provider, physician, or supplier if possible. The statement should describe the circumstances, such as the manner of payment, and the reasons for not obtaining a receipt or any proof of payment. If there were any witnesses to the pay ment, the contractor obtains their statements on Form SSA-795. The contractor refers any questions as to the acceptability of proof of payment to the RO.  When the beneficiary or other person on behalf of the beneficiary initially contacts the SSO, that office sends the statements and evidence relevant to the indemnification claim to the appropriate contractor. If future contact with the beneficiary or other  person is necessary, the contractor proceeds with a direct contact unless the assistance of the SSO is needed.   100.4 - Beneficiary Requests Indemnification, but Had No Financial Interest in the Claim  (Rev. 1, 10- 01-03)  If a request for indemnification is received from the beneficiary but the beneficiary did not have full financial interest in the claim, then any other person(s) who made full or partial payment to the provider, practitioner, or supplier must be contacted to ascertain if that person wishes to file for indemnification.
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If the individual declines to file for the indemnification payment, the SSO or contractor staff should assist in preparing a statement to that effect for the individuals signature. No payment is made in this instance; however, the contractor notifies all involved parties.   If more than one person helped pay the bill; e.g., sons and daughters of the beneficiary got together and each paid a portion of the bill; the contractor must determine the indemnification amount for each payer unless they all agree in writing that payment  is to be made to one person.  Explain this to the requester for indemnification in such instances.   100.5 - Questionable Indemnification Requests Procedure  (Rev. 1, 10- 01-03)  If the contractor receives a request for indemnification that does not appear to meet the conditions outlined in 100.2, and there is some uncertainty concerning the indemnification claim, it undertakes development to resolve the issues. If the issues cannot be adequately resolved, it obtains the assistance of the RO.   100.6 - Determining the Amount of Indemnification  (Rev. 1, 10- 01-03)  In accordance with 1879(b)  of the Act, the contractor indemnifies the beneficiary or other person(s) for actual charges paid to a provider, practitioner, or supplier, rather than the usual allowable charges as determined by the Medicare program, PPS amounts, or established per diem  rates that apply to certain provider, practitioner, or suppliers.  Additionally, 4096 of P.L. 100- 203 (OBRA of 1987) revises certain limitation on liability requirements for indemnification under 1879(b) of the Act. A beneficiary qualifying for indemnification for denied items and services furnished on or after January  1, 1988 is no longer responsible for paying deductible and coinsurance charges related to the denied claim. Where such indemnification is made, the contractor may not charge the beneficiarys Medicare utilization record for the denied items and services furnished.   100.7 - Notifying the Provider, Practitioner, or Supplier  (Rev. 1, 10- 01-03)
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100.7 - Notifying the Provider, Practitioner, or Supplier  (Rev. 1, 10- 01-03)  After the contractor has reviewed the claim for indemnification and the indemnification amount has been determined, it notifies the provider or physician/supplier of the proposed indemnification action. (A sample letter for these situations is contained in  100.10, Exhibit l .) The essential elements of this written notice are:    An explanation of the items and services for which the provider or physician/supplier is liable with reference to the original notice to the provider or physician/supplier;    A statement of the provision of 1879 which allows the program to indemnify the beneficiary and recover an overpayment from the provider, practitioner, or supplier;    An explanation of the amount determined payable to the requester for indemnification;   A statement that the amount the contractor has determined to be payable is paid to the requester and that it constitutes an overpayment to the provider, practitioner, or supplier which is to be recovered from future Medicare payments made to it;    A statement encouraging the provider, practitioner, or supplier to refund any amount(s) already collected; and    A reminder to the provider, practitioner, or supplier of his/her/its Medicare appeal rights.  If the provider, practitioner, or supplier does not respond to this notice within 15 days, the contractor makes payment to the requester in accordance with 100.8. If the provider, practitioner, or supplier disputes the indemnification or the amount to be paid, the contractor resolves any discrepancies before making payment. The payment process takes place even if the provider, practitioner, or supplier might appeal the contractors initial determination which held the provider, practitioner, or physician liable and that appeal is still pending at the time payment of the indemnification amount is to take place. If the appeal decision reverses the initial determination, then adjustments are to be made at that time in the contractor and provider, practitioner, or suppli er records. In all cases, the contractor encourages the provider, practitioner, or supplier to refund any and all amounts collected to this point. If the provider, practitioner, or supplier chooses to refund any money collected, the contractor verifies tha t such a refund has actually been made to the requester.