evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Notification to a beneficiary who has been deemed legally incompetent is typically made to an authorized representative of the beneficiary.  However, if a beneficiary is temporarily incapacitated, a person (typically, a family member or close friend) whom the hospital or CAH has determined could reasonably represent the beneficiary, but who has not been named in any legally binding document, may be a representative for the purpose of receiving the MOON.  Such a representative should act in the beneficiarys best interests and in a manner that is protective of the beneficiary and the beneficiarys rights.  Therefore, a representative should have no relevant conflict of interest with the beneficiary.   In instances where the notice is delivered to a representative who has not been named in a legally binding document, the hospital or CAH annotates the MOON with the name of the staff person initiating the contact, the name of the person contacted, and the date, time, and method (in person or telephone) of the contact.  NOTE:   There is an exception to the in- person notice delivery requirement.  If the MOON must be delivered to a representative who is not physically present to receive delivery of the notice, the hospital or CAH is not required to make an off -site delivery to the representative.  The hospital or CAH must complete the MOON as requir ed an d telephone the representative.    The information provided telephonically includes all contents of the MOON;    Note the date and time the hospital or CAH communicates (or makes a good faith attempt to communicate) this information telephonically, per 400.2 above, to the representative is considered the receipt date of the MOON;    Annotate the Additional Information section to reflect that all of the information indicated above was communicated to the representative; and    Annotate the Additional Information section with the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called.   Mail a copy of the annotated MOON to the representative the  day telephone contact is made.
(Medicare Claims Processing Manual)
Mail a copy of the annotated MOON to the representative the  day telephone contact is made.   A hard copy of the MOON must be sent to the representative by certified mail, return receipt requested, or any other delivery method that can provide signed verification of delivery (e.g., FedEx, UPS).  The burden is on the hospital or CAH to demonstrate that timely contact was attempted with the representative and that the notice was delivered.   If the hospital or CAH and the representative both agree, the hospital or CAH may send the notice by fax or e -mail; however, the hospital or CAHs fax and e -mail systems must meet the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security requirements.  400.3.7 - Ensuring Beneficiary Comprehension  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The OMB -approved standardized MOON is available in English and Spanish.  If the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, hospitals and CAHs must employ their usual procedures to ensure notice comprehension.  Usual procedures may include, but are not limited to, the use of translators, interpreters, and assistive technologies.  Hospitals and CAHs are reminded that recipients of Federal financial assistance have an independent obli gation to provide language assistance services to individuals with limited English proficiency (LEP) consistent with section 1557 of the Affordable Care Act and Title VI of the Civil Rights Act of 1964.  In addition, recipients of Federal financial assistance have an independent obligation to provide auxiliary aids and services to individuals with disabilities free of charge, consistent with section 1557 of the Affordable Care Act and section 504 of the Re habilitation Act of 1973.  400.3.8 - Completing the Additional Information Field of the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  This section may be populated with any additional information a hospital wishes to convey to a beneficiary.   Such information may include, but is not limited to:    Contact information for specific hospital departments or staff members.
(Medicare Claims Processing Manual)
This section may be populated with any additional information a hospital wishes to convey to a beneficiary.   Such information may include, but is not limited to:    Contact information for specific hospital departments or staff members.    Additional content required under applicable State law related to not ice of observation services.   Part A cost -sharing responsibilities if a beneficiary is admitted as an inpatient before 36 hours following initiation of observation services.    The date and time of the inpatient admission if a patient is admitted as an inpatient prior to delivery of the MOON.    Medicare Accountable Care Organization information.   Hospital waivers of the beneficiarys responsibility for the cost of self -administered drugs.    Any other information pertaining to the unique circumstances regarding the particular beneficiary.   If a hospital or CAH wishes to add information that cannot be fully included in the Additional Information section, an additional page may be attached to supplement the MOON.   400.3.9 - Notice Retention for the MOON  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  The hospital or CAH must retain the original signed MOON in the beneficiarys medical record.   The beneficiary receives a paper copy of the MOON that includes all of the required information described in section 400.3.2 and, as applicable, sections 400.3.5, 400.3.6 and 400.3.8.  Electronic notice retention is permitted.  400.4 - Intersection with State Observation Notices  (Rev. 3698, Issued: 01- 27-17, Effective: 02 -21-17; Implementation: 02 -21-17)  As noted in sections 400.3.1 and 400.3.8 above, hospitals and CAHs in States that have State -specific observation notice requirements may add State -required information to the Additional Information field, attach an additional page, or attach the notice required under State law to the MOON.   500 - Glossary  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    The following terms are defined only for purposes of this Chapter 30 of the Medicare Claims Processing Manual.
(Medicare Claims Processing Manual)
The following terms are defined only for purposes of this Chapter 30 of the Medicare Claims Processing Manual.    Advance notice of non -coverage  42 CFR 418.408(d)(2) states that if Medicare would be likely to deny payment as not medically reasonable and necessary, before the service was provided, the physician informed the beneficiary, or someone acting on the beneficiary's behalf, in writing that the physician believed Medicare was likely to deny payment for the specific service and that the beneficiary signed a statement agreeing to pay for that service. This statement may appear as the  notice of non -coverage (e.g.  Advance Beneficiary Notice of Non -coverage (ABN), Form CMS -R-131, Skilled  Nursing Facility Advance Beneficiary Notice of Non- Coverage (SNF ABN), Form CMS10055, Home Health Change of Care Notice (HHCCN), Form CMS -10280), as defined in 42 CFR 411.404.)     Advance Beneficiary Notice of Non -coverage (ABN, Form CMS -R-131) -  Issued by healthcare providers and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied.     Authorized representative  An individual authorized under State or other applicable law, e.g., a legally appointed representative or guardian of the beneficiary (if, for example, the beneficiary has been legally declared incompetent by a court) to act on behalf of a beneficiary when the beneficiary is temporarily or permanently unable to act for himself or herself.  The authorized representative will have all of the rights and responsibility of a beneficiary or party, as applicable.  In states which have health care consent statutes providing for health care decision making by surrogates on behalf of patients who lack advance directives and guardians, reliance upon individuals appointed or designated under such statutes to act as authorized representatives is permissible.  The Appointment of Representative , Form CMS -1696 is available for the convenience of the beneficiary or any other individual to use when appointing a representative.
(Medicare Claims Processing Manual)
For purposes of this chapter, when the term beneficiary is used, for legal purposes, and the beneficiary has an authorized representative, the use of either beneficiary or authorized representative are exchangeable of each other, unless otherwise indicated.     Beneficiary  Individual who is enrolled to receive benefits under Medicare Part A and/or Part B.     Detailed Explanation of Non -Coverage (DENC, Form CMS -10124)  Medicare FeeFor -Service (FFS) Expedited Determination Notice given only if a beneficiary requests an expedited determination.  The DENC explains the specific reasons for the end of services.     Detailed Notice of Discharge (DND, Form CMS -10066)  Hospital Discharge Appeal Notice given to beneficiaries who choose to appeal a discharge decision from the hospital or their Medicare Advantage plan, if applicable.    Financial Liability Protections (FLP) Provisions  The FLP provisions of the Social Security Act protect beneficiaries, healthcare providers, and suppliers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay.  The FLP provisions apply after an  item or services coverage determination is made.     Healthcare provider  Healthcare provider means a provider of services (or provider) (as defined under Section 1861(u) of the Social Security Act), a hospital, a critical access hospital (CAH), a skilled nursing facility (SNF), a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization or intensive outpatient  services).     Home Health Change of Care Notice (HHCCN, Form CMS -10280) -  Used by Home Health Agencies (HHAs) to notify Original Medicare beneficiaries receiving home health care benefits of plan of care changes.  HHAs are required to provide notification to beneficiaries before reducing or terminating an item and/or service.
(Medicare Claims Processing Manual)
Hospital -Issued Notices of Non -coverage (HINNs) - Hospitals provide to beneficiaries prior to admission, at admission, or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving, or is about to receive, is not covered by Medicare.     Important Message from Medicare (IM, Form CMS -R-193)  Hospital Discharge Appeal Notice delivered to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients.  The IM informs hospitalized inpatient beneficiaries of their hospital discharge  appeal rights.     Limitation on Liability (LOL) Provision  The LOL provisions, 1879(a) -(g) of the Social Security Act, fall under the FLP provisions and provide financial relief and protection to beneficiaries, healthcare providers, and suppliers by permitting Medicare payment to be made, or requiring refunds t o be made, for certain items and/or services for which Medicare payment would otherwise be denied.    Limitation on Recoupment  The requirement that (in certain cases) Medicare must cease or delay recovery of an overpayment when a valid first or second level appeal request is received from a provider on an overpayment, in accordance with Section 1893 of the Social Security Act.  For more information, see 100- 06 Medicare Financial Management Manual, Chapter 3, Overpayments.    Medicare Beneficiary Identifier (MBI) -  is a general term describing a beneficiary's  Medicare identification number.  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.    Medicare Contractor -  An entity that contracts with the Federal government to review and/or adjudicate claims, determinations and/or decisions.     Medicare Outpatient Observation Notice (MOON, Form CMS -10611) - A standardized notice to inform Medicare beneficiaries (including health plan enrollees) that they are outpatients receiving observation services and are not inpatients of a hospital or CAH.
(Medicare Claims Processing Manual)
Notice of Medicare Non -Coverage (NOMNC, Form CMS -10123) -  FFS Expedited Determination Notices that informs beneficiaries on how to request an expedited determination from their Quality Improvement Organization (QIO) and gives beneficiaries the opportunity to request an expedited determination from a QIO.     Overpayment Recovery Waiver  An allowance providing that beneficiaries, healthcare providers, and suppliers can keep Medicare overpayments (in certain circumstances) if they are determined to be without fault for causing the overpayment, in accordance with Section 1870 of the Soci al Security Act.  For more information, see 100- 06 Medicare Financial Management Manual, Chapter 3, Overpayments.     Refund Requirements (RR) for Non -assigned Claims for Physicians Services -  Under 9332(c) of OBRA 1986 (P.L. 99- 509), which added 1842(l) to the Social Security Act, new liability protections for Medicare beneficiaries affect nonparticipating physicians.     Refund Requirements (RR) for Assigned and Non- assigned Claims for Medical  Equipment and Supplies  Under 132 of SSAA -1994 (Social Security Act  Amendments of 1994, P.L. 103- 432) which adds 1834(a)(18) to the Social Security Act, and under 133 of SSAA -1994 which adds 1834(j)(4) and 1879(h) to the Social Security Act, new liability protections for Medicare beneficiaries affect suppliers of medic al equipment and supplies.  All suppliers who sell or rent medical equipment and supplies to Medicare beneficiaries are subject to the refund provisions of 1834(a)(18), 1834(j)(4) and 1879(h) of the Social Security Act.     Skilled Nursing Facility Advance Notice of Non -coverage (SNF ABN, Form CMS - 10055)  Issued in order for a Skilled Nursing Facility (SNF) to transfer financial liability to an Original Medicare beneficiary for items or services, paid under the SNF PPS, that Medicare is expected to deny payment (entirely or in part).     Supplier  Unless the context otherwise requires, a physician or other practitioner, a facility, or entity (other than a provider of services) that furnishes health services covered by Medicare.
(Medicare Claims Processing Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024  13222  R11210CP  01/21/2022  Expedited Review Process for Hospital Inpatients in Original Medicare  04/21/2022  12546 R10862CP  07/14/2021  Section 50 in Chapter 30 of Publication (Pub.) 100- 04 Manual Updates  10/14/2021  12242 R4197CP  01/11/2019  Chapter 30 Revisions in Publication (Pub.) 100-04, Medicare Claims Processing Manual  04/15/2019  10848 R4250CP  03/08/2019  Update to Chapter 30 in Publication (Pub.) 100-04 to Provide Language -Only Changes for the New Medicare Card Project  04/08/2019  11165 R4198CP  01/11/2019  Skilled Nursing Facility Advance Beneficiary Notice of Non -Coverage (SNF ABN)  04/30/2018  10567 R4001CP  03/16/2018  Internet Only Manual Updates to Pub. 100-01, 100- 02 and 100- 04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512 R4011CP  03/30/2018  Skilled Nursing Facility Advance Beneficiary Notice of Non -Coverage (SNF ABN) - Rescinded and replaced by Transmittal 4198  04/30/2018  10567 R3698CP  01/27/2017  Medicare Outpatient Observation Notice (MOON) Instructions  02/21/2017  9935 R3695CP  01/20/2017  Medicare Outpatient Observation Notice (MOON) Instructions   Rescinded and replaced by Transmittal 3698 02/10/2017  9935 R3560CP  07/15/2016  Correction of Remark Code Information  10/17/2016  9641 Rev #  Issue Date  Subject  Impl Date  CR#  R3187CP  02/06/2015  Language Only Update to Pub 100- 04, Chapter 30 for ASC X12 and Claim References  03/06/2015  8992 R2911CP  03/14/2014  Manual Updates to Clarify Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Requirements Pursuant to Jimmo vs.
(Medicare Claims Processing Manual)
X12 and Claim References  03/06/2015  8992 R2911CP  03/14/2014  Manual Updates to Clarify Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Requirements Pursuant to Jimmo vs. Sebelius  03/25/2014  8644 R2878CP  02/21/2014  Correction CR -  Advance Beneficiary Notice of Noncoverage (ABN), Form CMS -R-131 05/15/2014  8597 R2782CP  09/06/2013  Advance Beneficiary Notice of Noncoverage (ABN), Form CMS -R-131 12/09/2013  8404 R2781CP  09/06/2013  Home Health Change of Care Notice (HHCCN), Form CMS -10280, Manual Instructions.  This CR rescinds and fully replaces CR 7323. 12/09/2013  8403 R2711CP  05/24/2013  Expedited Determinations for Provider Service Terminations  08/26/2013  7903 R2480CP  06/01/2012  Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS -R-131, Updated Manual Instructions  09/04/2012  7821 R2362CP  12/01/2011  Home Health Advance Beneficiary Notice, (HHABN), Form CMS -R-296 02/03/2012  7323 R1983CP  06/11/2010  Clarification on Use of the SNF ABN and Denial Letters  07/12/2010  6987 R1587CP  09/05/2008  Revised Form CMS -R-131 Advance Beneficiary Notice of Noncoverage  03/01/2009  6136 R1257CP  05/25/2007  Important Message From Medicare (IM) and Expedited Determination Procedures for Hospital Discharges  07/02/2007  5622 Rev #  Issue Date  Subject  Impl Date  CR#  R1186CP  02/23/2007  Changes to Chapter 30 -   Updates to Amount in Controversy Requirement and Correction of Appeals Terminology 05/23/2007  5348 R1035CP  08/18/2006  Updating Publication 100- 04, Chapter 30 Regarding the CD ROM Initiative for the Annual "Dear Doctor" Mailing  09/18/2006  5214 R1025CP  08/11/2006  Revised Home Health Advance
(Medicare Claims Processing Manual)
08/18/2006  Updating Publication 100- 04, Chapter 30 Regarding the CD ROM Initiative for the Annual "Dear Doctor" Mailing  09/18/2006  5214 R1025CP  08/11/2006  Revised Home Health Advance Beneficiary Notice  09/01/2006  5009 R994CP  06/30/2006  Special Issues Associated with the Advance Beneficiary Notice (ABN) for Hospice Providers and Comprehensive Outpatient Rehabilitation Facilities (CORFs)  09/29/2006  5117 R594CP  06/24/2005  Preliminary Instructions: Expedited Determinations/ Reviews for Original Medicare  07/01/2005  3903 R577CP  06/03/2005  Preliminary Instructions: Expedited Determinations/Reviews for Original Medicare  07/01/2005  3903 R001CP  11/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter
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CMS Manual System  Department of Health & Human Services (DHHS)  Pub 100 -08 Medicare Program Integrity  Centers for Medicare & Medicaid Services (CMS)  Transmittal  829 Date: October 2, 2018   Change Request 10901   Transmittal 829, dated October 3, 2018, is being rescinded and replaced by Transmittal 854, dated January 11, 2019, to update 3 business requirements (BR) and their related chapter 13 manual instructions.  This correction will revise BRs 10901.7 and 10901.7.1, including the related section 13.2.4.3, to add language that indicates that MACs have the discretion to host multi -jurisdictional CACs ; revise BR 10901.24, including the related section 13.5.2.2, to strike the words in their proposed LCD and strike the words "meeting logistics" and repla ce with "attendance information"; and BR 10901.26, including the related section 13.5.3, to add language that allows MACs the option of providing a hyperlink to the FDA clearance to market.  All other information remains the same.   SUBJECT: Local Coverage Determinations (LCDs)
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