evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
DRG claims with cost outlier payments with discharge dates on or after October 1, 1997, must have an Occurrence Code (OC) 47 on the claim unless there are enough full and/or coinsurance days to cover all the medically necessary days or the only available benefits are LTR days and there are enough LTR days to cover all the med ically necessary days.  DRG claims without cost outlier payments can never have regular benefit days combined with LTR benefit days.   Once the cost outlier threshold is known, providers must add the daily covered charges for the claim until they determine the day that covered charges reach the cost outlier threshold.  Providers must exclude days and covered charges during noncovered spans, e.g., during Occurrence Span Code (OSC) 74, 76, or 79 dates.  Providers must then submit the date of the first full day of cost outlier status (the day after the day that covered charges reach the cost outlier threshold) on the bill using OC 47.  The OC  47 date cannot be equal to or during OSC 74, 76, or 79 dates.  Providers must determine the amount of regular, coinsurance, and LTR days the beneficiary has available per CWF inquiry or their FI.   Any nonutilization days after the beneficiary exhausts coinsurance or LTR days before the OC 47 date will be identified using OSC 70.  LTR days should be used as necessary and as elected by the beneficiary.  If coinsurance days are exhausted during the inl ier portion of the stay and there is a period of nonutilization indicated by the presence of OSC 70 and the beneficiary elects not to use LTR days, covered charges are limited to the exact amount of the cost outlier threshold and both OC A3, which shows the last covered day, and OC 47, which shows the following day which is the first full day of cost outlier status, must be shown.  When coinsurance and/or LTR days are exhausted during the cost outlier portion of the stay, OC A3 should be used as appropriate  to report the date benefits are exhausted.  Covered charges should be accrued to reflect the entire period of the bill if the bill is fully covered or the entire period up to and including the date benefits were exhausted, if benefits were exhausted.   Assumptions for all of the following examples:
(Medicare Claims Processing Manual)
Assumptions for all of the following examples:   1. Cost outlier threshold amount is $50,000.  2. Threshold amount is reached on the 25th day.   3. Billed charges are $1,000 each day thereafter.   4. Beneficiary elects to use any available LTR days.   EXAMPLE 1: LTR Days Cover Cost Outlier   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available  30 LTR  Covered days  30 Noncovered days  0 Cost report days  30 All charges for Medicare approved revenue codes billed as covered  No OC 47 needed   Reimbursement:  Full DRG plus cost outlier based on $55,000 covered charges   EXAMPLE 2:  LTR Days Exhaust in the Cost Outlier   Dates of service:  1/1 - 2/10 discharge  Medically necessary days:  40 Covered charges:  $65,000  Benefits available:  30 LTR  Covered days:  30 Noncovered days:  10 Cost report days:  30 30 days covered charges for Medicare approved revenue codes and 10 days noncovered charges.  OC 47:  1/26 OC A3:  1/30 Reimbursement:  Full DRG plus cost outlier based on $55,000 covered charges ($50,000 inlier and $5,000 outlier   EXAMPLE 3:  LTR Days Exhaust Prior to Cost Outlier   Dates of service:  1/1 - 1/31 discharge  Medically necessary days:  30 Covered charges:  $55,000  Benefits available:  20 LTR  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3  1/25 OSC 70:  1/21 -1/25 Reimbursement:  Full DRG payment, no cost outlier   EXAMPLE 4:  Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available
(Medicare Claims Processing Manual)
EXAMPLE 4:  Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available:  20 coinsurance  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3:  1/25 OSC 70:  1/21 - 1/25  Reimbursement:  Full DRG payment, no cost outlier   EXAMPLE 5: Coinsurance Days Exhaust Prior to Cost Outlier.  LTR Days Exhausts in the Cost Outlier   Date of Service:  1/1 - 2/10 discharge  Medically necessary days  40 Covered charges  $65,000  Benefits available:  20 coinsurance and 10 LTR  Covered days:  30 Noncovered days:  10 Cost report days:  35 35 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3:  2/4 OSC 70:  1/21 - 1/25  Reimbursement:  Full DRG payment, plus cost outlier based on $60,000 covered charges ($50,000 inlier, $10,000 outlier, $5,000 noncovered)   EXAMPLE 6: Full and Coinsurance Days Cover Cost Outlier   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available:  10 full and 20 coinsurance  Covered days:  30 Noncovered days:  0 Cost report days:  30 All charges for Medicare approved revenue codes billed as covered.  OC 47:  Not needed  Reimbursement:  Full DRG payment plus cost outlier based on $55,000 covered charges.   EXAMPLE 7: Coinsurance Days and LTR Days Exhaust in the Cost Outlier
(Medicare Claims Processing Manual)
EXAMPLE 7: Coinsurance Days and LTR Days Exhaust in the Cost Outlier   Date of Service:  1/1 - 2/28 discharge  Medically necessary days  58 Covered charges  $83,000  Benefits available:  10 full, 30 coinsurance and 10 LTR  Covered days:  50 Noncovered days:  8 Cost report days:  50 50 days covered charges for Medicare approved revenue codes and 8 days noncovered charges  OC 47:  1/26 OC A3:  2/19 Reimbursement:  Full DRG payment, plus cost outlier based on $75,000 covered charges ($50,000 inlier, $25,000 outlier, $8,000 noncovered)   EXAMPLE: 8: LTR Days Exhaust Prior to Cost Outlier and Noncovered Span(s) Present   Dates of service:  1/1 - 1/31 discharge  Medically necessary days:  28 OSC 76  1/10 - 1/11 Covered charges:  $55,000  Benefits available:  20 LTR  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/28 OC A3  1/27 OSC 70:  1/23 -1/27 Reimbursement:  Full DRG payment, no cost outlier   20.8 - Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare Advantage (MA) Enrollees  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04 -07-08)  During the period January 1, 1998 through December 31, 1998, hospitals received 20 percent of the fee -for-service DGME and operating IME payment. This amount increased by 20 percentage points each consecutive year until it reached 100 percent in calendar year (CY) 2002.  Non-IPPS hospitals and units may submit their MA claims to their respective A/B MACs (A) to be processed as no -pay bills so that the MA inpatient days can be accumulated on the Provider Statistics & Reimbursement Report (PS&R) (report type 118) for DGME pa yment purposes through the cost report.   This applies to the following hospitals and units excluded from the IPPS:    Rehabilitation units    Psychiatric units
(Medicare Claims Processing Manual)
This applies to the following hospitals and units excluded from the IPPS:    Rehabilitation units    Psychiatric units    Rehabilitation hospitals    Psychiatric hospitals    Long- term Care hospitals    Childrens hospitals    Cancer hospitals   In addition, this applies to all hospitals that operate a nursing or an allied health (N&AH) program and qualify for additional payments related to their MA enrollees under 42 CFR 413.87(e).  These providers may similarly submit their MA claims to their r espective A/B MACs (A) to be processed as no -pay bills so that the MA inpatient days can be accumulated on the PS&R (report type 118) for purposes of calculating the MA N&AH payment through the cost report.   Non-IPPS hospitals, hospitals with rehabilitation and psychiatric units, and hospitals that operate an approved N&AH program must submit claims to their regular A/B MAC (A) with condition codes 04 and 69.  The provider uses Condition code 69 to indicate that the claim is being submitted as a no -pay bill to the PS&R report type 118 for MA enrollees in non- IPPS hospitals and non- IPPS units to capture MA inpatient days for purposes of calculating the DGME and/or N&AH payment through the cost report.
(Medicare Claims Processing Manual)
The A/B MAC (A) submits the claim to the Common Working File (CWF).  The CWF determines if the beneficiary is a MA enrollee and what his/her plan number and effective dates are.  The plan must be a MA plan, per 42 CFR 422.4.  Upon verification from CWF that the beneficiary is a MA enrollee, the A/B MAC (A) adds the MA plan number and an MA Pay Code of 0 to the claim.  For fee -for-service claims that were previously paid and posted to history for the same period (due to late posting of MA enrollment data) , an L -1002 Automatic Cancellation Adjustment Report will be sent to the A/B MAC (A) when a DGME -only or a N&AH- only claim from a non- IPPS hospital or unit is accepted for payment by CWF. No deductible or coinsurance is to be applied against this claim nor  is the beneficiary's utilization updated by CWF for this stay.  If CWF enrollment records do not indicate that the beneficiary is a MA enrollee, CWF rejects the claim and the A/B MAC (A) notifies the hospital of this reason.  The hospital may resubmit the claim after 30 days to see if the enrollment data has been updat ed. No interim bills should be submitted for DGME -only or N&AH -only claims and no Medicare Summary Notices should be prepared for these claims.  The DGME payments are made using the same interim payment calculation A/B MACs (A) currently employ.  Specifically, A/B MACs (A) must calculate the additional DGME payments using the inpatient days attributable to MA enrollees.  As with DGME and N&AH educa tion payments made under fee -for-service, the sum of these interim payment amounts is subject to adjustment upon settlement of the cost report.  Note that these DGME and/or N&AH payments apply both to IPPS and non- IPPS hospitals and units.
(Medicare Claims Processing Manual)
Teaching hospitals that operate GME programs (see 42 CFR 413.86) and/or hospitals that operate approved N&AH education programs (see 42 CFR 413.87) must submit separate bills for payment for MA enrollees.  The MA inpatient days are recorded on PS&R repor t type 118. For services provided to MA enrollees by hospitals that do not have a contract with the enrollees plan, non- IPPS hospitals and units are entitled to any applicable DGME and/or N&AH payments under these provisions.  Therefore, such hospitals and units should submit bills to their A/B MAC (A) for these cases in accordance with this sections instructions.  In addition to submitting the claims to the PS&R report type 118, hospitals must properly report MA inpatient days on the Medicare cost report , Form 2552- 96, on worksheet S -3, Part I, line 2 column 4, and worksheet E -3, Part IV, lines 6.02 and 6.06.  30 - Medicare Rural Hospital Flexibility Program and Critical Access Hospitals (CAHs)  (Rev. 68, 10- 16-04)  A3-3610.19, HO -415.19, A3- 3610.20, HO -415.20  The Medicare law allows establishment of a Medicare rural hospital flexibility program by any State that has submitted the necessary assurances and complies with the statutory requirements for designation of hospitals as critical access hospitals (CAHs).
(Medicare Claims Processing Manual)
The Medicare law allows establishment of a Medicare rural hospital flexibility program by any State that has submitted the necessary assurances and complies with the statutory requirements for designation of hospitals as critical access hospitals (CAHs).   To be eligible as a CAH, a facility must be a currently participating Medicare hospital, a hospital that ceased operations on or after November 29, 1989, or a health clinic or health center that previously operated as a hospital before being downsized to a  health clinic or health center.  The facility must be located in a rural area of a State that has established a Medicare rural hospital flexibility program, or must be located in a Metropolitan Statistical Area (MSA) of such a State and be treated as bein g located in a rural area based on a law or regulation of the State, as described in 42 CFR 412.103.  It also must be located more than a 35- mile drive from any other hospital or critical access hospital unless it is designated by the State, prior to Janua ry 1, 2006, to be a "necessary provider".  In mountainous terrain or in areas with only secondary roads available, the mileage criterion is 15 miles.  In addition, the facility must make available 24 -hour emergency care services, provide not more than 25 beds for acute (hospital -level) inpatient care or in the case of a CAH with a swing bed agreement, 60 used for SNF -level care.  The CAH maintains a length of stay, as determined on an annual average basis, of no longer than 96 hours.   The facility is also required to meet the conditions of participation for CAHs  (42 CFR Part 485, Subpart F ).  Designation by the State is not sufficient for CAH status.  To participate and be paid as a CAH, a facility must be certified as a CAH by CMS.   A. - Grandfathering Existing Facilities   As of October 1, 1997, no new Essential Access Community Hospital (EACH) designations can be made.  The EACHs designated by CMS before October 1, 1997, will continue to be paid as sole community hospitals for as long as they comply with the terms, conditions, and limitations under which they were designated as EACHs.   30.1 - Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part Units  (Rev. 771, Issued: 12- 02-05, Effective: 01 -03-06, Implementation: 01- 03-06)
(Medicare Claims Processing Manual)
30.1 - Requirements for CAH Services, CAH Skilled Nursing Care Services and Distinct Part Units  (Rev. 771, Issued: 12- 02-05, Effective: 01 -03-06, Implementation: 01- 03-06)  A CAH may provide acute inpatient care for a period that does not exceed, as determined on an annual average basis, 96 hours per patient.  The CAH's length of stay will be calculated by their A/B MAC (A) based on patient census data and reported to the CMS  regional office (RO).  If a CAH exceeds the length of stay limit, it will be required to develop and implement a corrective action plan acceptable to the CMS RO, or face termination of its Medicare provider agreement.   Items and services that a CAH provides to its inpatients are covered if they are items and services of a type that would be covered if furnished by an acute care hospital to its inpatients.  A CAH may use its inpatient facilities to provide post -hospital S NF care and be paid for SNF -level services if it meets the following requirements:    1. The facility has been certified as a CAH by CMS;    2. The facility operates up to 25 beds for either acute (CAH) care or SNF swing bed care (any bed of a unit of the facility that is licensed as a distinct- part SNF is not counted under paragraph (1) of this section); and   3. The facility has been granted swing- bed approval by CMS.   A CAH that participated in Medicare as a rural primary care hospital (RPCH) on September 30, 1997, and on that date had in effect an approval from CMS to use its inpatient facilities to provide post -hospital SNF care, may continue in that status under the same terms, conditions, and limitations that were applicable  at the time those approvals were granted.  A CAH may establish psychiatric and rehabilitation distinct part units effective for cost reporting periods beginning on or after October 1, 2004.  The CAH distinct part units must meet the following requirements:    1. The facility distinct part unit has been certified as a CAH by CMS;    2. The distinct part unit meets the conditions of participation requirements for hospitals;
(Medicare Claims Processing Manual)
1. The facility distinct part unit has been certified as a CAH by CMS;    2. The distinct part unit meets the conditions of participation requirements for hospitals;    3. The distinct part unit must also meet the requirements, other than conditions of participation requirements, that would apply if the unit were established in an acute care hospital;    4. Services provided in these distinct part units will be paid under the payment methodology that would apply if the unit was established in an acute care (non- CAH) hospital paid under the hospital inpatient PPS; Inpatient Rehabilitation Facilities in CAH s are paid under the Inpatient Rehabilitation Facility PPS (see Pub 100- 04, Chapter 3, Section 140 for billing requirements) and the Inpatient Psychiatric Units in CAHs are paid on a reasonable cost basis until a prospective payment system is created (expe cted in 2005);    5. Beds in these distinct part units are excluded from the 25 bed count limit for CAHs;    6. The bed limitations for each distinct part unit is 10; and  If a distinct part unit does not meet applicable requirements with respect to a cost reporting period, no payment may be made to the CAH for services furnished in the unit during that period.  Payment may resume only after the CAH has demonstrated that the unit meets applicable requirements.   30.1.1 - Payment for Inpatient Services Furnished by a CAH  (Rev. 530, Issued:  04- 22-05; Effective: 01 -05-04 - HPSA Bonus; 01 -03-05 - Physician Scarcity; 07- 01-01; Implementation:  07 -05-05)  For cost reporting periods beginning after October 1, 1997, payment for inpatient services of a CAH is the reasonable cost of providing the services. Effective for cost reporting periods beginning after January 1, 2004, payment for inpatient services of a CAH is 101 percent of the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except the following principles do not apply:    The lesser of costs or charges (LCC) rule;    Ceilings on hospital operating costs;    The reasonable compensation equivalent (RCE) limits for physician services to hospitals; and
(Medicare Claims Processing Manual)
 The lesser of costs or charges (LCC) rule;    Ceilings on hospital operating costs;    The reasonable compensation equivalent (RCE) limits for physician services to hospitals; and   The payment window provisions for preadmission services treated as inpatient services under 40.3.  (Because CAHs are exempt from the 1 - and 3- day window provisions, services rendered by a CAH to a beneficiary who is an outpatient prior to that beneficiary s admission to the CAH as an inpatient, are not bundled on the inpatient bill.  Outpatient CAH services must be billed as such and on a separate bill (85x TOB) from inpatient services.  CWF and the shared system shall bypass the CAH provider numbers when applying the edits that compare hospital outpatient and inpatient bills to apply the window provisions.  Outpatient services rendered on the date of admission to an inpatient setting are still billed and paid separately as outpatient services in a CAH.)   Low Osmolar Contrast Material (LOCM) furnished as part of medically necessary imaging procedures for inpatients is paid for based on bill type 11X (for LOCM furnished during an inpatient stay covered under Part A), or 12X(for LOCM furnished to an inpatient  where payment is under Part B because the stay is not covered under Part A). Bills must include revenue code 636 along with one of the following HCPCS codes as appropriate:   A4644 Supply of low osmolar contrast material (100 -  199 mgs of iodine);   A4645 Supply of low osmolar contrast material (200 -  299 mgs of iodine); or   A4646 Supply of low osmolar contrast material (300 -  399 mgs of iodine).  Payment for inpatient CAH services is subject to Part A deductible and coinsurance requirements.  Inpatient services should be billed on an 11X type of bill.  30.1.1.1 - Payment for Inpatient Services Furnished by an Indian Health Service (IHS) or Tribal CAH  (Rev. 231, Issued 07- 23-04, Effective: 01 -01-04, Implementation: 01- 03-05)
(Medicare Claims Processing Manual)
Reimbursement to IHS or Tribal CAHs for covered inpatient services is based on a facility specific per diem rate that is established on a yearly basis from the most recently filed cost report information.   Payment for inpatient IHS or Tribal CAH services is at 100% of the facility specific per diem rate less applicable deductible and coinsurance.  Inpatient services should be billed on an 11X type of bill.   Beginning January 1, 2004, IHS or Tribal CAHs are paid 101% of the facility specific per diem rate.  30.1.2 - Payment for Post -Hospital SNF Care Furnished by a CAH  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   The SNF -level services provided by a CAH, are paid at 101% of reasonable cost.  Since this is consistent with the reasonable cost principles, A/B MACs (A) will now  pay for those services at 101% reasonable cost.  Hospitals must follow the rules for payment in 60 for swing -bed services.   Coinsurance and deductible are applicable for inpatient CAH payment.   All items on the ASC X12 837 institutional claim format are completed in accord with the implementation guide applicable to the dates of the stay.  All items on Form CMS -1450 are completed in accordance with Chapter 25.   30.1.3 - Costs of Emergency Room On -Call Providers  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)
(Medicare Claims Processing Manual)
30.1.3 - Costs of Emergency Room On -Call Providers  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  For dates of service on or after January 1, 2005, the reasonable costs of outpatient CAH services may include the reasonable compensation and related costs for an emergency room provider who is on call but not present at the premises of the CAH, if the provider is not otherwise furnishing provider services and is not on call at any other provider or facility.  The costs are allowable only if they are incurred under a written contract that requires the provider to come to the CAH when the providers presence  is medically required.  An emergency room provider must be a doctor of medicine or osteopathy, physician assistant, nurse practitioner, or clinical nurse specialist who is immediately available by telephone or radio contact, and available on site, on a 24-hour a day basis, within 30 minutes, or within 60 minutes in areas described in 42 CFR  1395(g)(5) .  For dates of service from October 1, 2001, through December 31, 2004, this provision covers only emergency room physicians.  An emergency room physician must be a doctor of medicine or osteopathy.   30.1.4 - Costs of Ambulance Services  (Rev. 1, 10- 01-03)  Effective for services furnished on or after December 21, 2000, payment for ambulance services furnished by a CAH or by an entity that is owned and operated by a CAH is, under certain circumstances, the reasonable cost of the CAH or the entity in furnishing those services.  Payment is made on this basis only if the CAH or the entity is the only provider or supplier of ambulance services located within a 35- mile drive of the CAH or the entity.  Reasonable cost will be determined without regard to any per -trip limits or fee schedule that would otherwise apply.