evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
 Using another person's Medicare card to obtain medical care.   20.3.2 - Definition and Examples of Abuse  (Rev. 1, 09- 11-02)  Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program.  Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally.  Following are three standards that CMS uses when judging whether abusive acts in billing were committed against the Medicare program:    Reasonable and necessary;    Conformance to professionally recognized standards; and    Provision at a fair price.   Examples of abuse include, but are not limited to, the following:    Charging in excess for services or supplies;    Providing medically unnecessary services or services that do not meet professionally recognized standards;    Billing Medicare based on a higher fee schedule than for non- Medicare patients;    Submitting bills to Medicare that are the responsibility of other insurers under the Medicare secondary payer (MSP) regulation; and    Violating the participating physician/supplier agreement.  Although these types of practices may initially be categorized as abusive in nature, under certain circumstances they may develop into fraud if there is evidence that the subject was knowingly and willfully conducting an abusive practice.   30 - Federal Government Administration of the Health Insurance Program  (Rev. 1, 09- 11-02)  The DHHS has overall responsibility for administering the hospital insurance and voluntary SMI programs.  Two major agencies -  CMS and the Public Health Service - are involved in specified administrative functions.   30.1 - CMS Responsibilities  (Rev. 1, 09- 11-02)  The CMS is responsible for policy formulation.  The central and regional offices are responsible for the general management and operation of the program.  In brief, CMS's responsibilities include the following:    Determining an individual's entitlement to benefits in consultation with the Social Security Administration (SSA);   Determining the nature and duration of services for which a beneficiary's benefits may be paid;    Establishing, maintaining, and administering agreements with State agencies, providers of services, and A/B MACs (A) and (HHH);    Establishing operational policy for contractors;    Developing operational instructions and official interpretations of policy for contractors;    Formulating major policies regarding conditions of participation for providers in consultation with the Public Health Service;    Developing and maintaining statistical research and actuarial programs; and
(Medicare General Information, Eligibility, and Entitlement)
 Developing operational instructions and official interpretations of policy for contractors;    Formulating major policies regarding conditions of participation for providers in consultation with the Public Health Service;    Developing and maintaining statistical research and actuarial programs; and    Managing general finances of the program; and    Managing the Medicare Premium Collection Operation.  The regional offices are responsible for assuring that contractors meet applicable Federal requirements under the provisions of their contracts.  They also:    Provide liaison, direction, and technical assistance to contractors in the day -to-day management of their operations;    Interpret CMS guidelines, policies, and procedures applicable to contractor activities;    Analyze contractor budgets and spending patterns to assure that funds are economically and appropriately utilized;    Conduct assessments of contractor operations;    Review contractor actions; and    Provide feedback to each contractor.   30.2 - Public Health Service Responsibilities  (Rev. 1, 09- 11-02)  The Public Health Service is responsible for administering the professional health aspects of the program.  In brief, its responsibilities include the following:    Consulting and recommending to CMS matters concerning the development of health and safety standards and other guidelines needed for determining whether providers of services meet the conditions of participation under the program;    Consulting and advising State agencies concerning the application of standards for providers; and    Coordinating programs and activities necessary in studying the utilization of services under the program.   30.3 - State Agencies  (Rev. 1, 09- 11-02)  The States, by agreement with the Secretary, are assigned significant administrative functions to the extent that each is willing and capable of discharging such responsibilities.  30.3.1 - Certification by State Agencies  (Rev. 1, 09- 11-02)  Facilities desiring to participate in either the Medicare or Medicaid programs must meet participation conditions for certification.  State agencies certify to DHHS whether providers satisfy, and continue to satisfy, their respective conditions of participation in the Medicare and Medicaid programs.  The Secretary, DHHS, certifies facilities requesting participation in the Medicare and Medicaid programs.  States certify those facilities that request participation in the Medicaid program only.  The State function of making certifications is intended to be a natural adjunct to ongoing State activities (such as the licensing of health care facilities and the setting of standards).   30.3.2 - Consultation by State Agencies  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
30.3.2 - Consultation by State Agencies  (Rev. 1, 09- 11-02)  A State consults with providers of services that need and request participation condition assistance.  For Medicare participation, the Secretary, DHHS, must approve the consultation service rendered by the State certifying agency.   30.3.3 - Coordination by State Agencies  (Rev. 1, 09- 11-02)  A State coordinates activities with other State programs that involve payment for health care, quality of care, and location of health facilities.  Coordinating these activities is essential in assuring effective and economical use of existing State facilities and trained personnel and to prevent duplication of effort.  40 - Role of A/B MACs (A) and (HHH)  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  The A/B MAC (A) and (HHH) is a public or private agency or organization that has entered into an agreement with CMS to enroll legitimate providers into the Medicare program and process Medicare claims under both Part A and Part B services under the supplementary medical insurance program (e.g., hospitals, SNFs, HHAs, hospices, CORFs, OPTs, occupational therapy, and speech -language pathology providers, and ESRD facilities).   A/B MACs (A) and (HHH) make payments to providers.  The amount of payment to a provider is restricted to the lower of the billed charge, the reasonable cost of covered services or the fee schedule amount.  Hospices are paid on a per diem amount that is prospectively set. SNFs and HHAs are paid based on a Prospective Payment System (PPS).  (See Provider Reimbursement Manual, Part 1, 2800ff.)   Hospitals are paid based on the PPS. Under this system, Medicare payment is made at a predetermined, specific rate for each hospital discharge.  This statement applies to inpatient for acute care hospitals and to inpatient rehabilitation hospitals.  Whereas inpatient acute and rehab PPS payment is based on the discharge date, Outpatient PPS (OPPS) payments are based on Ambulatory Patient Classification payment for the date of service.
(Medicare General Information, Eligibility, and Entitlement)
The amount of payment to other types of providers is restricted to the lesser of (a) the reasonable cost of covered services and items; or (b) the billed charges with respect to such services; or (c) the fee schedule amount.   In addition, A/B MACs (A) and (HHH) assist in applying safeguards against unnecessary use of covered services, furnish consultative services to serve as a center for communicating with providers, conduct audits of provider records, assist in the beneficiary appeals process, and provide information and advice to institutions and organizations that wish to qualify as providers of services.   (See http://www.cms.gov/Medicare/Medicare- Contracting/Medicare- Administrative -Contractors/Home- Health -Hospice-Regions.html  for a list of A/B MACs (A) and (HHH) and service areas.)   40.1 - Assignment of A/B MAC (A) and (HHH)  (Rev. )  CMS assigns MACs based upon jurisdictions as described in:  http://www.cms.gov/Medicare/Medicare-Contracting/Medicare- Administrative -Contractors/MACJurisdictions.html    There are no alternate selections permitted, effective with the implementation of MACs.
(Medicare General Information, Eligibility, and Entitlement)
There are no alternate selections permitted, effective with the implementation of MACs.   40.2 - A/B MAC (A) and (HHH)  Service to HHAs  (Rev. )  All HHAs bill the assigned A/B MAC (HHH) and are paid by that MAC.  In the case of HHAs and hospices based in another Medicare provider (e.g., a hospital or SNF), audit, cost report settlement, and other fiscal functions (such as setting interim payment rates) are performed by the A/B MAC (A) serving the parent provider.  50 - Role of A/B MACs (B) and DME MACs  (Rev. 1, 09-11-02)  The law requires the Secretary, DHHS, to enter into contracts with A/B MACs (B) and DME MACs to serve in the operation and administration of the non-provider Part B program.  A/B MACs (B) enroll physicians, non- physician health care practitioners and other entities that will submit claims to the A/B MAC (B), and process Medicare claims and make payments for services and supplies covered by Part B.  Other major functions include, for example, controlling over-utilization and communicating with beneficiaries and the health community.  DME MACs have been given the responsibility of processing durable medical equipment, prosthetic, orthotic, and supply (DMEPOS) claims.  See Claims Processing Manual, chapter 1, for description of jurisdiction.  60 - Background and Responsibilities of the Peer Review Organization (PRO)  (Rev. 1, 09- 11-02)  Section 1153 of the Social Security Act (the Act) requires the Secretary to enter into contracts with physician- approved or physician- access organizations defined as PROs.  The PROs are organizations who are responsible for monitoring the quality of care provided to Medicare patients by hospitals, SNFs, home health agencies, Medicare+Choice plans, and other types of health care providers.   PRO review is governed by titles XI and XVIII of the Act as amended, and by regulations contained in:    42 CFR 411 -  Limitation on liability;    42 CFR 412 -  Outlier review, diagnosis related group (DRG) validation, and hospital notices of non coverage;
(Medicare General Information, Eligibility, and Entitlement)
 42 CFR 411 -  Limitation on liability;    42 CFR 412 -  Outlier review, diagnosis related group (DRG) validation, and hospital notices of non coverage;    42 CFR 417.605 -  Immediate PRO review of Health Maintenance Organization (HMO)/Competitive Medical Plan (CMP) notices of discharge;    42 CFR 422.622 -  Immediate review of Medicare+Choice discharge notices;    42 CFR 475 -  Definition of eligible organizations and area designation;    42 CFR 476 -  Assumption and conduct of review;    42 CFR 478 -  PRO reconsideration and appeals;    42 CFR 480 -  Disclosure of information;    42 CFR 482 -  Hospital conditions of participation; and    42 CFR 1004 -  PRO recommendations of sanctions.  60.1 - Purpose of PRO Review for the Individual Medicare Beneficiaries  (Rev. 1, 09- 11-02)  The PROs review items or services provided to Medicare beneficiaries to determine:    Whether services provided or proposed to be provided are reasonable and medically necessary for the diagnosis and treatment of illness or injury, or to improve functioning of a malformed body member, or for prevention of an illness, or for the palliation and management of terminal illness;    Whether those services furnished or proposed to be furnished on an inpatient basis could be effectively furnished on an outpatient basis, or in an inpatient health care facility of a different type;    Medical necessity, reasonableness, and appropriateness of inpatient hospital care for which additional payment is sought under the outlier provisions of PPS;    Whether a hospital has misrepresented admission or discharge information, or has taken an action that results in the unnecessary admission of an individual entitled to benefits under Part A, unnecessary multiple admissions of an individual, or other inappropriate medical or other practices with respect to beneficiaries, or billing for services furnished to beneficiaries;    The validity of diagnostic and procedural information supplied by the provider to the A/B MAC (A) for payment purposes;    The completeness and adequacy of hospital care provided; and    Whether the quality of services meets professionally recognized standards of health care.
(Medicare General Information, Eligibility, and Entitlement)
 The completeness and adequacy of hospital care provided; and    Whether the quality of services meets professionally recognized standards of health care.   These activities enable PROs to determine whether Medicare payment may be made for the services claimed and to identify and initiate corrective action where appropriate.  PROs have the authority to deny Medicare payment for medically inappropriate and unnecessary admissions. They also investigate individual beneficiary complaints about the quality of care received.   60.2 - PRO Responsibility for the Overall Approach to Health Care  (Rev. 1, 09- 11-02)  In addition to individual case review, PROs also help providers improve the overall approach to health care for Medicare beneficiaries.   This function includes the following activities:    Using clinical and other data bases to examine patterns of care and outcomes, rather than focusing on isolated cases;    Identifying systemic variations of concern or interest by monitoring patterns of care and outcomes;    Working with providers to identify provider -specific root causes of systemic variations; and    Working cooperatively with the health care community to measurably improve the processes and outcomes of care for Medicare beneficiaries.   60.3 - Other PRO Responsibilities  (Rev. 1, 09- 11-02)  A. Responsibilities Prior to Review   The PROs are responsible for:    Specifying in their plan and instructions to practitioners and providers the type of evidence they require to document the care ordered or furnished to provide medically necessary, appropriate, and quality health care services; and    Applying professionally developed criteria for providing care, diagnosis, and treatment based upon typical patterns of practice within their geographic area to evaluate the medical necessity, quality, or appropriateness of services ordered or furnished.  B. Ongoing Review Activities   As a part of their ongoing review activities, PROs must:    Notify the appropriate agency of the State or Federal government when they become aware of situations which appear to be improper, but which do not fall within their review responsibilities (e.g., poor quality care in a renal dialysis center);    Use their authority or influence to enlist the support of other professional or Government agencies to ensure that all providers and practitioners for which they have review responsibilities comply with their obligations (see 1156 of the Act.); and    Perform beneficiary and physician outreach activities.  C. Responsibilities as a Result of PRO Review   To act upon information they obtain as a result of their review activities, PROs must:
(Medicare General Information, Eligibility, and Entitlement)
 Perform beneficiary and physician outreach activities.  C. Responsibilities as a Result of PRO Review   To act upon information they obtain as a result of their review activities, PROs must:    Provide information on results of their review (e.g., annual report, periodic meetings with providers/practitioners);    Identify and seek correction of situations that, if continued, would result in violations under 1156 of the Act;    Submit reports to the Office of the Inspector General on providers and practitioners found to have substantially violated an obligation in a substantial number of cases, or to have grossly and flagrantly violated an obligation in one or more instances.  This includes referring certain cases to State licensing boards.   D. Additional Activities   PROs perform all other activities specified in the Scope of Work, including any modifications, CMS regulations and instructions, and relevant statutory provisions.  E. Payment Error Prevention Program (PEPP)   In order to reduce inpatient PPS payment errors, PROs must initiate a program of Payment Error Prevention Projects (PEPPs). CMS defines the payment error rate as the number of dollars found to be paid in error out of the total of all dollars paid for inpatient PPS services.  CMS provides State -specific error rates to PROs to evaluate performance.   60.4 - Statutory Obligations of Practitioners and Other Persons  (Rev. 1, 09- 11-02)  It is the obligation of any health care practitioner or other person who furnishes or orders health care items or services that may be reimbursed under Medicare, to ensure that to the extent of his or her authority, those services are:    Furnished economically and only when and to the extent medically necessary;    Of a quality that meets professionally recognized standards of health care; and    Supported by evidence of the medical necessity and quality of the services in the form and fashion that the reviewing PRO may reasonably require (including copies of the necessary documentation) to ensure that the practitioner or other person is meeting the obligations imposed by Section 1156(a) of the Act.  These obligations apply whether payment is made directly to the provider (i.e., assignment) or to the beneficiary, or even if payment is not made.   60.5 - Responsibilities of Designated Agents Working With PROs; Organizations Subcontracted for Review  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
60.5 - Responsibilities of Designated Agents Working With PROs; Organizations Subcontracted for Review  (Rev. 1, 09- 11-02)  The PRO has ultimate responsibility for monitoring the compliance of practitioners and providers with statutory obligations.  It is not relieved of any of the responsibility under the sanction regulations in the event of non -performance by an organization with which it has subcontracted for review.   An organization with which the PRO subcontracts to carry out review functions is responsible for:   Ensuring that practitioners and other persons meet their obligations with respect to the items and services it reviews; and    Reporting to the PRO (primary contractor) those instances where it appears a violation of an obligation may have occurred or is occurring.   70 - Institutional Planning and Budgeting  (Rev. 1, 09- 11-02)  The Social Security Act requires each provider, as a condition of participation under Medicare, to have a written overall plan and budget reflecting an annual operating budget and a capital expenditures plan (that covers at least a 3 -year period including the year to which the operating budget is applicable).  For this requirement, provider means hospital, critical access hospital, SNF, comprehensive outpatient rehabilitation facility, home health agency, or hospice program.   The annual operating budget will include all anticipated income and expenses related to items which would under generally accepted accounting principles be considered income and expense items.  The capital expenditure plan would be expected to include and identify in detail the anticipated sources of finance for, the objectives of, each anticipated expenditure in excess of $l00,000 related to acquisition of land, the improvement of land, buildings, and equipment, and the replacement, modernization, and expansion of the buildings and equipment which would, under generally accepted accounting principles, be considered capital items.  The overall budget and plan will be prepared under the direction of the provider's governing body by a committee consisting of representatives of the governing body, administrative staff and if any, the medical staff.  Further, it will be reviewed and updated at least annually.  The purpose of the requirement is to assure that providers carry on budgeting and substance by the Government or any of its agents.  80 - CMS Managed Modules for Software Programs and Pricing/Coding Files  (Rev. 2, 2- 6-04)
(Medicare General Information, Eligibility, and Entitlement)
The CMS Managed Modules contains scheduled release dates for software programs and pricing/coding files.  Medicare contractors will be receiving subsequent quarterly updates of the CMS Managed Modules via a Recurring Update Notification.  Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI   12/21/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update  01/02/2024  13496  R94GI  10/16/2015  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (2015)  11/16/2015  9336  R80GI  10/26/2012  Manual Updates to Clarify SNF Claims Processing  04/01/2013  8044  R42GI  11/09/2006  Swing Bed Hospital Updates  12/11/2006  5114  R28GI  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100 -01 09/12/2005  3912  R02GI  02/06/2004  Scheduled Release for April Updates to Software Programs and Pricing/Coding Files  03/08/2004  3123  R01GI  09/11/2002  Initial Publication of Manual  NA NA  Back to top of Chapter
(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 2 - Hospital Insurance and Supplementary Medical Insurance  Table of Contents  (Rev. 12046, 05-18-23)   Transmittals for Chapter 2   10 - Hospital Insurance Entitlement 10.1 - Insured Status  10.2 - Hospital Insurance for the Aged  10.3 - Hospital Insurance for Disability Beneficiaries  10.4 - Hospital Insurance for Persons Needing Kidney Transplant or Dialysis   10.4.1 - Effective Date of Entitlement for Persons on Dialysis  10.4.2 - Entitlement Based on Transplant  10.4.3 - Effect on Self -dialysis Training on Entitlement  10.4.4 - End of Coverage Based on ESRD  10.4.5 - Reentitlement for Beneficiaries with ESRD  20 - Hospital Insurance  Obtained by Premium Payment  20.1 - Eligibility Requirements  20.2 - Premiums for Hospital Insurance                          20.2.1 - Premiums Paid by Other Than Enrollee                                      20.2.1.1 - Part A Buy -in States                           20.2.1.2 - Part A Group Payer States  20.3 - Beginning of Coverage  20.3.1 - Initial Enrollment Period (IEP)  20.3.2 - General Enrollment Period (GEP)  30 - End of Coverage for Hospital Insurance  40 - Supplementary Medical Insurance (SMI)  40.1 - Eligibility for Enrollment 40.2 - Automatic Enrollment in SMI  40.3 - Enrollment Periods  40.3.1 - Enrollment During the Individual's Initial Enrollment Period 40.3.2 -  Enrollment During General Enrollment Period 40.3.3 -  Enrollment During the Individual's Special Enrollment Period                                                                                   (SEP) Related  to Coverage Under Group Health Plans  40.3.4 SEP for International Volunteers  40.3.5 SEP for Certain TRICARE Beneficiaries  40.3.6 SEP for Beneficiaries for Whom Medicare is Now the        Primary Payer (D -SEP)  40.3.7 Special Enrollment Period for Exceptional Conditions   40.3.7.1 SEP for Individuals Impacted by an Emergency or      Disaster 40.3.7.2 SEP for Individuals Affected by Employer Misrepresentation   40.3.7.3 SEP for Formerly Incarcerated Individuals    40.3.7.4 SEP for Termination of Medicaid Coverage