evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Vendor software is normally tested when it first begins to be used by providers, billing agents or clearinghouses/VANs.  At the request of a vendor or a clearinghouse/VAN, an A/B MAC, DME MAC, CEDI or other contractor if designated by CMS may, but is not required to, test new software before a provider has agreed to begin using that software to exchange Medicare eligibility transactions with the contractor.  When testing software prior to use by a provider, an A/B MAC, DME MAC, CEDI or other contractor if designated by CMS may not furnish a software vendor who does not currently submit or receive Medicare transactions with an EDI access number or password which would permit the vendor to access to actual Medicare beneficiary data.  That software is to be tested using a test database or by other means that would not disclose actual beneficiary data to the vendor.  This EDI access limitation for testing of new software does not apply to a clearinghouse/VAN with a history of submi ssion/receipt of EDI transactions with the contractor, or when a software vendor is also a clearinghouse/VAN or a provider billing agent (in which case, testing should only involve data for beneficiaries for which the entity already submit/receives transac tions).  40.2.2.4 - Release of Medicare Data  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)
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40.2.2.4 - Release of Medicare Data  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  The CMS is required by law to protect all Medicare beneficiary -specific information from unauthorized use or disclosure.  Disclosure of Medicare beneficiary data is restricted under the provisions of the Privacy Act of 1974 and HIPAA.  CMS instructions allow release of data to providers or their authorized billing agents for the purpose of preparing an accurate claim.  Such information may not be disclosed to anyone other than the provider, supplier, or beneficiary for whom the claim was filed.  A/B MACs, DME MACs or other contractors if designated by CMS must give access to any clearinghouse that requests access to data on behalf of providers as long as they adhere to the following rules:   Each clearinghouse requesting access to eligibility data must sign a Trading Partner Agreement (TPA) and agree to adhere to CMS rules of behavior (Refer to www.cms.gov/HETSHelp);   Each provider that contracts with a clearinghouse must sign a valid EDI Enrollment Form before data can be sent to the third party (see Section 30.1);    The provider must explain the type of EDI services to be furnished by its clearinghouse in a signed statement authorizing the clearinghouses access to data;    The clearinghouse must be able to associate each inquiry with the provider making the inquiry.  That is, for each inquiry made by a provider through a clearinghouse, the clear inghouse must be able to identify the correct provider making the request for each beneficiarys information and be able to assure that responses are routed only to the provider that originated each request; and    There is no record of prior violation of a TPA by this clearinghouse with the A/B MAC, DME MAC or other contractor if designated by CMS to whom a request for access to the data is submitted that would indicate that beneficiary data could be at risk of improper disclosure if access was approved for this clearinghouse.   A. All providers and clearinghouses that wish to obtain Medicare beneficiary data must apply to A/B MACs, DME MACs or other contractor if designated by CMS for access to the records.
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A. All providers and clearinghouses that wish to obtain Medicare beneficiary data must apply to A/B MACs, DME MACs or other contractor if designated by CMS for access to the records.   B. Providers and clearinghouses must submit each query to the A/B MACs, DME MACs or other contractor if designated by CMS with which they are registered.  CMS supports multiple EDI and non -EDI methods for obtaining eligibility data, including ASC X12 270/271 eligibility (see IOM Pub. 100- 04 Chapter 31 for more information on the ASC X12 270/271 eligibility transaction).   C. When an inquiry is submitted, the A/B MAC, DME MAC, HETS 270/271, or other contractor if designated by CMS must be able to ensure that:    An EDI agreement has been signed by the provider;   A TPA has been signed by the clearinghouse; and   Each inquiry identifies the provider that initiated the query and to which the response will be routed.   D. Providers must be notified that:    they may obtain eligibility data only for the approved use of pre paring accurate Medicare claims;    access to eligibility data is limited to individuals within a providers organization who are involved in claim preparation and submission; and    they and their authorized third party agents must agree not to request eligibility data for a beneficiary unless the provider has been contacted by the beneficiary, a personal representative of a beneficiary such as a relative or friend, or a health care provider currently treating the beneficiary concerning provision of heal th care services or supplies to the beneficiary.   E. Medicare contractors, as designated by CMS, must:    Provide notification of these requirements to all providers requesting electronic receipt of eligibility data;    remind providers to notify them when the re is a change in clearinghouse, arrangements cease with a clearinghouse, or the provider leaves the Medicare program;   delete each provider from their EDI eligibility security file if there is no longer a business relationship between the Medicare contractor and provider, or if the Medicare contractor or the provider is no longer serving the Medicare program; and   remind providers, clearinghouses and other third parties that access rights to beneficiary eligibility data may be revoked if they fail to adhere to the requirements for access.
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 remind providers, clearinghouses and other third parties that access rights to beneficiary eligibility data may be revoked if they fail to adhere to the requirements for access.   40.2.2.5 - EDI Enrollment and EDI Claim Record Retention  (Rev. 2965, Issued: 05- 23-14, Effective: 07-25-14, Implementation: 07-25-14)  In order for an entity to become an EDI trading partner, an EDI enrollment form must be completed, approved, and on file with an A/B MAC or CEDI.  A/B MAC or CEDI are required to retain all EDI enrollment forms according to the same CMS Records Schedule retention requirements that apply to the CMS- 855 Medicare Enrollment Application.   The paper claim retention schedule can be found at Pub 100-01, Chapter 7, Section 30: http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downlo ads/ge101c07.pdf    Once a trading partner has been tested and approved for electronic submission of claims, they can begin submitting electronic claims to Medicare. A/B MAC, DME MACs or CEDI are required to retain electronically filed claims under the same CMS Records Retention Schedule retention requirements that apply to hardcopy claim.   40.2.3 - General EDI Outreach Activities  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A/B MACs, DME MACs and CEDI are to actively encoura ge providers to increase their use of EDI transactions.  Also see  60 of this Chapter for EDI Edit Requirements.  Specific outreach requirements are included in the CMS requirements for implementation of new or revised EDI standards.  A/B MACs, DME MACs a nd CEDI are also required to notify providers about the need to file most claims with Medicare electronically. See  90 for specific referenced to Mandatory Submission of Medicare Claims. In general, A/B MACs, DME MACs and CEDI must:   1. Feature information on EDI during trade shows, vendor fairs, educational forums, and vendor association meetings that they sponsor or in which they participate;
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1. Feature information on EDI during trade shows, vendor fairs, educational forums, and vendor association meetings that they sponsor or in which they participate;   2. Provide educational information on EDI to providers identified in internal analysis described in Se ction 40.2.3.1 as well as to the software vendors and clearinghouses that serve or market services to Medicare providers;   3. Make themselves available whenever possible, and invited to participate as an EDI speaker on the agenda of organized provider group meetings, such as state or local chapters of AAHAM, HFMA, MGMA, EDI user groups, state and local medical societies, and other provider and related vendor trade groups.  DME MACs shall participate in regional meetings that entail supplier use of EDI; and    Include specific and meaningful EDI messages in provider newsletters, addressing the themes described in Section 40.2.3.4 below, other issues that may be pertinent to the A/B MAC (B), DME MACs, or A/B MACs (A) geographic area, and as directed in individua l EDI instructions issued by CMS.  A/B MACs, DME MACs and CEDI are expected to point out the advantages to providers in the use of EDI transactions.  See the Medicare Beneficiary and Providers Communication Manual (100- 09) for definitive guidance on Medica res provider outreach requirements.  Provider outreach activities, including those that involve EDI are funded through the Provider Education and Training budget issued to Medicare contractors.   40.2.3.1 - A/B MAC and DME MAC Analysis of Internal Informat ion (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs and  DME MACs must contact providers with the highest number of paper claim transactions to have them begin submission of claims electronically as required under 90 of this chapter for ASCA enforcement Reviews. A/B MACs, DME MACs, and CEDI are also to strongly encourage providers to conduct their claims status, beneficiary eligibility, payment and remittance advice transactions electronically.    40.2.3.2 - Contact Wi th New Providers  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)
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40.2.3.2 - Contact Wi th New Providers  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs must conduct an analysis of the capability of each provider (including physicians and suppliers) that contact a Medicare contractor to begin submission of Medicare claims, or for DME MACs, when notified by the National Supplier Clearinghouse that new supplier identification numbers have been issued.  A/B MACs  shall use provider education to ensure that all providers/submitters are aware that EDI transacti ons are to be presented as the normal mode of business for Medicare claims, claim status, and remittance.  A/B MACs  shall also use provider education to ensure that all providers/submitters are aware that EFT is the normal mode for funds transfer. See Chap ter 31 for HETS information on eligibility verification ASC X12 270/271 eligibility transaction queries.  Where the provider does not have the related capability, A/B MACs, DME MACs and CEDI are to inform the providers of available options to begin use of EDI, e.g., list of vendors and clearinghouses and billing services, availability of Medicares free software.   40.2.3.3 - Production and Distribution of Information to Increase Use of EDI (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, DME MACs, and CEDI are required to post information on their provider web page to educate and influence providers in all aspects of EDI.  They must include the following information at a minimum:    Earlier payment of electronic claims that comply with HIPAA standards requirements;    The benefit of earlier detection of errors via edits conducted upon submission of electronic transactions;    The relative ease of use of EDI and the support available from the contractor to assist them in beginning use of EDI transactions;    Advantages of online correction of errors (A/B MAC (A) only);    Lower administrative, postage, and handling costs;    Electronic adjustments (A/B MAC (A)  only);    Availability of free software:   o PCACE Pro32 -  Part A/B and D ME;  o Medicare Remit Easy Print Software (MREP) -  Part B and DME; and
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 Availability of free software:   o PCACE Pro32 -  Part A/B and D ME;  o Medicare Remit Easy Print Software (MREP) -  Part B and DME; and   o Medicare Standard Electronic PC Print Software (PC Print) -  Part A/B.   o Availability of batch claims status inquiries. The information must be updated on a regular basis.  Availability of batch claims status inquiries. The information must be updated on a regular basis.  A/B MACs, DME MACs, and CEDI are encouraged to issue these materials via the Internet or E -Mail when possible, but paper copies may be distributed where most cost effect ive or when a provider may not have Internet or E- Mail access.   40.2.3.4 - Production and Distribution of Material to Market EDI  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  A/B MACs, DME MACs, and CEDI are required to produce and distribute material to educate and influence providers in all aspects of EDI.  They must include the following themes in published material:   1. Earlier payment of claims because of different payment floor requirements;  2. The benefit of earlier detectio n of errors via edits; 3. The relative ease of EDI and support available;  4. Advantages of online correction of errors (A/B MAC (A) only); 5. Lower administrative, postage, and handling costs; 6. Electronic adjustments (A/B MAC (A) only);  7. Availability of free software;  8. Claims status inquiry; and  9. Eligibility query.   They must include in written materials testimonials and/or case studies from providers and facilities that have benefited from using EDI transactions.
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They must include in written materials testimonials and/or case studies from providers and facilities that have benefited from using EDI transactions.   These materials may be pr oduced in-house or by local printing companies.  The contents must be maintained up to date.  Therefore, A/B MACs, DME MACs, and CEDI must carefully plan print quantities to match planned distribution to avoid unnecessary waste.  They must make the materia l available to staff that have contact with the provider community and make arrangements for distribution at trade shows and seminars that the A/B MACs, DME MACs, and CEDI do not attend as well as those that they do attend.  40.2.4 - Trading Partner Management  (Rev. 2803, Issued: 10- 28-13, Effective: 09-17-13, Implementation: 09-17-13)  Medicare FFS Trading Partner Agreement is comprised of two forms: 1) EDI Registration and 2) EDI Enrollment.  The forms are identified under CMS form 10164 and can be accessed at:  EDI Registration - https://www.cms.gov/cmsforms/downloads/CMS10164A.pdf and  EDI Enrollment - https://www.cms.gov/cmsforms/downloads/CMS10164B.pdf   40.2.4.1 - User Guidelines  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, and CEDI must make information available to potential users (preferably via their Web page or the Internet) of each EDI transaction supported by Medicare with detailed information on:    The telephone numbers of appropriate staff to contact to:   o Get started with electronic billing and other EDI transactions; and  o Obtain on- going support for electronic transactions.   o Testing requirements and the submitters and A/B MACs, and CEDI level of responsibility throughout each step of the testing process. See Section 40.1.2.1. for further testing details;   The availability of the appropriate specifications for providers and instructions for accessing these via the Internet or other cost effective means;    The availability  of the A/B MACs to provide  providers bulletins via the Internet and/or bulletin board system;
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 The availability of the appropriate specifications for providers and instructions for accessing these via the Internet or other cost effective means;    The availability  of the A/B MACs to provide  providers bulletins via the Internet and/or bulletin board system;    The availability of the A/B  MACs, and CEDI to provide EDI instructions or procedures via the Internet and/or bulletin board system;    The availability of the A/B MACs, and CEDI to provide free Medicare EMC software;    The availability of the A/B MACs free PC -Print software and the A/B  MACs, and CEDIs free Medicare Remit East Print (MREP) software for the printing of the Electronic Remittance Advice.    Login requirements;    Hours of operation, system and support;    Telecommunication options and requirements;    Procedures for updating submit ters with any billing changes;    EDI formats required for input to the A/B MACs and CEDI system.  These specifications must be in sufficient detail for the submitters use, and must include information regarding code, record length(s), field positioning within record(s), labeling and any other conventions necessary for compatibility with the A/B MACs or CEDI system;    All acceptance and rejection formats and content for output from the A/B MACs, or CEDI;     Availability of online claim entry, claim correction (A/B MAC (A) only), claim status check, eligibility verification, claim development via DDE or otherwise, and the procedure for accessing these transactions;    Availability of claim status check and eligibility verification and the procedure for accessing these transactions (A/B MACs only);    Specifications of the A/B MACs, and CEDIs front -end editing process (except in those cases when disclosure of specific edits is related to medical Review or another sensitive area for which disclosure is not a dvisable) with complete list of error codes and resolution, including those conditions that will result in the rejection of entire EDI transmissions/batches;   Conventions for acknowledging claims received and for recovering data known to be lost;    Instruct ions for submitters to notify their A/B MACs and CEDIs changes to the submitter profile in regard to use of clearinghouses, billing agents, EDI transactions and software for submission/receipt of those transactions;
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 Instruct ions for submitters to notify their A/B MACs and CEDIs changes to the submitter profile in regard to use of clearinghouses, billing agents, EDI transactions and software for submission/receipt of those transactions;    A/B MACs and CEDI listings of vendors a nd clearinghouses that are approved for production;    Data requirements for reporting third party Medigap payers,    Frequently asked questions and answers about EDI.   DME MACs  must make information available to potential users (preferably via their web page  or the Internet) of each EDI transaction supported by Medicare with detailed information on:    How to contact CEDI to:   o Get started with electronic billing and other EDI transactions; and  o Obtain on- going support for electronic transactions.   The availability of DME MACs  provider bulletins via the Internet and/or bulletin board system;    The availability of CEDIs free Medicare EMC software    The availability of the CEDI free Medicare Remit East Print (MREP) software for the printing of the Electronic Remittance Advice.    Special instructions related to specific diagnosis or procedure codes, i.e., the necessity for attachments or modifiers and appropriate placement within the electronic record and;    Data requirements for reporting third party payers, i.e., Medigap, crossover, Medical Assistance and private insurance.   40.2.4.2 - Technical Assistance to EDI Trading Partners  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs and CEDI will provide help desk support to a ssist submitters and receivers with inquiries related to file transmission and acknowledgment, file retrieval, transaction requirements/specifications and the use of free software.  Help desk support will be available during normal business hours at a mini mum.  Time zone differences at the providers location should be accommodated if possible.  Help desk activities are to be controlled and monitored through an automated call management system that provides the following functions:    Control (login) of all incoming calls: identification of caller, reason for call, date and time;   Track activities related to the call to the final resolution of the call: identification of routing, callbacks, issues(reason for call), resolution, date and time;    Workload distribution of open items;
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 Track activities related to the call to the final resolution of the call: identification of routing, callbacks, issues(reason for call), resolution, date and time;    Workload distribution of open items;    Classification of call types for resource planning, provider education, management reporting; and    Storage of caller -specific audit trails.   In addition to an automated call system, A/B MACs and CEDI must provide for receipt of e-mail or voice mail when the help desk is not available.  Receipt of customer service inquiries must be acknowledged within one business day, or attempts to acknowledge the inquiry within this time must be documented if contact has not been made successfully.   Where transmission, retrieval or file problems are reported, a plan of action to resolve the issue must be provided to the inquirer within three (3) business days. This plan should include one or more of the following:    An indication that the A/B MACs or CEDI looked into the issue and did not identify a problem;    The submission of a new corrected file (A/B MAC or CEDI only);    An explanation which either solves the problem or indicates action which the submitter or receiver can take to resolve the problem;    An indication of the need for further investigation, with an estimated time frame for responding with more information and or a resolution;    An indication that resolution requires A/B MACs or CEDI action, and a description of the plan for resolution and estimated completion date.   Where the problem affects multiple submitters the A/B MAC or CEDI makes information on the issue available to all affected submitters.   40.2.4.3 - Training Content and Frequency  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09 -17-13)