evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
350.12 - Appeals on Claims for Emergency and Foreign Services  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  When a MAC receives a beneficiary appeal of a claim submitted by the beneficiary for services provided by a non-participating provider, the MAC will process the appeal in accordance with the guidelines in Pub. 100- 04 chapter 29.   When a MAC receives an appeal from a non -participating provider of a claim that was submitted by, or on behalf of, a beneficiary, the MAC shall dismiss the appeal request as the non -participating provider is not a proper party. The MAC shall send a copy of  the dismissal to the beneficiary.  A non- participating provider does not have standing to file an appeal for the individual claims for payment it submits on behalf of a beneficiary, or for claims the beneficiary submits for services it has furnished.  See , 42 CFR 405.906(a)(3) and 405.902 (for the definition of provider); Pub. 100- 04, chapter 29, 210 and the glossary in Pub. 100- 04, chapter 29, 110 (for the definition of provider).  Only a beneficiary (or the beneficiarys authorized representative, or an appointed representative on behalf of the beneficiary) can appeal claim determinations for services furnished by a non- participating provider.  NOTE:   Non -participating providers have appeal rights under the provider and supplier enrollment appeals process in 42 CFR Part 498 for MAC determinations related to the non- participating providers election to file claims (see 350.10).   NOTE:   The RRB conducts Part B redeterminations under the Railroad Retirement Act for services rendered in Canada.   360 - Payment for Services Received By Nonparticipating Providers  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the 42 CFR 424.100- 109,  Subpart G Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital.  The Form CMS -1450 or its electronic equivalent must be used.  A.  Hospital Filed Claims
(Medicare Claims Processing Manual)
The Form CMS -1450 or its electronic equivalent must be used.  A.  Hospital Filed Claims   1.  Inpatient Services   The payment rate for inpatient claims is 100 percent of the nonparticipating providers customary charges (see 42 C.F.R. 413.74(b) and 42 C.F.R. 424.104(a)(3)).   The cost of the services is adjusted by any applicable deductible and coinsurance amounts for which the beneficiary is responsible.   Payment will be made to Federal hospitals that furnish emergency services, on an inpatient basis, to individuals entitled to hospital benefits.  Payment will be based on the lower of the actual charges from the hospital or rates published for Federal hospi tals in the Federal Register under Office of Management and Budget -  Cost of Hospital and Medical Care and Treatment Furnished by the United States; Certain Rates Regarding Recovery from Tortiously Liable Third Persons.   Medicare will not pay federal hospitals for emergency items or services furnished to veterans, retired military personnel or eligible dependents.  However, Medicare can pay for the inpatient deductible charged by VA hospitals, or credit that amount to the Medicare Part A deductible, for emergency services furnished to veterans.  If a Part A claim is denied, a denial notice will be forwarded to the beneficiary from the MAC.  The beneficiary can use this notice to forward to their private insurer, if applicable.   The VA or Department Of Defense hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.   2.  Outpatient Services   The amount paid by Medicare for emergency outpatient claims is obtained as follows:    Eighty- five percent of the total covered charges is the estimated cost figure.  The applicable Part B deductible is subtracted.  Coinsurance is subtracted from the remainder.    Subtracting the deductible from 85 percent of the total covered charges and applying the 20 percent coinsurance rate to the remainder obtains the patients coinsurance amount.  The hospital will be paid cost (85 percent of covered charges) minus deductible  and coinsurance.   3.  Part B Medical and Other Health Services
(Medicare Claims Processing Manual)
3.  Part B Medical and Other Health Services   Part B medical and other health services, including hospital -based ambulance services whether hospital or beneficiary filed, may be covered and paid on a non- emergency basis.  To calculate the amount paid by Medicare, the hospital subtracts the Part B deductible from the total covered charges and applies the 80 percent payment rate.  4.  Special Letters for Partially or Totally Denied (Hospital- Filed) Claims for Emergency Inpatient Services   The patient receives a notice from CMS covering the emergency payment of a partially denied claim.  A denial letter and a Part B explanation of benefits is sent to the patient.  The MAC includes its address on this letter.   B.  Beneficiary Filed Claim  1.  Emergency Inpatient Claims   The payment computation follows:    Any noncovered accommodation charge is subtracted from the total accommodation charges.  The amount of the inpatient deductible or coinsurance met on this bill is subtracted.  Any remainder is multiplied by 60 percent.    The total noncovered ancillary charge is subtracted from the total ancillary charge.  Any inpatient deductible or coinsurance that remains is subtracted.  The remainder is multiplied by 80 percent.    The benefit amounts obtained are added.   2.  Emergency Outpatient Services   To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply the 80 percent payment rate.   3.  Part B Medical and Other Health Services   Part B medical and other health services furnished by nonparticipating hospitals, including hospital -based ambulance services, may be covered and paid on a non- emergency basis.   To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply an 80 percent payment rate.   4.  Special Letters for Patient -Filed Claims for Emergency Inpatient Services   For emergency admissions to nonparticipating hospitals where direct payment is made to the patient, the MAC sends the beneficiary one of the letters described below, as appropriate.   The letter explains the Part A payments made.  Part B payments are made for ancillary services not covered by Part A and are also explained in a letter.  This letter also explains the beneficiarys right of appeal.
(Medicare Claims Processing Manual)
The letter explains the Part A payments made.  Part B payments are made for ancillary services not covered by Part A and are also explained in a letter.  This letter also explains the beneficiarys right of appeal.   The MAC retains a duplicate of all notices sent for documentation in any appeals process.  It enters the date the notice is released on both copies of all notices.   Sample paragraphs:    Enclosed is a check for $______, which is the amount Medicare can pay for inpatient hospital services you received from (date of admission) to (date of discharge) in (hospital).    Medicare is able to pay 60 percent of the charges for your room and board plus 80 percent of the charges for all other covered services during the period (date emergency began) to (date payment ended).   Medicare is able to pay 60 percent of the charges for your room and board, 80 percent of the charges for other separately identified charges, and 66 2/3 percent of the other charges which were not separately identified on the hospital bill.    Medicare does not pay (the first $ ____ of charges) (the first three pints of blood) ($ ____ a day after the 60th day) in a benefit period.  (Select one or more, if applicable.)    If lifetime reserve days are used, add $ ___ a day from ________ to _________.    If you believe your Medicare hospital insurance should have covered all or more of your expenses, you may get in touch with us at the address shown on this letter.    If you believe that the determination is not correct, you may request a reconsideration for hospital insurance (or a review for medical insurance).  You may make the request by mail to the address shown on this letter.  If you come in person, please bring this notice with you.    This check includes a medical insurance payment for 80 percent of the charges for certain nonroutine hospital services which you received from _______ through _______.  These services are listed on the enclosed form.
(Medicare Claims Processing Manual)
 If a hospital bill is not itemized, Medicare can pay 66 2/3 percent of the total covered charges.  Payment is being made at this rate for charges from (date emergency began) to (date payment ended).    We are enclosing a check for $ ______.  This is your payment under Part B for 80 percent of the charges for the services which you received from (admission date) through (discharge date) while in (name of hospital).  These services are listed on the enclo sed form.   When payment cannot be made under hospital insurance, medical insurance covers some, but not all, of the hospital services.  Room and board and certain other services are not covered by medical insurance.   360.1 - Payment for Services from Foreign Hospitals  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the 42 CFR 424.100- 109,  Subpart G Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital   A.  Hospital Filed Claim  A foreign hospital that elects to bill the Medicare program receives 100 percent of its customary charges, subject to applicable deductible and coinsurance amounts.  The hospital establishes its customary charges for the services by submitting an itemized bill with each claim.  This eliminates the need to file a cost report.   Regardless of the billing form used, the MAC must:   Recode the bill using revenue codes for the Form CMS-1450;   Prepare an HUIP or HUOP input record for CWF; and   Send a Medicare Summary Notice (MSN) to the beneficiary.   The nonparticipating hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.   Payment is subject to the official exchange rate on the date the patient is discharged.
(Medicare Claims Processing Manual)
The nonparticipating hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.   Payment is subject to the official exchange rate on the date the patient is discharged.   B.  Beneficiary Filed Claim  To calculate the amount paid by Medicare for Part B Hospital -Based Ambulance Claims, the hospital must subtract any unmet Part B deductible from the total covered charges and apply the 80 percent payment rate.  Payment to the beneficiary is subject to the official exchange rate on the date of discharge.  360.1.1 - Attending Physicians Statement and Documentation of Medicare Emergency  (Rev. 4111, Issued: 08-10- 18, Effective: 9 -11-18, Implementation: 9-11-18)  Form CMS -1771 - go to https://www.cms.gov/Medicare/CMS -Forms/CMS -Forms/CMS -Forms -List.html  360.2 - Designated Contractors  (Rev. 3287, Issued: 06- 30-15, Effective: 04-21-15, Implementation: 04-21-15)  Per Contractor Statement of Work (SOW) all contractors are designated to process claims for physicians and ambulance services furnished in connection with a covered hospital stay in Canada and Mexico for their beneficiaries who reside in the states/areas for which they process claims.   360.3 - Model Letters, Nonparticipating Hospital and Emergency Claims  (Rev. 3287, Issued: 06- 30-15, Effective: 04-21-15, Implementation: 04-21-15)  360.3.1 - Model Letter to Nonparticipating Hospital That Elected to Bill For Current Year  (Rev.3287, Issued: 6-30- 15, Effective:04 -21-15, Implementation: 04-21-15)  DEPARTMENT OF HEALTH AND HUMAN SERVICES   CENTERS FOR MEDICARE & MEDICAID SERVICES   REFER TO:
(Medicare Claims Processing Manual)
DEPARTMENT OF HEALTH AND HUMAN SERVICES   CENTERS FOR MEDICARE & MEDICAID SERVICES   REFER TO:   Identification Number:___________________  Dear _________________:  Your election to bill the Medicare program for emergency services furnished to Medicare beneficiaries will expire on December 31.  Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.   If you elect to bill the program, please return to us in the enclosed self -addressed envelope a statement signed by an authorized official of your hospital stating that you elect to claim payment under the Medicare program.  An election to bill cannot be w ithdrawn during the year.  If a statement is not received by December 31, we will assume that you do not wish to continue to bill the program at this time.  However, you still retain the right to elect to bill the program at any time during the coming year  if, when you make your election, you have not yet charged any Medicare beneficiary in that year for emergency hospital services rendered to him.   Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting the MAC serving nonparticipating hospitals in your State.  If you do not elect to bill, the beneficiary may apply for reimbursement by submi tting an itemized bill.   Please contact us if you need any further information.  In addition, if at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare MAC for complete particulars.   Sincerely,   360.3.2 - Model Letter to Nonparticipating Hospital That Did Not Elect to Bill for Current Year  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  DEPARTMENT OF HEALTH AND HUMAN SERVICES  CENTERS FOR MEDICARE & MEDICAID SERVICES   REFER TO:   Identification Number:______________________  Dear ___________________:
(Medicare Claims Processing Manual)
REFER TO:   Identification Number:______________________  Dear ___________________:   Under the Medicare program, hospital benefits ordinarily can be paid only for care furnished to patients of hospitals that are participating in the program.  However, the program can also pay for hospital services furnished to a beneficiary who is admitted to a nonparticipating hospital in an emergency.  To receive payments for emergency services, a nonparticipating hospital must meet certain conditions specified in the law.  We have determined that your hospital meets these condi tions.  Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.  Although your hospital did not elect to bill the program for the current calendar year, you may wish to bill for the coming year.  If you so choose, please have an authorized official of your hospital sign a statement to this effect and return in the enclosed self -addressed envelope.  R etain a copy for your records.  An election to bill cannot be withdrawn during the year.   If we have not received a statement from you by December 31, we will assume that you do not wish to bill the program at this time.  However, you still retain the right to elect to bill the program at any time during the coming year if, when you make your e lection, you have not yet charged any Medicare beneficiary in that year for emergency hospital services rendered to him.  Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting us.  If a hospital does not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.  If at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare intermediary for complete particulars.   Sincerely,   360.3.3 - Model Letter to Nonparticipating Hospital That Requests to Bill the Program  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  DEPARTMENT OF HEALTH AND HUMAN SERVICES   CENTERS FOR MEDICARE & MEDICAID SERVICES   REFER TO:
(Medicare Claims Processing Manual)
DEPARTMENT OF HEALTH AND HUMAN SERVICES   CENTERS FOR MEDICARE & MEDICAID SERVICES   REFER TO:   Identification Number:______________________  Dear ____________________:   This refers to your inquiry concerning payment for emergency hospital services rendered to a Medicare beneficiary in a hospital which is not participating in the Medicare program.  Under the Medicare program, hospital benefits ordinarily can be paid only f or care furnished to patients of hospitals that are participating in the program.  However, the program can also pay for hospital services furnished to a beneficiary who is admitted to a nonparticipating hospital in an emergency.  To receive payments for emergency services, a nonparticipating hospital must meet certain conditions specified in the law.  We have determined that your hospital meets these conditions.   Payment for emergency services can be made to a nonparticipating hospital only if you elect to receive reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.  Your hospital may now choose to bill the program for all emergency services furnished to Medicare beneficiaries during the current calendar year, if you have not yet charged any Medicare beneficiary this year for emergency hospital services rendered to him.   If you so choose, please have an authorized official of your hospital sign a statement to this effect and return in the enclosed self -addressed envelope.  Retain a copy for your records.  An election to bill cannot be withdrawn during the year.   Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting us.  If you do not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.   If at any time you decide to request full participation as a provider of hospital services under the Medicare program, please contact your Medicare intermediary for complete particulars.   Sincerely,    360.3.4 - Full Denial - Hospital -Filed or Beneficiary -Filed Emergency Claim  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)
(Medicare Claims Processing Manual)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re 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.     Contractors shall include beneficiary appeal rights language and include in the mailing a redetermination request form where applicable.   MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)   Date: ______________   Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES    We are sorry, but payment cannot be made for your stay from _______ through _______ at (hospital).  This is because the (hospital) does not participate in the Medicare program and it has been determined that your treatment there does not qualify as emergency care.   Under the law, payment for services received in a nonparticipating hospital can be made only if you go, or are brought to, the hospital to receive emergency care.  Emergency care under Medicare is defined as:   a. Care which is necessary to prevent the death or serious impairment to the health of the individual; and  b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) that has a bed available and is equipped to handle the emergency.   The medical facts of your hospital admission and stay have been carefully reviewed.  Based upon this review, we have found that, although it was necessary for you to be hospitalized, a medical emergency did not exist.  There would have been time for you to have been admitted to a hospital participating in Medicare.
(Medicare Claims Processing Manual)
If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.    You may send the request to our address above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.5 - Partial Denial - Hospital- Filed or Beneficiary -Filed Emergency Claim (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re 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.   MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)   Date: ______________   Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES
(Medicare Claims Processing Manual)
Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES    This refers to your request for payment under Medicare for the services received while a patient at (hospital), from _______ through _______.  Payment can be made under the hospital insurance part of Medicare only for the costs of your hospitalization from _______ to _______.  The (hospital) does not participate in the Medicare program.  Under the law, payment for services received in a nonparticipating hospital can be made only if you go, or are brought to, the hospital to receive emergency care.  Emergency care under Medicare is defined as:   a. Care which is necessary to prevent the death or serious impairment to the health of the individual; and  b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) which has a bed available and is equipped to handle the emergency.   Payment for emergency services stops when the emergency ends and it is permissible, from a medical standpoint, either to transfer the patient to a participating hospital or to discharge him.   The medical facts of your hospital admission and stay have been carefully reviewed.  Based upon this review, we have found that an emergency condition existed when you were admitted.  However, the medical information indicates that this emergency condition ended on ________.  At that time, your condition had improved to the extent that you could have been transferred to a hospital participating in the Medicare program.