evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
-  Appeal Rights  140.6 -  Processing Initial Denials  140.6.1 -  Initial Beneficiary Notices  140.6.2 -  Initial Physician Notices  140.7 -  Processing Beneficiary Requests for Appeal  140.8 -  Processing Physician Requests for Appeal  140.8.1 -  Appeal  of the Denial or Reduction in Payment  140.8.2 -  Beneficiary Given ABN and Agreed to Pay 140.8.3 -  Physician Knowledge  140.9 -  Guide Paragraphs for Inclusion in Appeal Determination  140.10 -  Physician Fails to Make Refund  140.11 -  OIG Referral Procedures  140.12 -  Imposition of Sanctions  150 -  DMEPOS Refund Requirements (RR) Provision for Claims for Medical Equipment and Supplies under 1834(a)(18), 1834(j)(4), and 1879(h) -  Instructions for Contractor s and Suppliers  150.1 -  Definition of Medical Equipment and Supplies  150.1.1 -  Unassigned Claims Denied on the Basis of the Prohibition on Unsolicited Telephone Contacts  150.1.2 -  Unassigned Claims Denied on the Basis of Not Being Reasonable and Necessary  150.1.3 -  Unassigned Claims Denied on the Basis of Failure of the Supplier to Meet Supplier Number Requirements  150.1.4 -  Assigned Claims Denied on the Basis of the Prohibition on Unsolicited Telephone Contacts  150.1.5 -  Assigned Claims Denied on the Basis of Failure of the Supplier to Meet Supplier Number Requirements  150.1.6 -  Assigned Claims Denied on the Basis of Not Being Reasonable and Necessary  150.2 -  Items and Services Furnished on an Unassigned Basis on or After January 1, 1995 150.3 -  Items and Services Furnished On an Assigned Basis On or After January 1, 1995 150.4 -  Time Limits for Making Refunds  150.5 -  Supplier Knowledge Standards for Waiver of Refund Requirement  150.5.1 -  Knowledge Standards for 1862(a)(1) Denials  150.5.2 -  Knowledge Standards for 1834(a)(15) Denials  150.5.2.1 -  Denial of Payment in Advance  150.5.2.2 -  When a Request for an Advance Determination of Coverage Is Mandatory  150.5.2.3 -  When a Request for an Advance Determination of Coverage Is Optional  150.5.2.4 -  Presumption for Constructive Notice  150.5.2.5 -  Presumption
(Medicare Claims Processing Manual)
Advance Determination of Coverage Is Mandatory  150.5.2.3 -  When a Request for an Advance Determination of Coverage Is Optional  150.5.2.4 -  Presumption for Constructive Notice  150.5.2.5 -  Presumption When Advance Determination was Requested  150.5.2.6 -  Presumption for Listed Overutilized Items  150.5.2.7 -  Presumption for Listed Suppliers  150.5.2.8 -  Presumption for Medical Necessity  150.5.2.9 -  Presumption About Beneficiary Knowledge  150.5.3 -  Knowledge Standards for 1834(a)(17)(B) Denials  150.5.4 -  Knowledge Standards for 1834(j)(1) Denials  150.5.5 -  Additional Knowledge Standards for All Medical Equipment and Supplies Denials  150.6 -  Advance Beneficiary Notice Standards for Waiver of Refund Requirement  150.7 -  Appeal Rights  150.8 -  Processing Initial Denials  150.9 -  Processing Beneficiary Requests for Appeal  150.10 -  Processing Supplier Requests for Appeal  150.10.1 -  Appeal  of the Denial of Payment  150.10.2 -  Beneficiary Given Advance Beneficiary Notice and Agreed to Pay 150.10.3 -  Supplier Knowledge  150.11 -  Guide Paragraphs for Inclusion in Appeal Determination 150.12 -  Supplier Fails to Make Refund  150.13 -  CMS Regional Office (RO) Referral Procedures  150.14 -  Imposition of Sanctions  150.15 -  Suppliers Right to Recover Resaleable Items for Which Refund Has Been Made  200 -  Expedited Determinations of Inpatient Hospital Discharges  200.1-   Statutory Authority 200.2 -  Scope  200.2.1 -  Exceptions  200.3 -  Important Message from Medicare (IM)  200.3.1 -  Alterations to the IM  200.3.2 -   Completing the IM  200.3.3 -  Hospital Delivery of the IM  200.3.4 -  Required Delivery Timeframes
(Medicare Claims Processing Manual)
200.3.4.1 First IM   200.3.4.2 Follow -up copy of the IM  200.3.5 -  Refusal to Sign the IM  200.3.6 -  Amending the Date of the IM  200.3.7 -  IM Delivery to Representatives  200.3.8 -  Notice Retention for the IM  200.4 -  Expedited Determination Process   200.4.1 -  Beneficiary Responsibilities   200.4.1.1 -  Timeframe for Requesting an Expedited Determination
(Medicare Claims Processing Manual)
200.4.1.2 -  Provide Information to BFCC -QIO  200.4.2 -  Beneficiary Liability During BFCC -QIO Review  200.4.3 -  Untimely Requests for Review  200.4.4 -  Hospital Responsibilities  200.4.5 -  The Detailed Notice of Discharge (DND)  200.5 -  BFCC- QIO Responsibilities  200.5.1 -  Receive Beneficiary Requests for Expedited Review  200.5.2 -  Notify Hospitals and Allow Explanation of Why Covered Services Should End  200.5.3 -  Validate Delivery of IM  200.5.4 -  Solicit the Views of the Beneficiary  200.5.5 -  Solicit the Views of the Hospital  200.5.6 -  Make Determination and Notify Required Parties  200.6 -  Effect of a BFCC -QIO Expedited Determination  200.6.1 -  Right to Pursue an Expedited Reconsideration  200.6.2 -  Effect of BFCC -QIO Determination on Continuation of Care  200.6.3 -  Right to Pursue the Standard Claims Appeal Process  220 -  Hospital Requested Expedited Review  220.1 -  Responsibilities of the Hospital 220.2 -  Responsibilities of the QIO  220.3 -  Effect of the Hospital Requested Expedited Determination  220.4 -  General Notice Requirements  220.5 -  Exhibit 3 -  Model Language Notice of Hospital Requested Review (HRR)  240 -  Preadmission/Admission Hospital Issued Notice of Noncoverage (HINN)  240.1 -  Delivery of the Preadmission/Admission HINN  240.2 -  Notice Delivery Timeframes and Liability  240.3 -  Timeframes for Submitting a Request for a QIO Review  240.4 -  Results of the QIO Review  240.5 -  Effect of the QIO Review  240.6 -  Exhibit 4 -  Model Language Preadmission/Admission Hospital Issued Notice of Noncoverage  260 -  Expedited Determinations of Provider Service Terminations  260.1 -  Statutory Authority 260.2 -  Scope  260.2.1 -  Exceptions  260.3 -  Notice of Medicare Non -Coverage  260.3.1 -  Alterations to the NOMNC  260.3.2 -  Completing the NOMNC  260.3.3 -  Provider Delivery of the NOMNC  260.3.4 -  Required Delivery Timeframes  260.3.5 -  Refusal to Sign the NOMNC
(Medicare Claims Processing Manual)
260.3.2 -  Completing the NOMNC  260.3.3 -  Provider Delivery of the NOMNC  260.3.4 -  Required Delivery Timeframes  260.3.5 -  Refusal to Sign the NOMNC  260.3.6 -  Financial Liability for Failure to Deliver a Valid NOMNC  260.3.7 -  Amending the Date of the NOMNC  260.3.8 -  NOMNC Delivery to Representatives  260.3.9 -  Notice Retention for the NOMNC  260.3.10-  Hours of NOMNC Delivery  260.4 -  Expedited Determination Process  260.4.1 -  Beneficiary Responsibilities  260.4.1.1 -  Timeframe for Requesting an Expedited Determination  260.4.1.2 -  Provide Information to QIO  260.4.1.3 -  Obtain Physician Certification of Risk (Home Health and CORF services only)  260.4.2 -  Beneficiary Liability During QIO Review  260.4.3 -  Untimely Requests for Review  260.4.4 -  Provider Responsibilities  260.4.5 -  The Detailed Explanation of Non- Coverage  260.5 -  QIO Responsibilities  260.5.1 -  Receive Beneficiary Requests for Expedited Review  260.5.2 -  Notify Providers and Allow Explanation of Why Covered Services Should End 260.5.3 - Validate Delivery of NOMNC  260.5.4 -  Solicit the Views of the Beneficiary  260.5.5 -  Solicit the Views of the Provider  260.5.6 -  Make Determination and Notify Required Parties  260.6 -  Effect of a QIO Expedited Determination  260.6.1 -  Right to Pursue an Expedited Reconsideration 260.6.2 -  Effect of QIO Determination on Continuation of Care  260.6.3 -  Right to Pursue the Standard Claims Appeal Process  261 -  Expedited Determination Notice Association with Advance Beneficiary Notices  300 -  Expedited Reconsiderations  300.1 -  The Role of the Beneficiary and Liability  300.2 -  The Responsibilities of the IRE  300.3 -  The Responsibilities of the QIO  300.4 -  The Responsibilities of the Provider  300.5 -  Coverage During an Expedited Reconsideration 400 -  Part A Medicare Outpatient Observation Notice  400.1 -  Statutory Authority 400.2 -  Scope  400.3 -
(Medicare Claims Processing Manual)
the QIO  300.4 -  The Responsibilities of the Provider  300.5 -  Coverage During an Expedited Reconsideration 400 -  Part A Medicare Outpatient Observation Notice  400.1 -  Statutory Authority 400.2 -  Scope  400.3 -  Medicare Outpatient Observation Notice  400.3.1 -  Alterations to the MOON  400.3.2 -  Completing the MOON  400.3.3 -  Hospital Delivery of the MOON  400.3.4 -  Required Delivery Timeframes  400.3.5 -  Refusal to Sign the MOON  400.3.6 -  MOON Delivery to Representatives  400.3.7 -  Ensuring Beneficiary Comprehension  400.3.8 -  Completing the Additional Information Field of the MOON  400.3.9 -  Notice Retention for the MOON  400.4 -  Intersection with State Observation Notices  500- Glossary  10 - Financial Liability Protections (FLP) Provisions of Title XVIII  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)
(Medicare Claims Processing Manual)
The FLP provisions of the Social Security Act (hereinafter referred to as the 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 afte r an item or services coverage determination is made.  This chapter discusses the following FLP provisions:    Limitation On Liability (LOL) under 1879(a) -(g) of the Act.    Refund Requirements (RR) for Non- assigned Claims for Physicians Services under 1842(l) of the Act.   Refund Requirements (RR) for Assigned and Non -assigned Claims for Medical  Equipment and Supplies under 1834(a)(18), 1834(j)(4), and 1879(h) of the Act.   In most cases, the FLP provisions apply only to beneficiaries enrolled in the Original Medicare FFS program Parts A and B.   The FLP provisions apply only when both of the following are met:    Items and/or services are denied on the basis of specific statutory or regulatory provisions.; and   Involve determinations about beneficiary and/or healthcare provider/supplier knowledge of whether Medicare was likely to deny payment for the items and/or services.    The LOL provisions apply to all Part A services and all assigned claims for Part B services.  The RR apply to both assigned and unassigned claims for medical equipment and supplies and to unassigned claims for physicians services.  However, RR do not apply to claims for Part A services.
(Medicare Claims Processing Manual)
20 - Limitation On Liability (LOL) Under 1879 Where Medicare Claims Are Denied  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19) In general, application of the LOL provisions depends upon two primary factors:  1. Whether the claim for the item and/or service provided was denied for certain specific reasons.  See 21 of this chapter for more examples.   Type of Denial  Description  Example  Statutory Basis  The LOL provisions apply only to claims for items and/or services submitted by healthcare providers or suppliers that have Items and services found to be not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the Type of Denial  Description  Example  taken assignment, and only to claims for items and/or services not otherwise statutorily excluded, that are denied on the basis of 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Act.  functioning of a malformed body member.  (1862(a)(1)(A) of the Act) Dependent Services  When Medicare payment is made under the LOL provisions, the payment determination includes claims for any dependent services that are denied as an indirect result of the original denial.  Thus, where a particular qualifying service is denied as not reasona ble and necessary under 1862(a)(1) (A) of the Act, any dependent services are also denied as not reasonable and necessary under 1862(a)(1)(A) of the Act.  If the LOL provisions apply to the denial of the qualifying service, it will also apply to the dependent service, and Medicare will mak e payment for both services, provided all other conditions for coverage and payment are met.  Under 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, home health aide services can be covered only if a beneficiary needs intermittent skilled nursing care.  When coverage is denied for intermittent skilled nursing services (the qualifying primary services)  under 1862(a)(1) or (9) of the Act, home health aide services (the dependent services) likewise are not covered.  In such cases, if Medicare payment is made under the LOL provision for the primary services, it would be made for the dependent services as well, provided
(Medicare Claims Processing Manual)
of the Act, home health aide services (the dependent services) likewise are not covered.  In such cases, if Medicare payment is made under the LOL provision for the primary services, it would be made for the dependent services as well, provided the services meet all conditions for coverage and payment (i.e. a physicians certification of the need for the dependent services and proof that the services are reasonable and necessary).  Higher Levels of Care and Excess Components  Normally, Medicare payment is denied for items and/or services that are not reasonable and necessary on the basis of 1862(a)(1)(A) of the Act.  However, the LOL provisions may apply if a reduction in payment occurs because the furnished items or services are at a higher level of care and provide more extensive items or services than was reasonable and necessary to meet the needs of the beneficiary.  A deluxe or aesthetic feature of an upgraded item of medical equipment is an excess component.  Charge increases on the basis of purported premium quality services are not considered to be excess components since that would constitute circumvention of payment limits and applicable charging limits (e.g., limiting charges in the case of unassigned claims for physicians services and fee schedule amounts in the case of assigned claims).
(Medicare Claims Processing Manual)
2. Whether the beneficiary and/or the healthcare provider or supplier knew or could reasonably have been expected to know that the item or service was not covered.   Knowledge of the Non -covered Item/Service  Liability  Payment Responsibility  If the beneficiary knew, or should have known (e.g. a valid liability notice such as an ABN, Form CMS -R-131 was issued and the beneficiary consented to receiving the item or service).  Rests with the beneficiary  The beneficiary is responsible for making payment for the usual and customary charges to the healthcare provider or supplier for the denied item and/or service.   If the beneficiary did not know (and should not have known), and the healthcare provider or supplier knew, or should have known.  Rests with the healthcare provider or supplier  The beneficiary may not be charged for any costs related to the denied item and/or service, including copayments and deductibles.  If neither the beneficiary nor the healthcare provider or supplier knew, and could not reasonably be expected to have known.  Neither the beneficiary or the healthcare provider or supplier  The Medicare program makes payment for the assigned claim.   20.1 - LOL Coverage Denials (Rev. 1, 10- 01-03) (Rev.:4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  A.  Statutory Basis   The following table provides examples of denials based on 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Act:
(Medicare Claims Processing Manual)
Statutory Provision  (section of the Act)  Description  1862(a)(1)(A)  Items and services found to be not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.  1862(a)(1)(B) & 1861(s)(10)  Pneumococcal vaccine and its administration, influenza vaccine and its administration, and hepatitis B vaccine and its administration furnished to an individual at high or intermediate risk of contracting hepatitis B, that are not reasonable and necessary for the prevention of illness.  1862(a)(1)(C)  In the case of hospice care, items and services that are not reasonable and necessary for the palliation or management of terminal illness.  Statutory Provision  (section of the Act)  Description  1862(a)(1)(E)  Items and services that, in the case of research conducted pursuant to 1142 of the Act, are not reasonable and necessary to carry out the purposes of that section (which concerns research on outcomes of health care services and procedures).  1862(a)(1)(F)  Screening mammography that is performed more frequently than is covered under 1834(c)(2) of the Act or that is not conducted by a facility described in 1834(c)(1)(B) of the Act and screening pap smears and screening pelvic exams performed more frequently than is provided for under 1861(nn) of the Act.  1862(a)(1)(F)  Screening for glaucoma, which is performed more frequently than is provided under 1861(uu) of the Act.  1862(a)(1)(G)  Prostate cancer screening tests (as defined in 1861(oo) of the Act), which are performed more frequently than is covered under such section.  1862(a)(1)(H)  Colorectal cancer screening tests, which are performed more frequently than is covered under 1834(d) of the Act.  1862(a)(1)(I)  The frequency and duration of home health services which are in excess of normative guidelines that the Secretary shall establish by regulation.  1862(a)(1)(J)  Drugs or biologicals specified in  1847A(c)(6)(C)  of the Act, for which
(Medicare Claims Processing Manual)
are in excess of normative guidelines that the Secretary shall establish by regulation.  1862(a)(1)(J)  Drugs or biologicals specified in  1847A(c)(6)(C)  of the Act, for which payment is made under part B, furnished in a competitive area under  1847B  of the Act, but not furnished by an entity under a contract under 1847(B) of the Act.  1862(a)(1)(K)  An initial preventive physical examination, which is performed more than 1 year after the date the individuals first coverage period begins under Medicare Part B.  1862(a)(1)(L)  Cardiovascular screening blood tests (as defined in 1861(xx)(1)  of the Act), which are performed more frequently than is covered under  1861(xx)(2) . 1862(a)(1)(M)  A diabetes screening test (as defined in  1861(yy)(1)  of the Act), which is performed more frequently than is covered under  1861(yy)(3)  of the Act . 1862(a)(1)(N)  An ultrasound screening for abdominal aortic aneurysm which is performed more frequently than is provided for under 1861(s)(2)(AA)  of the Act.  1862(a)(1)(O)  Kidney disease education services (as defined in 1861(ggg)(1) of the Act) which are furnished in excess of the number of sessions covered under 1861(ggg)(4) of the Act.  1861(dd)(3)(A)  Hospice care determined to be non -covered because the beneficiary was not terminally ill, as referenced by 1879(g)(2) of the Act since the Balanced Budget Act of 1997.  1862(a)(1)(O)  Personalized prevention plan services (as defined in  1861 (hhh)(1) of the Act), which are performed more frequently than is covered under such section.  Statutory Provision  (section of the Act)  Description  1814(a)(2)(C) & 1835(a)(2)(A) on or after July 1, 1987
(Medicare Claims Processing Manual)
1879(g)(1) before December 31, 1995  Home health services determined to be non -covered because the beneficiary was not homebound or did not require intermittent skilled nursing care.  1879(e)  Inpatient hospital services or extended care services if payment is denied solely because of an unintentional, inadvertent, or erroneous action that resulted in the beneficiarys transfer from a certified bed (one that does not meet the requirements of 1861(e) or (j) of the Act) in a skilled nursing facility (SNF) or hospital.  1862(a)(9)  Custodial care, unless otherwise permitted under paragraph 1862(a)(1)(C) of the Act.      20.2 - Denials When the LOL Provision Does Not Apply   (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Type of Denial  Description  Example(s)  Categorical  Categorical Denials are circumstances in which the LOL provision does not apply because the Medicare payment denial is based on a statutory provision not referenced in 1879 of the Act.  Refer to 1862(a)  of the Act for a complete listing.   Personal comfort items (1862(a)(6) of the Act).   Routine physicals and most screening tests (1862(a)(7) of the Act).    Most immunizations (vaccinations) (1862(a)(7) of the Act).   Routine eye care, most eyeglasses and examinations (1862(a)(7) of the Act).   Hearing aids and hearing aid examinations (1862(a)(7) of the Act).   Cosmetic surgery (1862(a)(10) of the Act).   Orthopedic shoes and foot supports (orthotics) (1862(a)(8) of the Act).
(Medicare Claims Processing Manual)
Type of Denial  Description  Example(s)  NOTE:   22.1 of this chapter provides a more expansive list of examples.  Technical  When coverage requirements are not met for a particular item or service, it is not a Medicare benefit; therefore, Medicare denies payment or when payment for a medically unreasonable or unnecessary item or service that is also barred because of failure to meet a condition of payment required by regulations.    Payment for the additional cost of a private room in a hospital or SNF is denied when the private accommodations are not required for medical reasons (1861(v)(2) of the Act).   Payment for a dressing is denied because it does not meet the definition for surgical dressings (1861(s)(5) of the Act).   Payment for SNF stays not preceded by the required 3 -day hospital stay or Payment for SNF stay because the beneficiary did not meet the requirement for transfer to a SNF and for receiving covered services within 30 days after discharge from the hospital and because the special requirements for extension of the 30 days were not met (1861(i) of the Act).   Drugs and biologicals which are usually self -administered by the patient.   Ambulance services denied because transportation by other means is not contraindicated or because regulatory criteria specified in 42 CFR 410.40, such as those relating to destination or nearest appropriate facility, are not met.  (See the Medicare Benefit Policy Manual, Chapter 10 )  Other items or services that must be denied under 42 CFR 410.12 through  410.105 of the Medicare regulations.    20.2.1 - Categorical Denials  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Below is a more expansive list of examples of categorical denials:   Statutory Provision