evekhm/cms_iom_500 huggingface dataset:
(Medicare Program Integrity Manual)
The contractor shall establish a single point of contact for ALJ offices on administrative matters involving notifications, scheduling, information sharing, and other coordination necessary between the ALJ, the appellant, and other contractors.   3.10  Prior Authorization  (Rev. 876; Issued: 04- 12-19; Effective: 05 -13-19; Implementation: 05 -13-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A.  Overview   Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the item or service is furnished to the beneficiary and before the claim is submitted for processing.  It is a process that permits the submitter (e.g., provider, supplier, beneficiary, etc.) to send in medical documentation in advance of providing and billing for an item or service, to verify its eligibility for Medicare claim payment.  Contractors shall, at the direction of CMS or other authorizing entity, conduct prior authorizations and alert the submitter of any potential issues with the information, as submitted.  For any item or service to be covered by Medicare it must:    Be eligible for a defined Medicare benefit category,    Be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functi oning of a malformed body member, and    Meet all other applicable Medicare coverage, coding and payment requirements.  Contractors shall communicate to the submitter (and beneficiary upon request) their prior authorization decision and the assigned unique t racking number (UTN), which indicates that the submitter requested a prior authorization, for corresponding claim submissions.
(Medicare Program Integrity Manual)
Contractors shall communicate to the submitter (and beneficiary upon request) their prior authorization decision and the assigned unique t racking number (UTN), which indicates that the submitter requested a prior authorization, for corresponding claim submissions.   For certain prior authorization programs, the requirement to prior authorize is a condition of payment, as further described in the sections below.  Absent any explicit CMS instruction to the contrary, submitters may correct identified issues with their prior authorization request(s) and resubmit their request(s) for prior authorization without restriction.  Contractors shall conduct prior authorization reviews within the timeframes defined by CMS in the corresponding prior authorization program operational instruction(s).  The prior authorization process is further described in following sections.  B.  Condition of Payment   Contractors shall determine if the requirement to prior authorize a particular item or service is a condition of payment, as specified in the individual operational instruction(s).  If prior authorization is a condition of payment, claims submitted without  an indication that the submitter made a prior authorization request (i.e., UTN) shall be denied upon receipt.   C.  Outreach and Education  Contractors shall educate stakeholders each time a new prior authorization program is launched for  a particular item or service, the requisite information and timeframes for prior authorization submissions, and the vehicle(s) for submitting such information to the contractor for assessment.  Contractors shall make sure submitters are aware of the timeframes for contract ors to render prior authorization decisions, for each individual prior authorization program.  Each prior authorization program will have an associated Operational Guide and will be available on the CMS website.  Contractors shall, at a minimum, provide public access to agency -developed prior authorization operational guides, by posting the link(s) on their website.   Contractors shall hold group or individualized training sessions, as appropriate, to notify the stakeholders of upcoming prior authorization programs and to make sure there is ongoing understanding of the specific requirements for those applicable prior authorization programs.  D.  Prior Authorization Submission   Contractors shall assess the information/documentation included in the prior author ization submission for completeness.  Requisite information for individualized prior authorization programs will be included in the operational guides, and shall be available on the CMS website.   Requisite information may include, but is not limited to:   Beneficiary Information (i.e., name, Medicare beneficiary identifier, date of birth)
(Medicare Program Integrity Manual)
Requisite information may include, but is not limited to:   Beneficiary Information (i.e., name, Medicare beneficiary identifier, date of birth)    Physician/Practitioner Information (i.e., name, provider identification number, address)    Supplier Information (i.e., name, national supplier clearinghouse (NSC) number, identification number, address)    Documentation from the medical record to support the medical necessity of the item or service, and    Any other relevant documents as deemed necessary by the contractor to process the prior authorization.   E.  Prior Authorization Decisions   Contractors shall notify the submitter if their prior authorization submission results in a provisional affirmative, or non- affirmative decision.    A provisional affirmative decision is a preliminary finding that a future claim subm itted to Medicare for the item or service likely meets Medicares coverage, coding, and payment requirements.   A non- affirmative decision is a finding that the submitted information/documentation does not meet Medicares coverage, coding, and payment requi rements, and if a claim associated with the prior authorization is submitted for payment, it would not be paid.  Contractors shall provide notification of the reason(s) for the non -affirmation, if a request is non -affirmative, to the submitter.  If a prior  authorization request receives a non -affirmative decision, the prior authorization request can be resubmitted an unlimited number of times, unless otherwise specified.  Contractors shall send detailed decision letters to submitters.  As appropriate for the given prior authorization program, contractors shall send detailed decision letters to other stakeholders (e.g., beneficiaries) using their official address on file.  In addition, there may be certain prior authorization programs that require the contrac tors to notify the appropriate entity by other means, such as telephone.  If a claim is submitted for payment without an affirmative prior authorization decision on file, contractors shall use their existing processes to either suspend claims for additiona l review or to process claims as denials, based on each individualized prior authorization program, as detailed in the operational instruction.   F.  Expedited Request
(Medicare Program Integrity Manual)
F.  Expedited Request   For certain items or services, delays in receipt of a prior authorization decision could jeopardize the life or health of the beneficiary.  Contractors shall, for such items or services, expedite their decisions based on the operational instruction.  If the claim processing systems would unavoidably delay the delivery of the UTN in an expedit ed fashion, contractors shall nonetheless render an affirmative or non- affirmative decision to the submitter within the mandated, expedited timeframe.  Contractors shall alert the submitter that the decision is being provided as expediently as possible, so that the item or service may be provided, but that the submitter should hold their claim and not submit it until such time as the UTN is received (in order to avoid a claims payment denial).   3.10.1 - Prior Authorization Program for Certain DMEPOS  (Rev. 937; Issued: 01- 31-20; Effective: 03 -02-20; Implementation: 03 -02-20)  A prior authorization program for certain DMEPOS items that are frequently subject to unnecessary utilization is described in 42 CFR 405 and 414.234.  Among other things, these sections establish a Master List of certain DMEPOS items meeting inclusion criteria and potentially subject to prior authorization.  CMS will select Healthcare Common Procedure Coding System (HCPCS) codes from the Prior Authorization Master List that shall require prior authorization, at its discretion.  In selecting HCPCS codes, C MS may consider factors such as geographic location, item utilization or cost, system capabilities, emerging trends, vulnerabilities identified in official agency reports, or other analysis, and may implement prior authorization nationally or locally.  The Prior Authorization Master List is the list of DMEPOS items that have been identified using the inclusion criteria described in 42 CFR 414.234.  The Master List can be found on the CMS website.  The Required Prior Authorization List is the items selected from the Prior Authorization Master List to be implemented in the Prior Authorization Program.  The Required Prior Authorization List can be found on the CMS website, and will be updated as additional codes are selected for prior authorization.
(Medicare Program Integrity Manual)
CMS may el ect to exempt suppliers from prior authorization program upon demonstration of compliance with Medicare coverage, coding, and payment rules.  The CMS may suspend prior authorization requirements generally or for a particular item or items at any time and w ithout undertaking rulemaking.  CMS provides notification of the suspension of the prior authorization requirements via (i) Federal Register notice; and (ii) Posting on the CMS prior authorization Web site.  3.10.1.1- Voluntary Prior Authorization (PA) for DMEPOS Accessories   (Rev: 12056; Issued: 05 -25-23; Effective: 06 -26-23; Implementation: 06-26-23)  The 2019 ESRD and DMEPOS final rule (84 Fed. Reg. 60648 (Nov. 8, 2019)) permits CMS to develop a program to allow suppliers to voluntarily include certain accessories on prior authorization requests submitted for items on the Required Prior Authorization List. These accessories may receive a prior authorization decision for operational simplicity, even if the accessory itself is not on the Required Prior Authorization List. Voluntarily submitting a prior authorization request for accessories does not create a condition of payment and is not mandatory.  Prior authorization requests for accessories must include a corresponding item on the Required Prior Authorization List; otherwise, the prior authorization request for the accessory will be rejected. Accessories submitted on a prior authorization request where the corresponding item on the Required Prior Authorization List is non- affirmed will also be non- affirmed.   The list of DME items that require prior authorization can be found on  Required Prior Authorization List , and the list of selected accessories that can be voluntarily added to prior authorization requests can be found on the Voluntary Prior Authorization List . The Required Prior Authorization List and the Voluntary Prior Authori zation List will be updated as additional codes are selected.  For more information, please see the CMS DMEPOS Prior Authorization website.  3.10.2 - Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services  (Rev. 937; Issued: 01-31- 20; Effective: 03 -02-20; Implementation: 03 -02-20)
(Medicare Program Integrity Manual)
3.10.2 - Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services  (Rev. 937; Issued: 01-31- 20; Effective: 03 -02-20; Implementation: 03 -02-20)  A prior authorization process for certain hospital OPD services is described in 42 CFR 419.80 through 419.89 as a method for controlling unnecessary increases in the volume of covered services.  These sections establish requirements for the submission of a prior authorization request (PAR), the timeframes for the review of a PAR, and the process for CMS to exempt providers from prior authorization requirements.    The li st of hospital OPD services requiring prior authorization will be updated through formal notice -and-comment rulemaking.  Technical updates to the list of services, such as changes to the name of the service or the HCPCS code, will be published on the CMS w ebsite.   The CMS may elect to exempt a provider from this prior authorization process upon a providers demonstration of compliance with Medicare coverage, coding, and payment rules after semiannual assessments.  Providers must reach a prior authorization provisional affirmation threshold of 90 percent or greater to be eligible for exemption.  The CMS may suspend the outpatient department services prior authorization process requirements generally or for a particular service(s) at any time by issuing notification on the CMS website.                                       Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12056PI  05/25/2023  Update to Chapt er 3 of Publication (Pub.) 100-08 (Program Integrity Manual (PIM)) for the Voluntary Prior Authorization (PA) Process for Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Accessories
(Medicare Program Integrity Manual)
06/26/2023  13185  R11933PI  03/30/2023  Update to Process and Responsibility for Tracking Medicare Contractors' Prepayment and Post Payment Reviews in the RAC Data Warehouse (RACDW)  04/03/2023  12281  R11697PI  11/09/2022  Update to Process and Responsibility for Tracking Medicare Contractors' Prepayment and Post Payment Reviews in the RAC Data Warehouse (RACDW) - Rescinded and Replaced by Transmittal 11933  04/03/2023  12881 R11529PI  07/28/2022  Update of Chapter 3 in Publication (Pub.) 100-08, Including Update to Medicare Program Integrity Contractor Post- Payment Review Process, and Update of Chapter 8 Pub. 100-08, Including Revision to When Contractor Suspects Additional Improper Claims  08/30/2022  12827  R11032PI  09/30/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of Publication (Pub.) 100-08 11/10/2021  12375  R10984PI  09/09/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of Publication (Pub.) 100-08 - Rescinded and Replaced by Transmittal 11032  11/10/2021  12375  R10365PI  10/02/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and Exhibits of Publication (Pub.) 100-08  08/27/2020  11884  R10228PI  07/27/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and Exhibits of Publication (Pub.) 100- 08 Rescinded and Replaced by Transmittal #10365  08/27/2020  11884  R10197PI  06/26/2020  Publication (Pub.) 100 -08 Chapter 3 Updates to Section 3.2.3.2 (Timeframes for Submission) and Section 3.2.3.8 (No Response or Insufficient Response to Additional Documentation Requests 07/27/2020  11730  Rev #  Issue Date  Subject  Impl Date  CR#  (ADRs))  R10190PI  06/19/2020  Revising Chapters 3 and 5 of Publication (Pub.) 100- 08, to Reflect the Recent Final Rule
(Medicare Program Integrity Manual)
11730  Rev #  Issue Date  Subject  Impl Date  CR#  (ADRs))  R10190PI  06/19/2020  Revising Chapters 3 and 5 of Publication (Pub.) 100- 08, to Reflect the Recent Final Rule CMS -1713 -F 07/01/2020  11599  R10171PI  06/12/2020  Updates to Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) and Ambulance Certification Signature Requirements  07/13/2020  11763  R10132PI  05/15/2020  Revising Subsection 3.2.5, Targeted Probe and Educate (TPE), in Chapter 3 of Publication (Pub.) 100 -08 06/16/2020  11695  R10100PI  05/08/2020  Revision to Language in Chapter 3, Section 3.7.5 (Corrective Action Reporting Requirements) of Publication (Pub.) 100 -08 06/09/2020  11756  R937PI  01/31/2020  Updates to the Prior Authorization (PA) Guidance Within Publication (Pub.) 100-08  03/02/2020  11633  R933PI  01/10/2020  Update to Chapter 3, Section 3.2.3.1 Additional Documentation Requests (ADR) of Publication (Pub) 100-08  01/06/2020  10828  R912PI  10/18/2019  Medicare Administrative Contractor (MAC) Verification of Potential Errors and Corrective Actions Ta ken 11/19/2019  11463  R907PI  10/04/2019  Update to Chapter 3, Section 3.2.3.1 Additional Documentation Requests (ADR) of Publication (Pub) 100-08- Rescinded and Replaced by Transmittal #933  01/06/2020  10828  R902PI  09/27/2019  Updates to Chapters 3, 4, 8, 15, and Exhibits of Publication (Pub.) 100 -08 10/28/2019  11425  R876PI  04/12/2019  Update to Publication (Pub.) 100 -08 to Provide Language-Only Changes for the New Medicare Card Project  05/13/2019  11109  R853PI  01/04/2019  Updates to the Appeals Prioritization Process  02/05/2019  10641  R833PI  10/12/2018  Templates in Medical Review  11/13/2018  10930  R825PI
(Medicare Program Integrity Manual)
R853PI  01/04/2019  Updates to the Appeals Prioritization Process  02/05/2019  10641  R833PI  10/12/2018  Templates in Medical Review  11/13/2018  10930  R825PI  09/21/2018  Credentials of Reviewers (This Change Request (CR) Rescinds and Fully Replaces CR 10157.)  10/22/201 8 10909  R819PI  08/17/2018  Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in 09/17/2018  10876  Rev #  Issue Date  Subject  Impl Date  CR#  Publication (Pub.) 100 -08 R796PI  05/11/2018  Intent to Reopen  08/13/2018  9855  R802PI
(Medicare Program Integrity Manual)
06/21/2018  Use of Accessible and Applicable Claims History During Medical Review  07/24/2018  10640  R791PI  04/27/2018  Restoring Section 3.2.3 B. and Section 3.2.3 C. to Chapter 3 of Publication (Pub.) 100-08 in the In ternet Only Manual (IOM)  05/29/2018  10505  R786PI  04/13/2018  Reimbursing Providers and Health Information Handlers (HIHs) for Additional Documentation  05/14/2018  10529  R768PI  02/08/2018  Post-Payment Review Timeliness Requirements  04/01/2018  9990  R755PI  11/09/2017  Tracking Medicare Contractors' Prepayment and Postpayment Reviews  12/11/2017  10177  R751PI  10/20/2017  Clarifying Signature Requirements  11/20/2017  10322  R748PI  10/13/2017  Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings  11/14/2017  10226  R738PI  08/18/2017  Provider Error Rate Formula  09/19/2017  10210  R732PI  07/21/2017  Clarifying the Instructions for Amending or Correcting Entries in Medical Records  08/22/2017  10120  R721PI  06/09/2017  Elimination of Routine Reviews Including Documentation Compliance Reviews and Instituting Three  Medical Reviews  07/11/2017  9809  R713PI  05/05/2017  Scribe Services Signature Requirements  06/06/2017  10076  R698PI  01/20/2017  The Process of Prior Authorization  02/21/2017  9940  R674PI  09/02/2016  Duplicate Postpayment Claim Reviews  11/04/2016  9665  R663PI  07/15/2016  Denial Codes for Missing or Insufficient Documentation  08/16/2016  9690  R657PI  06/17/2016  Special Provisions for Lab Additional Documentation Requests (ADRs)  07/18/2016  9670  R634PI  01/22/2016  Reviewers' Credentials, Notifying the Provider, CARC Code Update  04/22/2016  9333  R628PI  12/04/2015  Update to CMS Publication 100 -08, Chapter 3, Section 3.2.3.2 (Time Frames for Submission)  01/06/2016  9438 R620PI  10/16/2015  Pub. 100 -08 Chapter
(Medicare Program Integrity Manual)
Update to CMS Publication 100 -08, Chapter 3, Section 3.2.3.2 (Time Frames for Submission)  01/06/2016  9438 R620PI  10/16/2015  Pub. 100 -08 Chapter 3 Updates: Section 3.2.3.2 Timeframes for Submission and Section 3.2.3.8 - No response to Additional 11/17/2015  9226  Rev #  Issue Date  Subject  Impl Date  CR#  Documentation Requests  Rescinded and not replaced  R617PI  10/09/2015  Update to Chapter 3 of Pub. 100 -08 11/10/2015  9303  R615PI  10/02/2015  Signature Requirements  11/02/2015  9332  R613PI  09/25/2015  Postpayment Review Requirements  10/26/2015  9323  R608PI  08/14/2015  Update to Pub. 100 -08 to Provide Language -Only Changes for Updating ICD-10 and ASC X12  09/14/2015  8747  R604PI  07/24/2015  Signature Requirements  08/25/2015  9225  R585PI  04/03/2015  Coding Determinations  05/04/2015  8937  R568PI  02/04/2015  Review Timeliness Requirements for Complex Review  03/01/2015  8443  R567PI  02/04/2015  New Timeframe for Response to Additional Documentation Requests  04/06/2015  8583  R566PI  01/07/2015  New Timeframe for Response to Additional Documentation Requests  Rescinded and replaced by Transmittal  567 04/06/2015  8583  R565PI  12/31/2014  Update to CMS Publication 100 -08, Chapter 3, Section 3.2.3.2 (Time Frames for Submission)  02/02/2015  9012  R557PI  11/26/2014  Update to CMS Publication 100 -08, Chapter 3, Section 3.2.3.4 (Additional Documentation Request Required and Optional Elements)  12/29/2014  8948  R554PI  11/14/2014  New Timeframe for Response to Additional Documentation Requests  Rescinded and replaced by Transmittal 566  04/06/2015  8583  R547PI  10/17/2014  Review Timeliness Requirements for Complex Review  Rescinded and replaced by Transmittal 566  02/24/201 5 8443  R543PI
(Medicare Program Integrity Manual)
566  04/06/2015  8583  R547PI  10/17/2014  Review Timeliness Requirements for Complex Review  Rescinded and replaced by Transmittal 566  02/24/201 5 8443  R543PI  09/26/2014  Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings  10/27/2014  8501  R541PI  09/12/2014  Claims that are Related  09/08/2014  8802  R540PI  09/04/2014  Claims that a re Related  Rescinded and replaced by Transmittal 541  09/08/2014  8802  R534PI  08/08/2014  Claims that are Related  Rescinded and replaced by Transmittal 540  09/08/2014  8802  R527PI  07/03/2014  Provider Notice on MAC Web sites  09/05/2014  8690  Rev #  Issue Date  Subject  Impl Date  CR#  R523PI  04/20/2014  Update to CMS Pub. 100 -08, Chapter 3  Rescinded and not replaced  07/22/2014  8791  R512PI  04/18/2014  Revision to the Program Integrity Manual, Chapter 3 Section 3.3  05/19/2014  8716  R505PI  02/05/2014  Removing Prohibition - Rescinded  03/06/2014  8425  R501PI  01/09/2014  Complex Medical Review  10/07/2013  8429  R500PI  12/27/2013  Third -party Additional Documentation Request CERT Update  01/28/2014  8547  R498PI  12/27/2013  Notifying the Provider of Postpayment Review Results  01/28/2014  8541  R496PI  12/12/2013  Tracking Medicare Contractors' Postpayment Reviews  10/03/2013  8362  R489PI  10/18/2013  100% Prepayment Review and Random Review Instructions  11/19/2013  8427  R488PI  09/20/2013  Acceptable Submission Methods for Responses to ADRs  10/21/2013  8436  R487PI  09/13/2013  Tracking Medicare Contractors' Postpayment Reviews  10/03/2013  8362  R486PI  09/06/2013  Complex Medical Review  Rescinded and replaced by Transmittal 501  10/07/2013  8429  R485PI  08/21/2013  Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor