evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
70 - CMS Defined File Formats  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  70.1 - General HIPAA EDI Requirements  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  As described in section 40.1.1, the A/B MACs, DME MACs and CEDI shall support the current versions adopted under HIPAA of the following transactions and their implementation guides for the electronic exchange of data with Medicare providers/submitters/receivers/COB trading partners. Electronic transactions that do not fully comply with the implementation guide requirements for th ese formats will be rejected.   ASC X12 837 claim, institutional and professional    NCPDP telecommunication and equivalent batch standard for retail prescription drug claims ( applicable for CEDI and  DME MACs only) and COB (see  40.1 of this chapter for addi tional information);   ASC X12 835 remittance advice (see chapter 22 for additional information); and    ASC X12 276/277 claim status request and response (see chapter 31 for additional information).   Links to sources of implementation guides for these standards are available at    www.cms.hhs.gov/ElectronicBillingEDITrans   Although not mandated by HIPAA, as noted in  40.1.2, CM S also requires that A/B MACs and CEDI issue an ASC X12 999 implementation acknowledgment transaction to electronic claim submitters to acknowledge receipt of claims (except where waived by a submitter) and to report syntax errors related to any ASC X12 transactions submitted to Medicare.
(Medicare Claims Processing Manual)
See Pub.100-09, the Medicare Contractor Beneficiary and Provider Communications Manual, regarding contractor requirements for furnishing Medicare claim remittance advice print software updates information to providers via the Internet and alternate methods to be used to furnish information to those providers that lack Internet access.  An overview of any changes to existing specifications, including effective dates will be issued to providers via A/B MACs and CEDI bulletins, on contractor Web pages, and will also be available via the Internet as Manual transmittals which can be viewed via a link from www.cms.hhs.gov/ElectronicBillingEDITrans/01_Overview.asp to the separate page for each EDI transaction format supported by Medicare fee- for-service plans.   70.2 - National Council for Prescription Drug Program (NCPDP) Claim Requirements  (Rev. 2803, Issued : 10-28-13, Effective: 09-17-13, Implementation: 09-17-13)  A. NCPDP Batch Transaction  The NCPDP batch transaction format is intended to provide a file transmission standard for submission in a non- real-time mode of the telecommunications standard transaction for drug claims from retail pharmacies. CEDI will not accept retail pharmacy drug claims that are not submitted as batch transactions.  NCPDP users are required to transmit National Drug Codes (NDCs) in the NCPDP standard for identification of prescription drugs dispensed through a retail pharmacy. NDCs replace the drug HCPCS codes for retail pharmacy drug transactions submitted to CEDI and delivered to the DME MACs via the NCPDP standard. The DME MAC shared system (VMS) will convert NDCs to HCPCS codes for internal claim processing. The CMS will provide the HCPCS codes for these drugs and an NDC to HCPCS crosswalk for use by VMS and the DME MACs.  B. Generating a Batch NCPDP Response
(Medicare Claims Processing Manual)
CEDI will return the NCPDP batch response for all NCPDP transmissions received. The NCPDP term transaction is equivalent to a Medicare service or line item and the NCPDP term transmission is equivalent to a Medicare claim. The NCPDP implementation guid e allows for up to 4 transactions (line items) per transmission (claim). This means that each claim can have up to 4 line items. Therefore, if one transaction (line item) rejects, the entire transmission (claim) will be returned. All transactions (up to 4)  in the transmission will be treated as one claim, and each transmission in a batch will be treated as a separate claim. For a transmission (claim) where one or more claim transactions (lines) have errors, the following will occur:   1. CEDI will reject all claim transactions (line items) in the transmission (claim) if any one claim (transmission) has detail errors.   2. The response status for all transactions will equal R (rejected).   3. CEDI will send up to 5 reject codes for claim transactions (line items) that ha ve detail errors.   4. No transaction level reject code will be reflected for the line item with no error.  Instead, the 504- F4 response message field at the header level is being used to denote acceptance or rejection of the entire claim.   C. NCPDP Implementat ion Guide (IG) Edits   CEDI shall allow segments to be submitted in any order including AM07, AM03 and AM11 as permitted by the NCPDP standard.  CEDI must create the NCPDP flat file segments in numeric order for receipt by the DME MACs shared system maintai ner.  D. Misdirected Claims   With the implementation of CEDI, there are no longer mis -directed claims.  CEDI receives all DME ASC X12 and NCPDP claims, performs all front end editing and translation.  Claims accepted by CEDI are assigned the Claim Contro l Number and delivered to the appropriate DME MAC based on the beneficiary state code submitted on the claim.   80 - Electronic Data Interchange (EDI) Reporting Requirements  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)
(Medicare Claims Processing Manual)
80 - Electronic Data Interchange (EDI) Reporting Requirements  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Contractors are required to participate in the following EDI reporting efforts as appropriate for their line of business. Each reporting effort has its own defined content and reporting frequency.   80.1  Contractor  Monthly Status  Reporting  (Rev. 10319, Issued: 08 -28-2020, Effective: 09- 29-2020, Implementation: 09- 29-2020)   The CMS Data Exchange (MDX) portal is a system that provides CMS automated capabilities for monitoring and analyzing data relating to the Medicare contractors on -going operational act ivities. A/B MACs are required to input their Electronic Data Interchange (EDI) workload statistics into MDX using the Monthly Status Report in Excel (MSRE) format. Contractors must prepare and submit to CMS the Medicare MSRE showing their EDI and manual t ransactions workload under the health insurance program. A separate report is required for each office assigned a separate contractor number.   The MSRE EDI claims processing data for PART A, Part B, and Home Health/Hospice (HHH) includes:   ACCEPTED CLAIM ST ATUS REQUESTS (276 - Electronic)   RESPONSES TO CLAIMS STATUS INQUIRIES (277 - Electronic)   REMITTANCE ADVICES -  NUMBER SENT (5010) -  835/ERA   REMITTANCE ADVICES -  NUMBER SENT (5010) -  SPR   REMITTANCE ADVICES -  NUMBER SENT (5010) -  Internet/Portal  NUMBER OF PAYME NTS TO PROVIDERS OR SUPPLIERS -  EFT   NUMBER OF PAYMENTS TO PROVIDERS OR SUPPLIERS -  Paper Checks   DOLLAR AMOUNTS ASSOCIATED W/PAYMENTS (5010) -  EFT   DOLLAR AMOUNTS ASSOCIATED W/PAYMENTS (5010) -  Paper Checks   ELECTRONIC CLAIMS PROCESSED (5010) - Electronic   ELEC TRONIC CLAIMS PROCESSED (5010) - DDE   DDE CLAIM ADJUSTMENTS REC'D -  DDE   DDE CLAIM STATUS RESPONSES -  DDE   PAPER CLAIMS PROCESSED   NCPDP RETAIL PHARMACY DRUG CLAIMS   Contractors shall reference Change Request (CR)10870 (Transmittal R21390TN, 9/17/18) for details on MDX reporting.
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Contractors shall reference Change Request (CR)10870 (Transmittal R21390TN, 9/17/18) for details on MDX reporting.   80.2 - Common Edits and Enhancement Module (CEM) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs are required to support a vigorous reporting system which will provide a full range  of routine and ad hoc workload reports and operational reports regarding Electronic Data Interchange (EDI) activities. The types of reports which are required include but are not limited to daily EDI workload statistics, edit exceptions, receipt- control -balancing, provider and submitter transaction version utilization data, transmission and receipt problems, etc.   A/B MACs will utilize the reporting functionality in the CEM to provide CMS with their EDI operational reports.   80.3 - Common Electronic Data I nterchange (CEDI) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  CEDI is required to support a vigorous reporting system which will provide a full range of routine and ad hoc workload reports and operational reports  regarding Electronic Data Interchange (EDI) activities. The types of reports which are required include but are not limited to daily EDI workload statistics, edit exceptions, receipt- control -balancing, provider and submitter transaction version utilization data, transmission and receipt problems, etc.   DME MACs will utilize the reporting functionality in the CEDI to provide CMS with their EDI operational reports.  80.4 - HIPAA Transition Reporting (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implemen tation: 09 -17-13)  As new HIPAA versions are named, contractors are required to report their implementation progress to CMS via transition reporting. Data collection will be achieved via an external, secure web -based reporting tool designed to support long  term, short term, and ad- hoc data gathering efforts, such as Electronic Data Interchange statistics and performance metrics.
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The contractor shall obtain access to the web -based reporting tool via self enrollment  contingent on CMS approval. Current reports vary in frequency from weekly to monthly; however, any future efforts will reflect the most appropriate time period. Contractors will always be notified via Technical Direction Letter (TDL) on the required start ing date of any transition reporting, the content of the transition data, and the frequency of the reporting effort.   Contractors will utilize the reporting functionality in their front end systems, in CEM, in the Shared System Maintainer, and/or in CEDI t o provide CMS with their EDI HIPAA transition reports.  80.5 - Administrative Simplification and Compliance Act (ASCA) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Contractors are required to report the status of their ASCA enforcement activities on a monthly basis. ASCA enforcement data will be submitted via an external, secure web -based reporting tool.   The contractor shall obtain access to the web -based reporting tool via self enrollment contingent on CMS approval. Contractors will always be notified via Technical Direction Letter (TDL) of any changes in the reporting requirements of the ASCA enforcement reporting, the content of the ASCA enforcement data, and the frequency of the ASCA enforcement reporting effor t.  Contractors shall reference Pub 100 -04, Chapter 24, Section 90 for the complete details and requirements on ASCA enforcement.   90 - Mandatory Electronic Submission of Medicare Claims  (Rev. 3491, Issued: 04- 05-16, Effective: 07- 01-16, Implementation: 07- 05-16)  Section 3 of the Administrative Simplification Compliance Act (ASCA), Pub.L. 107 -105, and the implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursement under Medicare, except from small providers, be submitted elec tronically as of October 16, 2003, with limited exceptions.  Initial claims are those claims submitted to a A/B MAC or DME MAC for the first time, including resubmitted previously rejected claims, claims with paper attachments, demand bills, claims where M edicare is the secondary payer, and non -payment claims.  Initial claims do not include adjustments or claim corrections submitted A/B MAC or DME MAC on previously submitted claims or appeal requests.
(Medicare Claims Processing Manual)
Medicare is prohibited from payment of  claims submitted  in a non- electronic manner that do not meet the limited exception criteria.  Claims required to be submitted electronically effective October 16, 2003, and later must comply with the appropriate claim standards adopted for national use under HIPAA (see se ction 70 of this chapter).  The mandatory electronic claim submission requirement does not apply to claims submitted by beneficiaries or by providers that only furnish services outside of the United States, claims submitted to Medicare managed care plans, to health plans other than Medicare, or for purchased only Expatriate beneficiary Durable Medical Equipment Prosthetics Orthotics Supplies (DMEPOS) claims.   90.1 - Small Providers and Full -Time Equivalent Employee Self -Assessments  (Rev.: 4388; Issued: 09- 06-19; Effective: 10- 07-19; Implementation: 10 -07-19)  A small provider is defined at 42 CFR section 424.32(d)(1)(vii) to mean A) a provider of services (as that term is defined in section 1861(u) of the Social Security Act) with fewer than 25 full -time equivalent (FTE) employees; or B) a physician, practitioner, facility or supplier that is not otherwise a provider under section 1861(u) with fewer than 10 FTEs.  To simplify implementation, Medicare considers all providers that have fewer than 25 FTEs and that are required to bill a Medicare A/B MAC (A)to be small; and considers all physicians, practitioners, facilities, or suppliers with fewer than 10 FTEs and that are required to bill a A/B MAC (B) or DME MAC to be small.
(Medicare Claims Processing Manual)
The ASCA law and regulation do not modify pre -existing laws or employer policies defining full time employment.  Each employer has an established policy, subject to certain non -Medicare State and Federal regulations, that define the number of hours employees must work on average on a  weekly, biweekly, monthly, or other basis to qualify for full -time benefits.  Some employers do not grant full- time benefits until an employee works an average of 40 hours a week, whereas another employer might consider an employee who works an average of  32 hours a week to be eligible for full -time benefits.  An employee who works an average of 40 hours a week would always be considered full time, but employees who work a lesser number of hours weekly on average could also be considered full time accordin g to the policy of a specific employer.   Everyone on staff for whom a health care provider withholds taxes and files reports with the Internal (Revenue Service (IRS) using an Employer Identification Number (EIN) is considered an employee, including if appl icable, a physician(s) who owns a practice and provides hands on services and those support staff who do not furnish health care services but do retain records of, perform billing for, order supplies related to, provide personnel services for, and otherwis e perform support services to enable the provider to function.  Unpaid volunteers are not employees.  Individuals who perform services for a provider under contract, such as individuals employed by a billing agency or medical placement service, for whom a provider does not withhold taxes, are not considered members of a providers staff for FTE calculation purposes when determining whether a provider can be considered as small for electronic billing waiver purposes.
(Medicare Claims Processing Manual)
Medical staff sometimes work part time , or may work full time but their time is split among multiple providers.  Part time employee hours must also be counted when determining the number of FTEs employed by a provider.  For example, if a provider has a policy that anyone who works at least 35 hours per week on average qualifies for full -time benefits, and has 5 full -time employees and 7 part -time employees, each of whom works 25 hours a week, that provider would have 10 FTEs (5+[7 x 25= 175 divided by 35= 5]).  In some cases, the EIN of a paren t company may be used to file employee tax reports for multiple providers under multiple provider numbers.  In that instance, it is acceptable to consider only those staff, or staff hours worked for a particular provider (National Provider Identifier (NPI) ) to calculate the number of FTEs employed by that provider.  For example, ABC Health Care Company owns hospital, home health agency (HHA), ambulatory surgical center (ASC), and durable medical equipment (DME) subsidiaries.  Some of those providers may bil l A/B MACs or DME MACs.  All have separate provider numbers but the tax records for all employees are reported under the same EIN to the IRS.  There is a company policy that staff must work an average of 40 hours a week to qualify for full time benefits.
(Medicare Claims Processing Manual)
Some of the same staff split hours between the hospital and the ASC, or between the DME and HHA subsidiaries.  To determine total FTEs by provider number, it is acceptable to base the calculation on the number of hours each staff member contributes to the support of each separate provider by provider number.  First, each provider would need to determine the number of staff who work on a full -time basis under a single provider number only; do not count more than 40 hours a week for these employees.  Then each provider would need to determine the number of part -time hours a week worked on average by all staff who furnished services for  the provider on a less than full - time basis.  Divide that total by 40 hours to determine their full- time equivalent total.  I f certain staff members regularly work an average of 60 hours per week, but their time is divided 50 hours to the hospital and 10 hours to the ASC, for FTE calculation purposes, it is acceptable to consider the person as 1 FTE for the hospital and .25 FTE for the ASC.  In some cases, a single provider number and EIN may be assigned, but the entitys primary mission is not as a health care provider.  For instance, a grocery stores primary role is the retail sale of groceries and ancillary items including ov er the counter medications, but the grocery store has a small pharmacy section that provides prescription drugs and some DME to Medicare beneficiaries.  A large drug store has a pharmacy department that supplies prescriptions and DME to Medicare beneficiar ies but most of the stores revenue and most of their employees are not involved with prescription drugs or DME and concentrate on non -related departments of the store, such as film development, cosmetics, electronics, cleaning supplies, etc.  A county government uses the same EIN for all county employees but their health care provider services are limited to furnishing of emergency medical care and ambulance transport to residents.  For FTE calculation purposes, it is acceptable to include only those staff  members of the grocery store, drug store, or county involved with or that support the provision of health care in the FTE count when assessing whether a small provider waiver may apply.
(Medicare Claims Processing Manual)
Support staff who should be included in the FTE calculation in these  instances include but are not necessarily limited to those that restock the pharmacy or ambulance, order supplies, maintain patient records, or provide billing and personnel services for the pharmacy or emergency medical services department if under the s ame EIN, according to the number of hours on average that each staff member contributes to the department that furnishes the services or supplies for which the Medicare provider number was issued.   Providers that qualify as small automatically qualify fo r waiver of the requirement that their claims be submitted to Medicare electronically.  Those providers are encouraged to submit their claims to Medicare electronically, but are not required to do so under the law.  Small providers may elect to submit some  of their claims to Medicare electronically, but not others.  Submission of some claims electronically does not negate their small provider status nor obligate them to submit all of their claims electronically.   In the event that a provider uses a clearing house or a billing agent to submit claims, it is the number of FTEs on the providers staff, not those on the staff of the billing agent or the clearinghouse, that determine whether the provider may be considered small for Medicare paper claim submission p urposes.   90.2 - Exceptions (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  It has been determined that due to limitations in the claims  transaction formats adopted for national use under HIPAA, it would not be possible in some cases to submit certain claims to Medicare electronically.  Providers are to self -assess to determine if they meet these exceptions.  At the present time, only the following claim types are considered to meet this condition for self -assessment purposes:   1. Roster billing of inoculations covered by Medicare-Although flu shots and similar covered vaccines and their administration can be billed to Medicare electronically, one claim for one beneficiary at a time, some suppliers have been permitted to submit a single claim on paper with the basic provider and service data and to attach a list of the Medicare beneficiaries to whom the vaccine was administered and related identification information for those beneficiaries. This is referred to as roster billing.  The claim IGs adopted under HIPAA provide for submission of single claims to a payer for single individuals, but cannot be used to submit a roster bill for multiple individuals.
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Flu and pneumonia inoculations are often administered in senior citizen centers, grocery stores, malls, and other locations in the field.  It is not always reasonable or hygienic to use a laptop computer to register all necessary data to enable a HIPAA -compliant claim to be submitted electronically in such field situations, particularly when a single individual is responsible for collection of the data and administration of the inoculations.  Due to the low cost of these vaccinations, it is not always cost effective to obtain all of the data normally needed for preparation of a HIPAA -compliant claim.  Such suppliers rarely have a long -term health care relationship with their patients and do not have a need for the extensive medical and personal history routinely collected in most other health care situations.  It is in the interest of Medicare and public health to make it as simple as possible for mass inoculation activities to continue.  Although suppliers are encouraged to submit these claims to Medicare electronically, one claim for one beneficiary at a time, this is not required except in the case of multi- state companies that signed an agreement with a single Medicare contractor for submission of all flu shots to that single contractor for those states, and who agreed to submit those claims electronically as a condition for centralized billing of those inoculations.  In the absence of an electronic format that would allow a single claim for the same service to be submitted on behalf of multiple patients using abbreviated data, suppliers currently allowed to submit paper roster bills may continue to submit paper roster bills for inoculations.  This inoculation waiver applies only to injections such as flu shots frequently furnished in non-traditional medical situations, and does not apply to injections including flu shots when furnished in a traditional medical setting such as a doctors office or an outpatient clinic as a component of other medical care or an examination.  In traditional medical situations where the provider is required to bill the other services furnished to the patient electronically, a flu shot or other inoculation is also to be included in the electronic claim sent to Medicare for the patient.