evekhm/cms_iom_500 huggingface dataset:
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 Services newly denied as a result of re- adjudication shall be reported as positive values.   Services that were denied, but are reinstated as a result of re-adjudication shall be repor ted as negative values.    The MACs, CERT, RACs, SMRC and UPICs shall document the rationale for denial and include the basis for revisions in each case (important for provider appeals). MACs, CERT, and UPICs should include copies of the NCD, coverage provis ions from interpretive manuals, or LCD and any applicable references needed to support individual case determinations. RACs and the SMRC shall include detailed rationale as outlined in their  SOWs.    The MACs have the discretion to deny payment without the r eview of the claim with a medically unlikely service  edit.  3.5.3 - CMS Mandated Edits  (Rev. 721; Issued: 06- 09-17; Effective: 07 -11-17; Implementation: 07 -11-17)  In past years, CMS created mandated edits that suspend certain claims for medical review coverage and coding review.  However, more recently, CMS has given the contractors the discretion to prioritize workload to effectively lower the error rate.  CMS is n ow in the process of removing such mandated coverage and coding review edits from CWF, pricer, grouper, fee schedules, etc.   Contractors may override CMS mandated edits that suspend for medical review coverage and coding review without performing review if  one or more of the following conditions apply:   1. The contractor does not have MR responsibility for the claim, or    2. The contractor's data analysis/priority setting/ MR strategy does not indicate this service is a problem in their jurisdiction, or   3. It is no t a skilled nursing facility (excluding swing beds) or a home health demand bill (these demand bills must be reviewed).   3.5.4 - Tracking Medicare Contractors'  Prepayment and  Postpayment Reviews  (Rev. 11933; Issued: 03- 30-23; Effective: 04 -01-23; Implement ation: 04 -03-23)
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Shared System Maintainers shall create a pre -payment claim file that is automatically uploaded to the RACDW by the VDC. Medicare Administrative Contractors (MACs) shall input all postpayment complex reviews into the Recovery Audit Data Wa rehouse.  All claims chosen for review by the MAC where an additional documentation request letter was issued to the provider before or after payment was made shall be included.  MACs shall include all reviews, even those that did not result in an improper payment.   Claims may be manually uploaded into the data warehouse or submitted by flat file. The Shared System Maintainers and MACs shall use the file layout provided by CMS for claims uploaded to the Recovery Audit Data Warehouse. Postpayment claims sha ll be submitted to the Recovery Audit Data Warehouse by the 20th day of every month for the previous month. Prepayment claims shall be submitted to the Recovery Audit Data Warehouse daily.   MAC staff who need access to the Data Warehouse shall contact RAC@cms.hhs.gov.  3.6 - Determinations Made During Review  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.   A. General   The MACs, CERT, Recovery Auditors, and UPICs shall be able to differentiate the type of determination made, ensuring that limitation of liability determinations are appropriate.  When the MAC determines, through prepayment data analysis or postpayment review, that an inappropriate claim has been submitted; or the Recovery Auditor determines, in post-payment review, that an improper payment has been made, the MAC and Recovery Auditor shall verify that the error represents an unacceptable practice and not just an explainable aberrancy. Some legitimate reasons for anomalous data include:    The provider may be associated with a medical school, research center, or may  be a highly specialized facility, for instance, the facility may be a Medicare- dependant hospital or CAH, which might skew the type of claims submitted; or   The community in which the provider practices may have special characteristics such as socio -economic level or a concentration of a specific age group that leads to an apparent aberrancy in the use of certain  services.
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 The community in which the provider practices may have special characteristics such as socio -economic level or a concentration of a specific age group that leads to an apparent aberrancy in the use of certain  services.   The MACs, CERT, Recovery Auditors, and UPICs have the discretion to make other determinations during the review of a claim to avoid or identify improper payments for such things as duplicate claims, etc. Other examples are listed below:   Example 1: A Medicare policy states that when three (3) procedures are performed during the same operative session, Medicare pays 100 percent for the first, 50 pe rcent for the second and 25 percent for the third. A claim is identified where all three (3) procedures were paid at 100 percent.  Example 2: A claim was paid using the fee schedule from the prior year.   Example 3: A Medicare payment policy states that in order to pay for a capped rental item, consideration shall be given to whether the item was in continuous use by the beneficiary for a specified time period. A claim is found to have been paid out of compliance with this policy provision.  If, at any time, the medical review detects potential fraud, MACs, CERT, and Recovery Auditors, shall refer the issue to the appropriate UPIC.  3.6.1 - Determining Overpayments and Underpayments  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, and UPICs. It does not apply to CERT or Recovery Auditors.  A. General
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This section applies to MACs, and UPICs. It does not apply to CERT or Recovery Auditors.  A. General   The results of the re-adjudication are used to determine the overpayment or underpayment amount for each claim. Re- adjudicating claims may not result in a payment correction. Where statistical sampling for overpayment estimation is used, refer to instructions in the PIM chapter 8, 8.4 and to Exhibits 9, 10, 11 and 12 for projection methodologies based on FFS claims. For claims paid under PPS rul es, MACs and UPICs shall develop projection methodologies in conjunction with their statisticians that are consistent with the requirements found in PIM chapter 8, 8.4. MACs and UPICs shall net out the dollar amount of services underpaid during the cost accounting period, meaning that amounts owed to providers are balanced against amounts owed from providers.  Amounts of the following overpayments are to be included in each provider's or suppliers estimate for the reviewed sample:    According to the provisions of 1879 of the Act, the provider or supplier is liable for the overpayment of initially paid claims that were later denied on re - adjudication if :   (1) The basis for denial is by reason of 1862(a) (l) or (9) of the Act   (2) The provider or supplier knew or could reasonably have been expected  to know that the items or services were excluded from coverage,  and   For denials of non-assigned claims make a1842(l) determination on denials for 1862(a)(1)   The provider or supplier was not without fault for the overpayment as defined  in 1870 of the Act.  For appeal purposes, overpayment estimations applicable under 1879 of the Act will be identified separately from denials in which 1879 of the Act does not apply. Where both types of denia ls occur in the sample, MACs and UPICs calculate and document separate under/overpayments for each type of denial. For recovery purposes, however, both denial results are combined.   3.6.2 - Verifying Errors  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08 -27-20)
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3.6.2 - Verifying Errors  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, and UPICs, as indicated.  Understanding the characteristics of the service area of the provider is a key element of claim data analysis. The areas selected for review by the contractor (e.g. , providers, services) must be deemed high priority and contractors must be able to document the rationale for selection.   3.6.2.1 - Coverage Determinations  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  The MACs, CERT, Recovery Auditors, and UPICs shall deny an item or service if it does not meet any of the conditions listed below:   The item or service does not fall into a Medicare benefit  category.    The item or service is statutorily excluded on grounds other than 1862(a) (1) (A) of the  Act.   The item or service is not reasonable and necessary under 1862(a) (1) (A) of the Act.    The item or service does not meet other Medicare program requirements  for payment.  3.6.2.2 - Reasonable and Necessary Criteria  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.   CMS issues national coverage determinations (NCDs) that specify whether certain items, services, procedures or technologies are reasonable and necessary under 1862(a) (1) (A) of the Act. In the absence of an NCD, Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors, a nd UPICs shall consider an item or service to be reasonable and necessary if the item or service meets the following criteria:    It is safe and effective;    It is not experimental or investigational; and   It is appropriate, including the duration and frequency in terms of whether the service or item  is:
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 It is safe and effective;    It is not experimental or investigational; and   It is appropriate, including the duration and frequency in terms of whether the service or item  is:  o Furnished in accordance with accepted standards of medical practice for  the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member;   o Furnished in a setting appropriate to the beneficiary's medical needs  and condition;   o Ordered and furnished by qualified personnel;  and,  o One that meets, but does not exceed, the beneficiary's medical  need.   There are several exceptions to the requirement that a service be reasonable and necessary for diagnosis or treatment of illness or injury in order to be considered for payment. The exceptions appear in the full text of 1862(a) (l) (A) of the Act. See also PIM chapters 13,  5.1 and 7.1.  3.6.2.3 - Limitation of Liability Determinations  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.   Section 1879(a) -(g) of the Act limits the financial liability of beneficiaries, providers, and suppliers by permitting Medicare payments, or requiring refunds, for certain services and items for which Medicare payment would otherwise be denied. The purpose of this provision is to protect beneficiaries from liability in certain cases of denied services. The limitation of liability provisions apply only to claims for services not statutorily excluded, that are denied for the following reasons:    The service or item did not meet the reasonable and necessary  criteria;    The beneficiary or provider did not know, or could not have been reasonably expected to know that the service or item would not be covered;  and   The beneficiary receives certain screeni ng tests and preventive services in  excess of the guidelines.
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 The beneficiary receives certain screeni ng tests and preventive services in  excess of the guidelines.  (See IOM Pub. 100-04, chapter30, 20 for more information).  The MACs, CERT, and UPICs shall first examine benefit categories and statutory exclusions to determine if a service or item is cover ed. Recovery Auditors shall examine categories and exclusions as outlined in their SOW. If the item or service meets the requirements of the appropriate benefit category and is not excluded by statute, the next consideration is whether the service was reasonable and necessary. When a claim is denied, in full or in part, because an item or service is not reasonable and necessary, MACs, CERT, Recovery Auditors, and UPICs shall make and document determinations as appropriate to 1879, 1870, and 1842(l) of the Act. Because the determinations can be appealed, it is important that the rationale for the determination be documented initially and at each level of appeal.   Limitations of liability provisions do not apply if there is a statutory exclusion, even if the service meets the reasonable and necessary criteria.   3.6.2.4 - Coding Determinations  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, SMRC, Recovery Auditors, and UPICs, as indicated.   ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided on and after the implementation of ICD-10- CM.. ICD -9-CM is used for discharges and other servi ces before that date.
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The MACs, CERT, SMRC, Recovery Auditors, and UPICs shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology- 4 (CPT -4), Coding Clinic for ICD, Coding Clinic for HCPCS, and any coding requirements listed in CMS manuals or MAC articles.  In certain situations, it is appropriate for contractors to up code or down code a claim (or items or services on a claim) and adjust the payment. When the medical record supports a higher or lower level code, the MACs, SMRC, CERT, UPICs and Recovery Auditors shall not deny the entire claim but instead shall adjust the code and adjust the payment.  The MACs, SMRC, CERT, UPICs and Recovery Auditors shall up code or down code when it is possible to pay for the item or service actually provided without making a reasonable and necessary determination or if otherwise specified in applicable CMS medical  review  instructions. The MACs, SMRC, CERT, UPICs and Recovery Auditors shall not substitute the payment amount of one item or service for a different item or service based on a reasonable and necessary  determination.   Example situations where it is appropriate to up code or down code a claim are:  1. CBC with diff was ordered and bill ed but CBC without diff was  provided;   2. X-ray with contrast  was ordered  and billed  but X-ray without  contrast  was provided;   3. E&M level 3 was billed but the medical record supports level 2 (or other  level);   4. PPS (DRG/RUG/HHRG)  code  was billed  but the medical  records  supports  a different code;  and  5. Quantity  of diabetic  test strips  exceeds  limits; for example,  quantity was provided for insulin treated but the patient was not insulin treated.   3.6.2.5 - Denial Types  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)
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3.6.2.5 - Denial Types  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  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.   This section applies to MACs , CERT, RACs, and UPICs, as indicated.   A. Distinguishing Between Benefit Category, Statutory Exclusion and Reasonable and Necessary  Denials   The MACs, CERT, RACs, and UPICs shall be cognizant that the denial type may affect the financial liability of beneficiaries. They shall ensure that benefit category denials take precedence over statutory exclusion and reasonable and necessary denials. They shall ensure that statutory exclusion denials take precedence over reasonable and necessary denials. MACs, CE RT, and UPICs shall use the guidelines listed below in selecting the appropriate denial reason. RACs shall follow denial reason guidance outlined in their SOW.   If additional documentation was requested from the provider or other entity for any MR reason ( benefit category, statutory exclusion, reasonable/necessary, or coding), and the information is not received within 45 calendar days or a reasonable time thereafter, the MACS, CERT, and UPICs shall issue a reasonable and necessary denial, in full or in part.   If additional documentation was requested because compliance with a benefit category requirement is questioned and the documentation received fails to support compliance with the benefit category, the MACs, CERT, and UPICs shall issue a benefit categor y denial.    If additional documentation was requested because compliance with a benefit category requirement is questioned and the received documentation shows evidence that the benefit category requirement is present but is defective, the MACs, and UPICs s hall issue a reasonable and necessary  denial.
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 If additional documentation was requested because compliance with a benefit category requirement is questioned and the received documentation shows evidence that the benefit category requirement is present but is defective, the MACs, and UPICs s hall issue a reasonable and necessary  denial.   EXAMPLE 1: A MAC is conducting a review of partial hospitalization (PH) claims from a provider who has a pattern of failing to comply with the benefit category requirement that there be a signed certification in the medical record. In the first medical record, the MAC finds that there is no signed certification present in the medical record. The MAC shall deny all PH services for this beneficiary under 1835(a) (2) (F) of the Act (a benefit category denial). However, in the second medical record, the MAC determines that a signed certification is present in the medical record, but the documentation does not support the physician's certification, the services shall be denied under 1862(a) (1) (A) of the Act (a reasonable and necessary denial) because the certification is present but defective.   Example 2: The MAC performs a medical record review on a surgical procedure claim and determines that the procedure was cosmetic in nature and was not reasonable and necess ary; the denial reason would be that the service is statutorily excluded since statutory exclusion denials take precedence over reasonable and necessary denials.   The MACs, CERT, RACs, and UPICs shall deny payment on claims either partially (e.g., by down coding or denying one line item on a multi -line claim) or in full, and provide the specific reason for the denial whenever there is evidence that a service:    Does not meet the Benefit Category requirements described in Title XVIII of the Act, NCD, or coverage provision in an interpretive manual;    Is statutorily excluded by other than 1862(a)(1) of the Act;   Is not reasonable and necessary as defined under 1862(a) (1) of the Act. MACs, CERT, RACs, and UPICs shall use this denial reason for all non-responses to documentation requests;    Was not billed in compliance with the national and local coding, payment or billing requirements; and/or   Was not delivered or provided to the beneficiary, or not provided as billed.
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 Was not billed in compliance with the national and local coding, payment or billing requirements; and/or   Was not delivered or provided to the beneficiary, or not provided as billed.   The denial explanation needs to be more specific than merely repeating one of the above bullets. The general exception to the need for a full denial explanation is in the event of a clerical error, for example, the billing entity transposes two digits in the Medicare beneficiary identifier on a claim. The claim is quickly returned, usually electronically, to the provider for correction. In the case of dual- eligible beneficiaries where there is a State -specific policy, see CMS IOM Pub. 100-04, chapter 30, 60.5 A for a detailed explanation of handling administrative denials.  3.6.3 - Beneficiary Notification  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, RACs, and UPICs, as indicated.  A. General   If a claim is denied through prepayment or postpayment review, the MAC shall notify the beneficiary consistent with the requirements in PIM chapter 3, 3.6.2.3. The MAC shall include limitation of liability and appeals information. Notification can occur via Medicare Summary Notice (MSN). The CERT, RACs, and UPICs are not required to issue beneficiary notices for claims they deny. Instead, CERT, RACs, and UPICs shall comm unicate sufficient information to the MAC to allow the MAC to develop an appropriate beneficiary  notice.   The MACs are required to give notice to Medicare beneficiaries when claims are denied in part or in whole based on application of a LCD. All denials t hat result from LCDs shall provide the MSN message 15.19 in addition to the current applicable message. Message 15.19 states ( IOM Pub. 100-04, chapter 21):
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A local coverage determination (LCD) was used when we made this decision. A LCD provides a guide to assist in determining whether a particular item or service is covered by Medicare. A copy of this policy is available from your local intermediary, carrier or (Medicare Administrative Contractor) by calling the number in the customer service information box on page one. You can compare the facts in your case to the guidelines set out in the LCD to see whether additional information from your physici an would change our decision.   The MACs shall make these messages available in Spanish where appropriate. The 15.19 portion of the MSN message states:   Una Determinacin de Cobertura Local (LCD, por sus siglas en ingls) fue utilizada cuando se tom esta decisin. La LCD es una gua que ayuda a determinar si un artculo o servicio en particular est cubierto por Medicare. Una copia de esta pliza est disponible en su intermediario, local o en su empresa de seguros Medicare, o en su Contratista Administrative de Medicare, al llamar al nmero que aparece en la informacin de Servicios al Cliente en la pgina uno. Usted puede comparar los datos de su caso con las reglas establecidas en la LCD para ver si obteniendo informacin adicional de su mdico pudiera c ambiar nuestra decisin.  The MACs shall use the above message in every instance of a prepayment denial where a LCD was used in reviewing the claim. Use this message, and message 15.20 (now for FISS MACs, and when 15.20 is fully implemented for contractors  on the MCS/VMS systems) on both full and partial denials, whether the denial was made following automated, non- medical review, or medical record review. MACs shall not use this message on denials not involving LCDs. For claims reviewed on a postpayment ba sis, include the language exactly as contained in the MSN message above if sending the beneficiary a new MSN. If sending a letter, include the language exactly as contained in the MSN message above. Message 15.20 currently states: