evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
160 - Necessary Changes to Implement Special Add -On Payments for New Technologies (Rev. 1, 10-01-03) A-02-124  160.1 - Special Add -On Payments For New Technologies (Rev. 1, 10-01-03)  Section 533(b) of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1886(d)(5) of the Act to add subparagraphs (K) and (L) and establish a process of identif ying and ensuring adequate payment for new medical services and technologies under Medicare. In the September 7, 200l, final rule (66 FR 46902), CMS established that cases using approved new technology would be appropriate candidates for an additional payment when: the technology represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries; the payment for such cases can be demonstrated to be inadequately paid otherwise under the diagnosis -related group (DRG) system; and data reflecting the costs of the technology would be unavailable to use to recalibrate the  DRG weights.  Under 42 CFR 412.88 of the regulations, an add -on payment is made for discharges involving approved new technologies, if the total covered costs of the discharge exceed the DRG payment for the case (including adjustments for indirect medical education (IME) and disproportionate share hospitals (DSH) but excluding outlier payments). PRICER calculates the total covered costs for this purpose by applying the cost -to-charge ratio (that is used for inpatient outlier purposes) to the total covered costs of the discharge. Payment for eligible cases is equal to:   The full DRG payment (see example 1  that follows); plus    The lesser of   1. 50 percent of the costs of the new medical service or technology (see example 2); or  2. 50 percent of the amount by which the total covered costs (as determined above) of the case exceed the DRG payment (see example 3 ); plus
(Medicare Claims Processing Manual)
2. 50 percent of the amount by which the total covered costs (as determined above) of the case exceed the DRG payment (see example 3 ); plus    Any applicable outlier payments if the costs of the case exceed the DRG, plus adjustments for IME and DSH, and any approved new technology payment for the case plus the fixed loss outlier threshold. The costs of the new technology are included in the deter mination of whether a case qualifies for outliers.   This instruction implements the above payment mechanism into the claims processing systems.   Below are three illustrative examples of this policy for cases involving an eligible technology estimated to cost $3,000 in a DRG that pays $20,000.  Example One   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $19,000. Medicare would pay $20,000, the full DRG payment. Even though the case involved a new technology eligible for add- on payments, the total covered costs of the case did not exceed the DRG payment, therefore, no additional payment is made.   Example Two:   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $25,000. Because, in this case, 50 percent of the costs of the new medical service or technology is less than 50 percent  of the amount by which the total covered costs (as determined above) of the case exceed the DRG payment, Medicare would pay 50 percent of the costs of the new technology (in addition to the DRG payment). Therefore, for this case, Medicare would pay $21,500 (the DRG payment of $20,000 plus one -half of $3,000, the estimated cost of the new technology).  Example Three:   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $22,000. Medicare would pay one -half of the amount by which the costs of the case exceed the DRG payment, up to the esti mated cost of the new technology. Therefore, for this case, Medicare would pay $21,000 (the DRG payment of $20,000 plus one -half of the costs above that amount).
(Medicare Claims Processing Manual)
160.1.1 - Identifying Claims Eligible for the Add -On Payment for New Technology  (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)   Technologies eligible for add- on payments are identified based on the applicable codes from the International Classification of Diseases, Clinical Modification.  Claims submitted with an ICD code indicating that a new technology was involved in the treatme nt of the patient is then eligible for add -on payments as described above.   The system maintainers pass (if present) the "principal" and up to twenty four "other procedure" codes to PRICER. If an eligible code is present, PRICER calculates an add -on payment if appropriate.   Additionally, the National Uniform Billing Committee has approved value code 77 for use on the ASC X12 837 institutional claim or Form CMS -1450 for A/B MAC (A) use only, defined as New Technology Add- On Payment.  This value code must be passed to CWF and the PS&R. The amount shown in this value code must be paid to PIP providers on a claim -by-claim basis the same as outlier payments are paid to PIP providers.   160.1.2 - Remittance Advice Impact  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)   In order to  process this special add -on payment for new technologies, and report in the Remittance Advice (electronic and paper), contractors shall submit code ZL in the AMT segment of the Loop 2110 AMT01 of the ASC X12 835 Transaction. Contractors shall also submit code CS in the composite data element of the PLB segment in the 835 ASC X12 Transaction.  For PIP payment, the contractor includes only the add-on payment on a claim-by- claim basis.   The following reflects the remittance advice messages and associated codes that will appear when processing claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: OA CARC: 94  RARC: N/A  MSN: N/A
(Medicare Claims Processing Manual)
Group Code: OA CARC: 94  RARC: N/A  MSN: N/A  170 - Billing and Processing Instructions for Religious Nonmedical Health Care Institution (RNHCI) Claims  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  170.1 - RNHCI Election Process  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  See Chapter 5, Section 40 of Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual for a definition of RNHCI providers.  See Chapter 1, Section 130 of Pub. 100-02, Medicare Benefit Policy Manual for more information about the RNHCI benefit and coverage.   170.1.1 - Requirement for RNHCI Election  (Rev. 2930, Issued: 04- 11-14, Effective: 07-14-14, Implementation: 07-14-14)  The RNHCI benefit provides only for Part A inpatient services.  For an RNHCI to receive payment under the Medicare program, the beneficiary must make a written election to receive benefits under 1821 of the Act.  To elect religious nonmedical health care services, the beneficiary or the beneficiarys legal representative must attest that the individual is conscientiously opposed to acceptance of nonexcepted medical treatment, and the individuals acceptance of such treatment would be inconsistent with the individuals sincere religious beliefs.
(Medicare Claims Processing Manual)
All submissions regarding RNHCI services are processed by a single Medicare contractor as a specialty workload.  Currently, this specialty workload is part of Medicare Administrative Contractor Jurisdiction 10.  The completed election form must be filed with the contractor and a copy retained by the RNHCI provider.  See section 170.1.3 below for instructions on the submission of the election to the contractor.  The RNHCI provider should question each beneficiary prior to executing the election statement to determine if the beneficiary has Medicare Part B coverage in effect via a health plan or has recently received care (services or items, including physician- ordered durable medical equipment) for which Medicare payment was sought.  An affirmative answer will alert the RNHCI provider that subsequent claims under the election may be denied.  Occasionally, a Medicare beneficiary may seek services at a RNHCI that do not qualify for Medicare coverage and for which the beneficiary may seek payment from another insurer.  The beneficiary is not required to make an election of RNHCI benefits in this case.   If the other insurer requires a denial from Medicare before making payment for these services, a denial notice cannot be processed by Medicare claims processing systems. Medicare systems require submission of a Notice of Election (NOE) before any RNHCI claims, including claims for denial, can be processed.  The RNHCI may request in writing a denial notice from the Medicare contractor.  The written request must describe the reason the beneficiary does not qualify for Medicare coverage.  It must also describe the specific services that will be provided to the beneficiary.  In response, the contractor will provide the RNHCI with a manual denial letter.  This letter may then be submitted to a secondary insurer as evidence of a prior Medicare denial .  170.1.2 - Revocation of RNHCI Election  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)
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170.1.2 - Revocation of RNHCI Election  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Under 1821(b)(3), a beneficiary may revoke an election in writing or by receiving nonexcepted medical care.  Once an election has been revoked, Medicare payment cannot be made to an RNHCI unless a new valid election is filed.  The RNHCI revocation does not interfere with the beneficiarys ability to seek other Medicare services within the limits of his/her Medicare coverage.  Multiple revocations may affect the beneficiarys ability to access the RNHCI benefit in the future (see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 130.2.2).  Written revocations received from a beneficiary must be filed by the RHNCI with their Medicare contractor and a copy retained by the RNHCI provider.  Revocations may be filed using the same format as elections, indicating a revocation in the type of bill code.  See section 170.1.3 below for details.  170.1.3 - Completion of the Notice of Election for RNHCI  (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)  Elections, revocations and cancellations of elections may be submitted to the contractor via the paper Form CMS-1450 or via the contractors Direct Data Entry (DDE) system.  Election transactions are not covered transaction under the Health Insurance Porta bility and Accountability Act of 1996 (HIPAA) and therefore the HIPAA standard claim transaction is not required.  Additionally, the HIPAA standard claim transaction (ASC X12 837 institutional claim format) does not support the data requirements of these transactions.   This section gives detailed information only for items required for the notice of election and related transactions.  The RHNCI does not need to complete items not listed.  Provider Name, Address, and Telephone Number
(Medicare Claims Processing Manual)
This section gives detailed information only for items required for the notice of election and related transactions.  The RHNCI does not need to complete items not listed.  Provider Name, Address, and Telephone Number   Required -  The minimum entry is the RNHCIs name, city, State, and ZIP code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five - or 9-digit ZIP codes are acceptable.  The RNHCI uses the information to reconcile provider number discrepancies.  Phone and/or FAX number s are desirable.   Type of Bill   Required -  The RNHCI enters the 3 -digit numeric type of bill code.  The first digit identifies the type of facility.  The second digit classifies the type of care.  The third digit (commonly referred to as a frequency code) indicates in this instance the nature of the election related transaction.   The RNHCI enters type of bill 41A, 41B, or 41D as appropriate.   Valid codes for RNHCI elections:       1st Digit -  Type of Facility   4- Religious Nonmedical Health Care Institution       2nd Digit -  Classification (Special Facility)   1- Inpatient (Part A)       3rd Digit -  Frequency   A - RNHCI election notice   B - RNHCI revocation notice   D - Cancellation   The RNHCI submits type of bill 41D to the specialty contractor as a cancellation of a previously submitted notice of election or notice of revocation, when it was submitted in error.  In situations where the RNHCI is correcting a previously submitted date, they submit a new type of bill 41A to the contractor for processing.   Patients Name   Required -  The RNHCI enters the patients name with the surname first, first name, and middle initial, if any.   Patients Address   Required -  The RNHCI enters the patients full mailing address including street name and number, post office box number or RFD, city, State, and ZIP code.   Patients Birth Date   Required -  (If available) The RNHCI enters the month, day, and year of birth.  If the date of birth cannot be obtained after a reasonable effort, the field will be zero- filled.   Patients Sex   Required -  The RNHCI enters an M for male or an F for female.   Admission Date
(Medicare Claims Processing Manual)
Patients Sex   Required -  The RNHCI enters an M for male or an F for female.   Admission Date   Required -  The RNHCI enters the date of the election, revocation or cancellation.  In no instance should the date be prior to July 1, 2000.  National Provider Identifier   Required -  The RNHCI enters their National Provider Identifier (NPI).  During Medicare processing, the NPI is matched to the RHNCIs CMS Certification Number (CCN).  RNHCI CCNs are composed of a 2 -digit state code and a 4 -digit provider identifier in the range 1990- 99.  Insureds Name   Required -  The RNHCI enters the beneficiarys name on line A if Medicare is the primary payer.  The RNHCI enters the name as on the beneficiarys Medicare card.  If Medicare is the secondary payer, the RNHCI enters the beneficiarys name on line B or C, as  applicable, and enters the insureds name on line A.  Insureds Unique Identification  Required -  On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is, the RNHCI enters the patients HICN.  The RNHCI enters the number as it appears on the patients Medicare Card, Social Security Award Certificate, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, etc., or as reported by the Social Security Office.   170.1.4 - Common Working File (CWF) Processing of Elections, Revocations and Cancelled Elections  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  The Medicare contractor with RNHCI specialty workload submits all RNHCI election, revocations and cancelled elections to CWF for approval.  The CWF will notify the contractor that these transactions were received and accepted.   The CWF uses these records to maintain a beneficiary file of all RNHCI beneficiary elections and revocations.  This file is used in processing claims for RNHCI services (see section 170.3 below) and for other Medicare services (see section 180).   CWF rejects any notices of revocations or cancellations when:
(Medicare Claims Processing Manual)
CWF rejects any notices of revocations or cancellations when:    CWF history shows no RNHCI elections are on file;    The submitted dates do not match the elections on file;    The revocation date is prior to the date of the election;    The election in question has already been revoked or cancelled; or    CWF history indicates an RNHCI claim has been processed during the election period to which the revocation or cancellation applies.  If these claims were submitted in error, the RNHCI must cancel the claims prior to resubmitting the revocation or cancellat ion.  170.2 - Billing Process for RNHCI Services  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  170.2.1 - When to Bill for RNHCI Services  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  RNHCIs submit claims to their Medicare contractor in the following situations:   At the time of beneficiary's discharge, or death.    At the time the beneficiary's benefits are exhausted    On an interim basis monthly.  RNHCIs submit a claim even where the charges do not exceed the beneficiary's deductible.  See section 40 for instructions regarding reporting of utilization days.  170.2.2 - Required Data Elements on Claims for RNHCI Services  (Rev. 3075, Issued; 09- 24-14, Effective: 11 -12-14, ICD -10: Upon Implementation of ICD- 10, Implementation: 11- 12-14, ICD -10: Upon Implementation of ICD -10)  The Social Security Act at 1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic form  required for billing RNHCI claims is the ASC X12 837 institutional claim transaction.  Since the data structure of the ASC X12 837 institutional claim transaction is difficult to express in narrative form and to provide assistance to small providers excepted from the electronic claim requirement, the instructions below are given relative to the Form CMS -1450 paper claim.
(Medicare Claims Processing Manual)
Both the electronic claim transaction and the paper claim form are suitable for use in billing multiple third party payers.  This section details only those data elements required for Medicare billing.  When RNHCIs are billing multiple third parties, they complete all items required by each payer who is to receive a claim for the services.   Provider Name, Address, and Telephone Number   Required -  The RNHCI must enter their name, city, State, and ZIP Code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five or 9- digit ZIP Codes are acceptable.   This information is used in connection with the Medicare provider number to verify provider identity.  Phone/Fax numbers are desirable.   Patient Control Number/Medicare Record Number  Optional -  The RNHCI may report a beneficiary's control number if they assign one and need it for association and reference purposes.   Type of Bill   Required -  This 3 -digit alphanumeric code gives three specific pieces of information.  The first digit identifies the type of facility.  The second classifies the type of care.  The third indicates the sequence of this claim in this particular episode of care.  It is a "frequency" code.   Valid codes for RNHCI claims:       1st Digit -Type of Facility  4 - Religious Nonmedical Health Care Institution       2nd Digit Classification (Except Clinics and Special Facilities)   1 - Inpatient (Part A)       3rd Digit -Frequency     Definition       0-Nonpayment/zero claims   Use when you do not anticipate payment from the payer for the bill but are merely informing the payer about a period of nonpayable confinement or termination of care.  The "Through" date of this bill is the discharge date for this confinement.  Nonpayment bills are required only to extend the "spell of illness."  See code 71 below.      l-Admit Through Discharge Claims  Use for a bill encompassing an entire inpatient confinement for which you expect payment from the payer or for which Medicare utilization is chargeable.       2-Interim- First Claim  Use for the first of an expected series of payment bills for the same confinement or course of treatment for which Medicare utilization is chargeable.       3-Interim- Continuing Claim  Use when a payment bill for the same confinement or course of treatment has been submitted, further bills are expected to be submitted and Medicare utilization is chargeable.
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3-Interim- Continuing Claim  Use when a payment bill for the same confinement or course of treatment has been submitted, further bills are expected to be submitted and Medicare utilization is chargeable.       4-Interim- Last Claim   Use for a payment bill which is the last of a series for this confinement or course of treatment when Medicare utilization is chargeable.  The "Through" date of this bill is the discharge date for this confinement.       7-Replacement of Prior Claim  Use to correct (other than late charges) a previously submitted bill. This is the code applied to the corrected or "new" bill.      8-Void/Cancel of a Prior Claim  This code indicates the bill is an exact duplicate of an incorrect bill previously submitted. Enter a code "7" (Replacement of Prior Claim) showing the correct information.   Statement Covers Period (From -  Through)   Required -  The RNHCI must enter the beginning and ending dates of the period covered by this bill.  Enter the date of discharge or the date of death in the space provided under "Through."  The statement covers period may not span 2 accounting years.   Patient's Name   Required -  The RNHCI must enter the beneficiary's last name, first name, and middle initial, if any.   Patient's Address   Required -  The RNHCI must enter the beneficiary's full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.  Patient Birth Date   Required -  The RNHCI must enter the month, day, and year of birth (MM -DD-YYYY) of the beneficiary.   Sex  Required -  The RNHCI must enter an M for male or an F for female.   Admission Date   Required -  The RNHCI must enter the date the beneficiary was admitted for inpatient care.   (MM -DD-YY).   Type of Admission   Required -  The RNHCI must enter the code indicating the priority of this admission.   Valid codes for RNHCI claims:   3 Elective   The beneficiary's condition permitted adequate time to schedule the availability of a suitable accommodation.   9 Information   Self-explanatory   Not Available   Point of Origin for Admission