evekhm/cms_iom_500 huggingface dataset:
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The provider submits late charges on bills to the FI as bill type xx5.  These bills contain only additional charges.  However, if the late charge is for:   Services on the same day as outpatient surgery subject to the ASC limit;  Services on the same day as services subject to OPPS;   ESRD services paid under the composite rate;   Inpatient accommodation charges;   Services paid under HH PPS; and   Inpatient hospital or SNF PPS ancillaries.  It must be submitted as an adjustment request.  The provider may submit the following charges omitted from the original paid bill to the FI as late charges:   Any outpatient services other than the exceptions stated in this paragraph.  This includes late charges for non- HH PPS services under Part B, hospice services other than the services of hospice -employed attending physicians, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation or the day of outpatient services subject to OPPS, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CMHC serv ices, ESRD services not included in the composite rate; and   Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS providers.  The provider may not submit late charges (xx5) for inpatient hospital or SNF accommodations.  The provider must submit these as adjustments (bill type xx7).  The FI has the capability to accept xx5 bill types electronically and process them as initial bills except as described in the following paragraph.  The FI also performs the following edit routines on any xx5 type bills received:   Pass all initial bill edits, including duplicate checks.   Must not be for any of: Inpatient hospital or SNF PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, services on the same day as services subject to OPPS, or ESRD services included in the composite rate.  These are rejected back to the hospital with the message,  This change requires an xx7 debit -only or xx8 cancel -only request from you.  Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC
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debit -only or xx8 cancel -only request from you.  Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, services on the same day as services subject to OPPS, or ESRD services included in the composite rate.   When an xx5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, Medicare beneficiary identifier equal, and patient surname equal), the FI must determine the status of the original paid bill.  If it is denied, the FI must deny the late charge bill.   If an xx5 does not suspend as a potential duplicate, the FI rejects it back to the provider with the message, No original bill paid.  Please combine and submit a single original bill (xx1).   If the original bill was approved and paid, the FI compares the revenue codes on the original paid bill with the associated late charge bill:  For all providers (any bill type), if any are the same, and are revenue codes 41x, 42x, 43x, 44x, 63x, 76x, or 91x, the FI rejects the bill back to the provider with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For HHA services not under a plan of care (bill type 34x), the FI must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 27x, 29x, 55x, 56x, 57x, 58x, 59x, 60x, or 63x, the FI rejects the bill back to the provider with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For hospital outpatient services (bill type 13x only), the FI must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 255, 32x, 33x, 34x, 35x, 40x, 62x, 73x, 74x, 92x, or 943, the FI rejects the bill  back to the hospital with the message,  You
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revenue codes 255, 32x, 33x, 34x, 35x, 40x, 62x, 73x, 74x, 92x, or 943, the FI rejects the bill  back to the hospital with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For RDFs (bill type 72x or 73x), the FI must apply the same logic for the following additional revenue codes; if any are the same and are revenue codes 634, 635, 82x, 83x, 84x, 85x, or 88x, the FI rejects the bill back to the provider with the message, You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   If the late charges bill relates to two or more original paid bills, and one of these is denied, the FI must suspend and investigate the late charge bill.  The FI must compare total charges on the original paid bill with those on the associated late charge bill, and suspend and investigate any xx5 bill type with total charges in excess of those on the original paid bill.  This edit suggests the provider may have rebilled the already paid services.  The FI may decide to perform additional edits on late charge bills.  130.2 - Inpatient Part A Hospital Adjustment Bills  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)
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The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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 co ntinue to use the HICN as part of their processes.   For adjustment requests reported as a claim record, the hospital must report the ICN/DCN of the original bill.  See the ASC X12 Institutional Claim Implementation Guide for instructions for the electronic format and Chapter 25 for instructions for Form CMS -1450.  Where payment is handled through the cost reporting and settlement processes, the hospital accumulates a log for those items not requiring an adjustment request.  For cost settlement, the A/B MAC (A) pays on the basis of the log.  This log must inc lude:    Patient name;   Medicare beneficiary identifier;   Dates of admission and discharge, or from and thru dates;   Adjustment in charges (broken out by ancillary or routine service); and   Any unique numbering or filing code necessary for the hospital to associate the adjustment charge with the original billing.   NOTE : Hospitals in Maryland, which are not paid under PPS or cost reports, submit an adjustment request for inpatient care of $500 or more, and keep a log as described above for lesser amounts.  Because there are no adjustment requests, the A/B MAC (A) enters the payment amounts from the summary log into the PPS waiver simulation and annually pays the items on the log after the cost report is filed.  After cost reports are filed, the A/B MAC (A) makes a lump sum payment to cover these charges as shown on the summary log.  The hospital uses the summary log for late charges only under cost settlement (outpatient hospital), except in Maryland.  Maryland and cost hospitals are required to meet the 12- month timeframe for timely filing of claims, including late charges.
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For all adjustments other than QIO adjustments (e.g., provider submitted adjustments and/or those the A/B MAC (A) initiates), the A/B MAC (A) submits an adjustment request to CWF following its acceptance of the initial bill.  To verify CMSs acceptance, the A/B MAC (A) can submit a status query.   Under inpatient hospital prospective payment, adjustment requests are required from the hospital where errors occur in diagnosis and procedure coding that changes the DRG, or where the deductible or utilization is affected.  A hospital is allowed 60 days f rom the date of the A/B MAC (A) payment notice (remittance advice) for adjustment requests where diagnostic or procedure coding was in error resulting in a change to a higher weighted DRG.  Adjustments reported by the QIO have no corresponding time limit and are adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an adjustment request.  However, if diagnostic and procedure coding errors have no effect on the DRG, adjustment requests are not required.  Under PPS, for long- stay cases, hospitals may bill 60 days after an admission and every 60 days thereafter if they choose.  The A/B MAC (A) processes the initial bill through Grouper and PRICER.  When the adjustment request is received, it processes it as an adjustment.  In this case, the 60- day requirement for correction does not apply.
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130.2.1 - Tolerance Guidelines for Submitting Inpatient Part A Hospital Adjustment Requests  (Rev. 1, 10- 01-03) A3-3664.1.A  When a bill is submitted and the hospital or the FI discovers an error, the hospital submits an adjustment request using the CMS -1450, if the error is a change in the:   Number of inpatient days (including a change in the length of stay, or a different allocation of covered/noncovered days);   Blood deductible;   Inpatient cash deductible of more than $1;   Servicing hospital;  For inpatient hospital bills paid under PPS, CMS also requires an adjustment request for a change in:   Discharge status in a PPS hospital;   The DRG code; or   Outlier payment amount.  The hospital submits most adjustment requests as debits, using bill type xx7. Also, it submits a debit- only adjustment request to the FI if it previously submitted an interim bill for a PPS hospital stay or wishes to change the number of days in any inpatient stay.  The FI then submits the adjustment to CWF.  An adjustment from the QIO for any of the above also requires a submission to CMS via CWF.  If an adjustment the hospital initiates results in a change to a higher weighted DRG, the FI edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.  If it is, the FI processes the claim for payment.  If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the FI processes the claim for payment and forwards it to CWF.   130.3 - SNF Part A Adjustments  (Rev. 1, 10- 01-03)   130.3.1 - Tolerance Guides for Submitting SNF Inpatient Adjustment Requests  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)
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130.3.1 - Tolerance Guides for Submitting SNF Inpatient Adjustment Requests  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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 Medic are card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   SNF inpatient adjustment requests adhere to the same billing instructions as non- inpatient adjustment requests with the following changes.  When an initial bill has been submitted and the provider or FI discovers an error on the bill, an adjustment request  is submitted if the change involves one of the following:    A change in the Part B cash deductible of more than $1.00  A change in the number of inpatient days;   A change in the blood deductible;   A change in provider number;   A change in coinsurance which involves an amount greater than $1.99;   A change in the HIPPS code to correct a data input error or,   Effective for changes for services June 1, 2000, change in HIPPS code due to an MDS correction.  (Such adjustments are required within 120 days of the through date on the initial bill.) NOTE:  See Chapter 6, Section 35 for information on submitting adjustments to HIPPS codes resulting from MDS corrections.  Late charge billings (type of bill xx5) are not acceptable for SNF PPS Part A services.  The reason for an adjustment (Claim Change Reasons) is reported in one of the condition code fields.  Claim Change Reason Codes applicable to SNFs are:   D0 Changes to Service Dates  D6 Cancel only to repay a duplicate OIG payment  D1 Changes to Charges  D7 Change to Make Medicare Secondary Payer  D2 Changes in Revenue codes/ HCPCS - HIPPS  D8 Change to Make Medicare Primary Payer  D4 Changes in Grouper code  D9 Any Other Change  D5 Cancel to correct Medicare beneficiary identifier or Provider ID  E0 Change in Patient Status
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The SNF selects the one code that best describes the change reason.  An adjustment may contain multiple changes even though only one reason code is reported.    130.3.2 - SNF Inpatient Claim Adjustment Instructions  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  1. Type of Bill is 217, (replacement bill).   2. Internal Control Number (ICN)/Document Control Number (DCN) Required.  All providers requesting an adjustment to a previously processed claim must insert the ICN/DCN of the claim to be adjusted.  Payer As ICN/DCN must be shown on line A.  Similarly, the ICN/DCN for Payers B and C must be shown on lines B and C respectively.   3. Appropriate Claim Change Reason Code.   4. The provider must submit an entire replacement debit.  Note:  Information regarding the form locator numbers that correspond to these data element names and a table to crosswalk UB -04 form locators to the 837 transaction is found in Chapter 25.   130.3.3 - Patient Does Not Return From  SNF Leave of Absence, and Last Bill Reported Patient Status as Still Patient (30)  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  Where the patient does not return from a leave of absence, regardless of the reason, the SNF must submit a discharge bill showing the date of discharge as the date the individual actually left.  If the patient status was reported as 30 (still patient) on  an interim bill and the patient failed to return from a leave of absence within 30 days, including the day leave began, or has been admitted to another institution at any time during the leave of absence, the SNF must submit an adjustment request to corre ctly indicate the day the patient left as the date of discharge.  (A beneficiary cannot be an inpatient in two institutions at the same time.)  This closes the open admission on the patients utilization record.   NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required.   EXAMPLE l:
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NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required.   EXAMPLE l:   The beneficiary goes on a leave of absence on January 3, expecting to return on January 10.  On January 6, the SNF receives word that the patient died on January 5.  The SNF submits a discharge bill showing January 3 as the date of discharge.   EXAMPLE 2:   The beneficiary goes on a leave of absence on February 6, expecting to return on February 12.  However, the beneficiary does not return on February 12 as expected and the SNF cannot determine whether the beneficiary will return.  The SNF submits a discharg e bill showing February 6 as the date of discharge as soon as practical, or after 30 days have elapsed from the day the leave began.  If an interim bill had been submitted showing the beneficiary in still patient status as of February 6 or later, the SNF  submits an adjustment request showing February 6 as the discharge date.  The advantage of delaying the discharge bill for 30 days is that it will make unnecessary a new admission notice in the event the beneficiary returns before 30 days have elapsed.   EXAMPLE 3:   The beneficiary goes on a leave of absence on March 4, and is expecting to return April 1 but does not.  The SNF submits a discharge bill showing March 4 as the date of discharge since the beneficiary did not return within the 30- day period.
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130.4 - Hospital and SNF Part B Adjustment Requests  (Rev. 1, 10- 01-03) 130.4.1 - Guidelines for Submitting Adjustment Requests  (Rev. 1, 10- 01-03) SNF -562, SNF -562.A  When an initial bill for outpatient services or inpatient Part B services has been submitted and the provider or the FI discovers an error, the provider submits an adjustment request to the FI.  The FI submits the adjustment to CMS if there is a change in:   The Part B cash deductible of more than $1;   Covered charges of more than $1 on bills for surgery or other outpatient procedures;   The servicing provider;   The Part B blood deductible;   The coinsurance amount greater than $1.99; or   Procedure codes.  130.5 - Home Health Adjustments  (Rev. 1, 10- 01-03)  130.5.1 - Submitting Adjustment Requests  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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.
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A home health agency submits a corrected Form CMS -1450 if any of the following apply:   A change in provider number;   A change in coinsurance involves an amount greater than $1.99; or   A change in visits (decrease or increase).  Where there are money adjustments other than a coinsurance amount greater than $1.99, the agency records the difference on a record sufficiently documented to establish an accounting data trail, including patients name and Medicare beneficiary identifier, first  and last dates of services, and any unique numbering or filing code necessary to associate the adjustment charge with the original billing.  A number of conditions can cause the episode payment to be adjusted.  Both RAPs and claims may be cancelled by HHAs if a mistake is made in billing (TOB 328), though episodes will be cancelled in CWF as well.  Adjustment claims may also be used to change i nformation on a previously submitted claim (TOB 327), which may also change payment.  RAPs can only be cancelled, not adjusted, but may be re -billed after cancellation.   130.6 - Adjustments to Reprocess Certain Claims Denied Due to an Open Common Working File (CWF) Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record Was Subsequently Deleted or Terminated  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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.
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Group Health Plan (GHP) Medicare Secondary Payer claims were not reprocessed automatically in situations where Medicare becomes the primary payer after an MSP GHP record was deleted, or when an MSP GHP record was terminated, after claims were processed subject to the CWF record. It was the responsibility of the beneficiary, provider, physician or other supplier to contact the Medicare contractor and request the denied claims be reopened when reopening was permitted. This was a burden on the beneficiary, physician, or other supplier. This instruction directs CWF to implement an automated process to reopen certain MSP claims when MSP GHP records were 1) deleted, or 2) under some circumstances, certain MSP GHP records were terminated and claims were denied (rej ected for Part A claims) due to MSP or Medicare made a secondary payment before the termination date was accreted.   The COBC currently identifies, deletes, and terminates MSP GHP records on the CWF when appropriate.  The 1 -800 Medicare also applies simple terminations to MSP GHP working aged records only. Upon deletion of an MSP record, or where a termination dated added to an MSP GHP (MSP Codes 12, 13, 43) record, this instruction directs the CWF to search the claims history for claims, with dates of service within 180 days of the deletion date, or the dat e the termination date was applied, which were processed for secondary payment or were denied because of the MSP edit  as set forth in 42 CFR 405, subpart G, H and I. The Shared Systems shall reopen these claims, as necessary, including locating any claims billed to Medicare as primary, or secondary, and denied (rejected for Part A claims) on the basis of the subsequently deleted CWF MSP GHP record. Claims with added termination dates shall be reopened no earlier than the termination date applied to CWF.
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The CWF shall generate an unsolicited response W and send this response with the 24 and 10 trailers containing the identifying information regarding any such claims found to the shared system.  The unsolicited response shall include all the necessary inf ormation to identify the claim(s), including the Document Control Number/Internal Control Number/Claim Control number, Medicare beneficiary identifier , beneficiary name, and date(s) of service.  The CWF electronically transmits this unsolicited response to the claims processing contractor(s) that originally processed the claim(s) or send the claim to the MAC contractor that assumed the workload for the original legacy contractor that processed the claim. The previously denied claim(s) (rejected for Part A) is not to be canceled and remains on the CWF claims history pending subsequent adjustment as warranted.   Upon receipt of the unsolicited response, the shared system software reads the claim information in the trailer for each claim and performs an automated reopening to each claim.  The claim(s) must be reopened and adjusted as warranted for all non -reimburse d/claim denials (part A rejections)/ where Medicare paid secondary or terminations that were based upon the MSP GHP record that was just deleted or terminated. The MSP unsolicited responses are reported with the current MSP responses when COB deletes an MS P record a 03 will be received. The shared systems release the adjusted claims. Adjustments are subject to all applicable edits as the original claim(s) and sent to the CWF so that the claim(s) on the CWF history are replaced with the adjusted claim(s) r ecords.