evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
microfiche, and photocopy the mail.  Contractors must also log and account for the checks, noting pertinent information, such as the provider or suppliers name and number, date of the check, the check number, the amount of the check, and the date the check was returned.  The carriers or DMERCs financial staff must either reissue the check based upon receipt of an updated, verified address, or systematically cancel the returned check and notify the provider enrollment staff that a provider must be flagged DNF.  The provider enrollment staff must annotate the provider or suppliers file with a DNF flag, pending receipt of a verified address.  Carriers and DMERCs must process any subsequent claims a flagged provider or supplier submits through the Common Working File (CWF) t o completion, but must not generate any additional check or checks for that provider or supplier until an authorized address correction is received and the flag removed. In addition, provider enrollment staff must alert the benefit integrity staff in the event that any investigations are currently taking place, which are affiliated with flagged providers or suppliers.  DMERCs must notify the National Supplier Clearing Hous e (NSC).  All carriers must implement a standardized reporting format for this process.  NOTE:  Because some providers get paid through electronic funds transfer (EFT), there may be cases where a provider does not have a correct address on file, but the contractor continues to pay the provider through EFT.  This instruction applies to providers receiving paper.  B.  Change of Address Process for Local Carriers and DMERCs  When a flagged provider or supplier notifies you that they have not received their checks, direct them to your provider enrollment staff.  The provider or supplier must complete a change of address Form CMS -855C, or other written notification.  The form or  written notification must bear an original signature from an authorized representative of the entity that completed the original registration form.  No copies, faxes, or stamps are acceptable.  For purposes of this process, the most important address is t he Pay To address.  If the provider or supplier did not furnish the Pay To address on Form CMS -855C, or other written notification, return it to the provider or supplier. The provider or supplier must furnish the Pay To address.  Addresses may not be  changed based on telephone calls.  Although the Pay to Address is the most
(Medicare Claims Processing Manual)
-855C, or other written notification, return it to the provider or supplier. The provider or supplier must furnish the Pay To address.  Addresses may not be  changed based on telephone calls.  Although the Pay to Address is the most critical, CMS requires corrections to all addresses before the contractor can remove the DNF flag and begin paying the provider or supplier again.  Therefore, carriers may not release any payments to DNF providers until the provider enrollment area or the NSC has verified and updated all addresses for that providers location When a provider enrollment staff member verifies an address, the provider must update the address for the provider or supplier and remove the DNF flag.  Provider enrollment staff must send a daily report to financial staff, advising which providers and suppliers are no longer flagged DNF.  Financial staff must generate all payment that is due the provider or supplier for claims that were adjudicated for the time period the provider or supplier was flagged.  C.  Educational Requirements  1.   Contractors must publish the requirement that providers must notify the Part B carrier or NSC of any changes of address, both on their Web sites and in their next regularly scheduled bulletins. 2.   Contractors must continue to remind suppliers and providers of this requirement in their bulletins at least yearly thereafter.
(Medicare Claims Processing Manual)
80.5.1.1 - Reporting Requirements - Carriers  (Rev. 2228, Issued: 05- 20-11, Effective:06 -06-11, Implementation:06- 06-11)  A. Field Definitions for DNF Spreadsheet   To be certain that all parties understand what information CMS needs to get from these reports, the following definitions have been created for each field. No rolling or annual totals should be included.  Suppliers/Providers Flagged/Corrected Counts Field #  Definition  1  New Flags: the number of all suppliers or providers the contractor flagged for DNF during the reporting quarter (regardless of whether or not they still have a flag, and regardless of whether the contractor flagged them due to a returned check or returned remittance advice), that were not flagged at the end of the previous reporting quarter.  2  Removed Flags: the number of all suppliers or providers who supplied a verified, correct address, causing the contractor to remove the DNF flag, during the reporting quarter.  3  Total Flags: the total number of all suppliers or providers who still have a DNF flag on the last day of the reporting quarter, regardless of whether the contractor flagged them due to a returned check or returned remittance advice), including those the contractor flagged in a previous quarter who did not supply a verified, corrected address.   Check Counts Field #  Definition  4  Returned Checks: the total number of checks the post office returned to the contractor due to an incorrect address during the reporting quarter, regardless of whether or not the supplier provided a corrected address and may have been reissued the check dur ing the quarter.  5  Held Checks: the total number of all checks that contractors did not issue due to DNF flags in the system during the reporting quarter, regardless of whether or not the supplier provided a corrected address and was later paid.  6  Reissued and Released Checks: the total number of all checks (both those the post office returned, and those the contractor had been holding due to a DNF flag in the system) the contractors reissued or released during the reporting quarter, to suppliers or  providers who submitted a verified, correct address.
(Medicare Claims Processing Manual)
Dollar Counts Field #  Definition  7  Amount Returned: the total dollar amount of all checks the post office returned due to an incorrect address during the reporting quarter, that you are still holding at the end of the reporting quarter.  8  Amount Held: the total dollar amount of all checks the contractors did not issue due to DNF flags in the system during the reporting quarter, that you are still holding at the end of the reporting quarter.  9  Amount Reissued/Released: the total dollar amount of all payments (both those the post office returned, and those the contractor had been holding due to a DNF flag in the system) the contractors reissued during the reporting quarter, to suppliers or providers who submitted a verified, correct address.  10  Net Amount: the value in field 7 plus the value in field 8, minus the value in field 9 - it is possible that this number will be a negative figure.   NOTE A   If a contractor flags a provider or supplier for DNF more than one time within a quarter, only count that supplier or provider once for fields 1, 2, and 3.  NOTE B   Multi- Carrier Systems contractors may use a claim count for items 4 -6, 8, and 9, rather than a check count.   B. Systems Requirements   Carriers and DMERCs generate reports out of the shared systems and must be able to generate figures for each field in accordance with the above descriptions.   Furthermore, shared systems must be certain that when the system calculates the totals, it includes the first returned check that prompted the DNF flag. The shared systems should program the reports so that the contractors may request monthly detail report s to verify the quarterly totals. However, carriers only send the quarterly reports to CMS central office (CO) and regional office (RO), not the monthly reports.   C. Quarterly Reporting Requirements   All contractors must submit their DNF reports by the fifteenth day of each month that follows the end of a quarter (i.e., January 15, April 15, July 15, and October 15). The instructions for the current process are defined in Section F, Deliverable Schedul e, of each individual contract.  Contractors (A/B MACs and DME MACs) must submit their DNF reports to CMS Automated Reporting Tracking System (CMS ARTs).  Legacy Contractors (Carriers) must submit their DNF reports to their appropriate CMS Central Office contact .  D. Other Requirements
(Medicare Claims Processing Manual)
D. Other Requirements   Contractors must continue to follow all other aspects of the DNF reporting initiative (e.g., use of Return Service Requested envelopes, assignment of a DNF flag to appropriate providers/suppliers) as instructed in the 80.5.   E.  Examples - Blank Report  DO NOT FORWARD PROJECT  Activity for the _____ Quarter of FY _____  $$ Region  Medicare Contractor      Suppliers/Providers Flagged/Correct Counts     1.     # new supplier/providers flagged during the reporting quarter     2.     # suppliers/providers whose flags were removed, end of the reporting quarter     3.     # suppliers/providers flagged, end of the reporting quarter         Check Counts     4.     # new checks returned during the reporting quarter     5.     # of checks held during the reporting quarter     6.     # checks reissued during the reporting quarter         Dollar Counts     7.     $ amount of new checks returned during the reporting quarter     8.     $ amount of checks held during the reporting quarter     9.     $ amount reissued during the reporting quarter     10.   $ amount returned to trust fund during the reporting quarter         Report By: ____________________________________     Report Date: __________________________________     Sample Completed Report  SAMPLE - DO NOT FORWARD PROJECT  Activity for the 3RD  Quarter of FY 2003  $$ Region  Medicare Contractor    Q XYZ Contractor  Suppliers/Providers Flagged/Correct Counts     1.     # new supplier/providers flagged during the reporting quarter  125   2.     # suppliers/providers whose flags were removed, end of the reporting quarter  30   3.     # suppliers/providers flagged, end of the reporting quarter  117       Check Counts     4.     # new checks returned during the reporting quarter  40   5.     # of checks held during the reporting quarter  100   6.     # checks reissued during the reporting quarter  60       Dollar Counts     7.     $ amount  of new checks returned during the reporting quarter  100,000    8.     $ amount of checks held during the reporting quarter  600,000    9.     $ amount reissued during the reporting quarter  500,000    10.   $ amount returned to trust fund during the reporting quarter  200,000
(Medicare Claims Processing Manual)
Report By:     ___Jane Doe______________________     Report Date:  __April 02, 2003___________________       80.6  Processing All Diagnosis Codes Reported on Claims Submitted to Carriers  (Rev.735, Issued: 10-31- 05, Effective: 04 -01-06, Implementation: 04-03-06) Carrier standard systems shall capture and process all diagnosis codes reported on a claim (both paper and electronic) up to the maximum permitted under the format.  The CWF shall process and maintain all diagnosis codes reported to CWF on a carrier processed claim.   90 - Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period  (Rev. 11731, Issued: 12-09-22, Effective: 01-11-23, Implementation: 01-11-23)
(Medicare Claims Processing Manual)
Where a patient either enrolls or disenrolls in an MA organization (See Pub. 100-01, the General Information, Eligibility, and Entitlement Manual, Chapter 5, 80 for definition) during a period of services, two factors determine whether the MA organization is liable for the payment.  Whether the provider is included in inpatient hospital or home health PPS, and  The date of enrollment. Hospital Services  If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patients status at admission or start of care  determines liability.  If the hospital inpatient was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment. For hospitals exempt from PPS (childrens hospitals, cancer hospitals, CAHs and Maryland waiver hospitals), if the MA organization has processing jurisdiction for the MA involved portion of the bill, it will direct the provider to split the bill and send t he appropriate portions to the appropriate FI or MA organization.  When forwarding a bill to an MA organization, the provider must also submit the necessary supporting documents. If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.  Home Health  If the patient was enrolled in the MA organization before start of care, the MA organization is liable until disenrollment. Upon disenrollment, an episode must be opened under home heath PPS for billing to the FI. If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the home health PPS episode will end as of the day before the MA enrollment.  The episode will be proportionately paid according to its shortened length (i.e., paid a pa rtial episode payment [PEP] adjustment).  The MA organization is responsible for payment as of the MA enrollment date.   91 - Moral and Religious Fee for Service Claims for Medicare Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans
(Medicare Claims Processing Manual)
100 - Medicare as a Secondary Payer  (Rev. 1, 10- 01-03) HO- 301, HO -469, CFR 411.32 The provider is required to determine whether Medicare is a primary or secondary payer for each inpatient admission of a Medicare beneficiary and outpatient encounter with a Medicare beneficiary.  Refer to the Medicare Secondary Payer Manual for specific MSP rules and for special admission and claims processing procedures for providers, suppliers, FIs, and carriers.  Medicare benefits are secondary to benefits payable by a third party payer, even if State law or the third party payer states that its benefits are secondary to Medicare benefits or otherwise limits its payments to Medicare beneficiaries.  Medicare will ma ke secondary payments except when the provider or supplier is either obligated to accept, or voluntarily accepts, as full payment, a third party payment that is less than its charges.  When a provider or supplier, or a beneficiary who is not physically or mentally incapacitated, receives a reduced third party payment because of failure to file a proper claim, the Medicare secondary payment may not exceed the amount that would have been payable if the third party payer had paid on the basis of a proper claim . The law mandates that Medicare is secondary payer for:   Claims involving Medicare beneficiaries age 65 or older who have GHP coverage based upon their own current employment status with an employer that has 20 or more employees, or that of their spouse of any age, or based upon coverage by a multiple employer, or multi- employer group health plan by virtue of their own, or a spouses, current employment status and the GHP covers at least one employer with 20 or more employees.  An individual has current employment status if the individual is actively working as a n employee, is the employer (including a self -employed person), or is associated with the employer in a business relationship; or is not actively working, but meets all of the following conditions:  o    Retains employment rights in the industry;  o    Has not had employment terminated by the employer, o    Is not receiving disability payments from an employer for more than six months;  o    Is not receiving social security disability benefits; and  o    Has group health plan (GHP) coverage based on employment that is not COBRA continuation coverage.  Examples of individuals who fall in the second group are teachers, employees who are on furlough or sick leave, and active union members
(Medicare Claims Processing Manual)
benefits; and  o    Has group health plan (GHP) coverage based on employment that is not COBRA continuation coverage.  Examples of individuals who fall in the second group are teachers, employees who are on furlough or sick leave, and active union members between jobs.   Claims involving beneficiaries eligible for or entitled to Medicare on the basis of end stage renal disease (ESRD) during a period of 30 months) except where an aged or disabled beneficiary had GHP or LGHP coverage which was secondary to Medicare at the ti me ESRD occurred;  NOTE : The Balanced Budget Act of 1997 extended the ESRD coordination period to 30 months from 18 months for any individual whose coordination period began on or after March 1, 1996.  Individuals whose period began before that date have an 18- month coordination period.  This issue may need to be clarified with ESRD beneficiaries upon admission.  Claims involving automobile or non- automobile liability or no -fault insurance;   Claims involving government programs, e.g., Workers Compensation (WC), services authorized and paid for by the Department of Veterans Affairs (DVA), or Black Lung (BL) benefits; and  Claims involving Medicare beneficiaries under age 65 who are entitled to Medicare on the basis of disability and are covered by an LGHP (plans or employers, or employee organizations, with at least one participating employer that employs 100 or more employees) based upon the beneficiarys own current employment status or the current employment status of a family member.  110 - Provider Retention of Health Insurance Records  (Rev. 1, 10- 01-03) HO- 413, HH -480, SNF -545 The provider must maintain health insurance materials related to services rendered under title XVIII for the retention periods outlined below unless State law stipulates a longer period.  It must keep them available for reference by CMS, carrier, or FI, DHHS audit, or specially designated components for bill review, audit, and other refe rences.  110.1 - Categories of Health Insurance Records to Be Retained  (Rev. 1, 10- 01-03) HO- 413, HH -480, SNF -545.1 Providers retain records in all categories as applicable:  A.  Billing Material Provider copies of Form CMS -1450 and any other supporting documents, e.g., charge slips, daily patient census
(Medicare Claims Processing Manual)
-480, SNF -545.1 Providers retain records in all categories as applicable:  A.  Billing Material Provider copies of Form CMS -1450 and any other supporting documents, e.g., charge slips, daily patient census records, and other business and accounting records referring to specific claims.  B.  Cost Report Material  All data necessary to support the accuracy of the entries on the annual cost reports, including original invoices, cancelled checks, and provider copies of material used in preparing them.  Also include other similar cost reports, schedules, and related worksheets and contracts or records of dealings with outside sources of medical supplies and services or with related organizations. C.  Medical Record Material  For hospitals, utilization review committee reports and discharge summaries.  For hospitals and home health agencies, physicians certifications, and recertifications, and clinical and other medical records relating to health insurance claims.  D.  Provider Physician Materials  Provider physician agreements upon which Part A and Part B allocations are based.  After payment of the bill, the provider should not retain administrative and billing work records if the material does not represent critical detail in support of summaries related to these records.  These include punch cards, adding machine tapes, or othe r similar material not required for record retention. 110.2 - Microfilming Records  (Rev. 1, 10- 01-03) SNF -545.3, HO -413, HH -480 The provider may microfilm all health insurance records.  Billing material and related attachments that the provider furnished to the carrier or FI may be microfilmed providing the microfilm accurately reproduces all original documents. The provider must retain copies of all other categories of health insurance records in their original form.  If it microfilms them, it should store them in a low cost facility for the retention period described in 110.3. 110.3 - Retention Period  (Rev. 1, 10- 01-03) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The provider must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.  The provider (hospital, skilled nursing facility, and home health agency) must retain medical records in their original or legally reproduced form for a period of at least five years after it files with its FI
(Medicare Claims Processing Manual)
the authentication and protects the security of all record entries.  The provider (hospital, skilled nursing facility, and home health agency) must retain medical records in their original or legally reproduced form for a period of at least five years after it files with its FI the cost report to which the records apply, unless State law stipulates a longer period of time.  After payment of the bill, the provider need not retain administrative and billing work records provided that, and only to the extent that, such material does not represent critical detail in support of summaries related to the records outlined in 110.2.  These records include punch cards, adding machine tapes, internal controls, or other similar material not required for record retention. Providers must retain clinical records as follows:   The period of time required by State law;   Five years from the date of discharge when there is no requirement in State law; or  For a minor, three years after a resident reaches legal age under State law.  110.4 - Destruction of Records  (Rev. 1, 10- 01-03) HO- 413.1, HH -480.1, SNF -545.4  The provider may destroy material that no longer needs to be retained for title XVIII purposes, unless State law stipulates a longer period of retention.  To insure the confidentiality of the records, they must be destroyed by shredding, mutilation or other protective measures.  The method of final disposition of the records may provide for their sale as salvage.  The provider must report monies received as an adjustment to expense in the cost report for the year sold.  120 - Detection of Duplicate Claims  (Rev. 2678, Issued: 03- 29-13, Effective: 04 -29-13, Implementation: 04- 29-13)