evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans  (Rev.4491, Issued: 01- 09- 20, Effective: 04-01-20, Implementation: 04-06-20)  If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to traditional fee for service Medicare to pay the claim if the MA plan denies coverage.  SNF providers shall apply the following policies to MA beneficiaries who are admitted to a SNF:   If the SNF is non-participating with the plan, the beneficiary must be notified of his or her status because he/she MAY be private pay in this circumstance, depending upon the type of MA plan in which he/she is enrolled;    If the SNF is participating with the plan, pre-approve the SNF stay with the plan;    If the plan denies coverage, appeal to the plan, not to the fee for service FI;    Count the number of days paid by the plan as Part A days used (this IS the beneficiarys 100 days of Medicare SNF benefits);    Submit a claim to the fee for service A/B MAC (A) to subtract benefit days from the CWF records. (Note: The plans do not send claims to CWF for SNF stays). Failure to send a claim to the A/B MAC (A) will inaccurately show days available.    If a beneficiary no longer requires skilled care under the MA plan the SNF may discharge the patient using a patient status code 04. No- payment bills are not required for beneficiaries that are receiving non-skilled care and are enrolled in an MA plan. If the beneficiary again requires skilled care after a period of non-skilled care, the provider should begin a new admission claim for Medicare to continue the spell of illness.   Billing Requirements   Submit covered claims and include a HIPPS code (use default code AAA00 prior to 10/1/2019 and ZZZZZ after 10/1/2019) if no assessment was done), room and board charges and condition code 04.
(Medicare Claims Processing Manual)
NOTE: If the beneficiary drops his or her MA plan participation during their SNF stay, the beneficiary is entitled to coverage under Medicare FFS for the number of days available that remain out of the 100 days available under the SNF benefit.    100 - Part A SNF PPS for Hospital Swing Bed Facilities  (Rev. 1, 10-01-03) PM A -02-016  Section 4432(a) of the Balanced Budget Act (BBA) of 1997 specifies that swing bed facilities must be incorporated into Part A SNF PPS by the end of the statutory transition period.  Effective with cost reporting periods beginning on or after July 1, 2002, swing bed bills are not paid on the cost-based method, but rather on the basis of the Part A SNF PPS.  These payment rates cover all payment for furnishing covered swing bed extended care services (routine, ancillary, and capital -related costs) other than approved educational activities as defined in 42 CFR 413.85.  Part A SNF PPS applies to short-term hospitals, long-term care hospitals, and rehabilitation hospitals that have Medicare swing bed agreements.  CAHs with swing beds are exempt from the Part A SNF PPS, and are not affected by these instructions.  The Part A PPS is phased in based on each swing bed hospitals fiscal year.  The transition to Part A PPS is effective with the start of the providers first cost reporting period that begins on or after July 1, 2002.  Consequently, billing for all benefic iaries in a swing bed must be split at the end of the providers fiscal year.  A new bill is created for beneficiaries remaining in the facility at the start of the new fiscal year.  The bill must be prepared under the Part A PPS claim guidelines described  in this chapter and in Chapter 1, General Billing Requirements.  Payment is made according to the instructions for SNFs under Part A PPS found in the Medicare Provider Reimbursement Manual.
(Medicare Claims Processing Manual)
Providers of swing bed services submit Part A inpatient claims using TOB 18X.  The swing bed program does not include an inpatient Part B benefit.  For beneficiaries who continue to receive extended care services after the end of a Part A stay (e.g., benefits exhausted, not receiving a skilled level of care, etc.), ancillary services may be billed under the hospital as inpatient Part B services.  If the beneficiary remains a resident in the swing bed facility after the end of the Part A stay, the hospital may submit a claim to the A/B MAC (A) for those inpatient services covered by Part B using TOB 12X.  The beneficiary would be eligible for the sa me benefits available to a hospital inpatient in a Part B stay.  The hospital provider of SNF level swing bed services must also file a Part A nonpayment bill monthly using the appropriate nonpayment code.  For Part A PPS purposes, A/B MACs (A) assign swing bed hospitals to provider type 38 on their Provider-Specific File.  Swing bed providers will be paid at 100 percent of the Federal rate.  Swing bed claims will be paid using the actual MSA code (based on county codes), and the related rural or urban rate tables.  A/B MACs (A) must set the Federal PPS Blend Indicator in the Provider-Specific file to 4.  The CMI ADJ CPD field should be blank.  Unless exceptions are noted, instructions applicable to SNFs are also applicable to swing bed providers e.g., demand bills, spell of illness, covered and noncovered days, nonpayment bills, and adjustment bills.  100.1 - Swing Bed Services Not Included in the Part A PPS Rate  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19) PM A -02-016
(Medicare Claims Processing Manual)
For their SNF -level inpatients, rural (non- CAH) swing bed hospitals must submit all services that are not specifically excluded from consolidated billing on their Part A swing bed bill (TOB 18x). However, they are eligible for additional payment outside the bundled SNF PPS rate for those services that are excluded from the SNF Part A consolidated billing requirements.  Further, because the swing bed hospital itself still remains subject to the hospital bundling requirements specified in 1862(a)(14) of the Act and in 42 CFR 411.15(m) , it retains the Medicare billing responsibility for any excluded services to which the hospital bundling provision applies.  Accordingly, it would use a separate inpatient Part B claim to bill for such services (see 10.2 of this chapter).    As noted above, if a swing bed hospital furnishes a service or supply to a beneficiary receiving SNF -level services, which is excluded from the Part A PPS rate, the swing bed hospital may submit a separate bill to the A/B MAC (A) for the SNF PPS -excluded service.  This bill must use TOB 13x with all appropriate revenue codes, HCPCS codes, and line item date of service billing information and will be paid as inpatient Part B services under the Outpatient Prospective Payment System (OPPS).  (By contrast, thos e services bundled into the SNF PPS rate may not be billed separately, and must all be included on the Part A swing bed bill (TOB 18x).)  A list of services that are excluded from the SNF PPS rate is found in 20.1 - 20.4 above.  Likewise, swing bed hospitals may file bills with the A/B MAC (A) for Part B Ancillary services furnished to beneficiaries who are not in a Part A PPS swing bed stay.  Such claims are billed as inpatient Part B services, and are paid under the OPPS.   110 - A/B MAC (B) /DME MAC Claims Processing for Consolidated Billing for Physician and Non -Physician Practitioner Services Rendered to Beneficiaries in a SNF Part A Stay  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)
(Medicare Claims Processing Manual)
For an overview of SNF consolidated billing, including types of facilities and services subject to consolidated billing, see sections 10 and 20.  110.1 - Correct Place of Service (POS) Code for SNF Claims  (Rev. 76, 02- 06-04)  Place of Service (POS) code 31 should be used with services for patients in a Part A covered stay and POS code 32 should be used with services for beneficiaries in a noncovered stay.  A/B MACs (B) should adjust their prepayment procedure edits as appropria te.  110.2 - CWF Edits  (Rev. 76, 02- 06-04)  The following edits have been implemented in CWF.   110.2.1 - Reject and Unsolicited Response Edits  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -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.   A.  Reject Edits
(Medicare Claims Processing Manual)
A.  Reject Edits   When CWF receives a bill from the SNF that shows that a beneficiary became a resident of a SNF, that SNF stay is posted to history.  Effective April 2002, for claims processed and adjusted with dates of service on or after April 1, 2001, CWF will apply the reject edits to any claims received after the SNF stay is posted that have dates of service during the periods the beneficiary is shown to have been a resident of the SNF based on that first SNF bill.  These claims can be correctly rejected since it will be clear that the beneficiary was in the SNF during those spans that were shown on the SNF claim.  This process will repeat when the next SNF bill is received.  The process will co ntinue until CWF posts a discharge date, date of death, or the covered number of SNF days has been used.  Based on the CWF line item rejects, A/B MACs (B)/DME MACs must deny assigned and unassigned services they have been billed that should have been consolidated and paid by the SNF and/or billed to the A/B MAC (A).  Appeals rights must be offered on all denials.  Shared systems must develop, and along with A/B MACs (B)/DME MACs must implement, an automated resolution process whereby when they receive a reject from CWF, they must pay those services correctly billed and only deny those services on the claim incorrectly billed to them.   B. Unsolicited Response Edits   Effective July 1, 2002, CWF implemented the unsolicited response edit based on the same coding files made available for the reject edits.  Upon receipt of a Part A SNF claim at CWF, CWF searches paid claims history and compares the period between the SNF from and through dates to the line item service dates of the claims in history.  It then identifies any services within the dates of the SNF stay that should have been subject to consolidated billing and should not have been separately paid by the A/B MAC ( B)/DME MAC.
(Medicare Claims Processing Manual)
The CWF generates an unsolicited response, with a trailer that contains the identifying information regarding the claim subject to consolidated billing and a new trailer containing line item specific information that identifies all the individual services on that claim that fall within the SNF period.  The unsolicited response provides all necessary information to identify the claim, including Document Control Number, Medicare beneficiary identifier, beneficiary name, date of birth, and beneficiary sex.  CW F electronically transmits this unsolicited response to the A/B MAC (B)/DME MAC that originally processed the claim with consolidated services.  These unsolicited responses are included in the CWF response file.  The unsolicited responses in that file for claims to be adjusted for consolidated billing are identified with a unique transaction identifier.  The previously paid claim is not canceled and remains on CWF paid claims history, pending subsequent adjustment.  Upon receipt of the unsolicited response, the shared system software reads the line item information in the new trailer for each claim and performs an automated adjustment to each claim.  Services subject to consolidated billing must be denied at the line level.  The adjusted claims must then be returned to CWF, so that the claim on CWF paid claims history is replaced with the adjusted record.  A/B MACs (B)/DME MACs must return the claims with entry code 5.  Both the covered and the non- covered services mus t be returned to CWF on the adjustment claim.  When CWF adjusts the claim on history, the deductible is updated on the beneficiarys file and the corrected deductible information is returned to the A/B MAC (B)/DME MAC in trailer 11.  To recover any monies due back to Medicare resulting from these denia ls, A/B MACs (B)/DME MACs must follow the criteria in current overpayment recovery for the policy guidelines for furnishing demand letters and granting appeals rights.  In cases where all services on the claim are identified in CWF as subject to consolidated billing, the claim is adjusted by the standard system to line item deny all the services on the claim.  These fully non- covered claims must be returned to CWF, in order to reflect the denial actions in CWF paid claims history and to update the information in CMSs national claims history
(Medicare Claims Processing Manual)
to line item deny all the services on the claim.  These fully non- covered claims must be returned to CWF, in order to reflect the denial actions in CWF paid claims history and to update the information in CMSs national claims history file.  A/B MAC (B)/DME MAC systems must employ existing processes for the submission of fully non- covered claims.
(Medicare Claims Processing Manual)
110.2.2 - A/B Crossover Edits  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  Effective April 1, 2002, CWF implemented the following crossover edits for A/B MAC (B) submitted claims.  Automated processes were implemented for the resolution of these edits based on the codes returned in the trailers from CWF.   A. Edits 7258 and 7259 - Part B Physical Therapy Claim Against an Inpatient SNF 21x and Inpatient Part B 22x Claim   Reject if an A/B MAC (B) claim is received containing physical therapy (type of service of W), occupational therapy, or speech -language pathology and From/Thru Dates overlap or are within the From/Thru Dates on an SNF inpatient claim (21x) or an inpatient Part B claim (22x).   Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim) or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider).   Bypass the edit in the following situations:    The 21x or 22x type of bill contains a cancel date.    The incoming claim from date equals the SNF 21x or 22x history claim discharge date or incoming through date equals the SNF 21x or 22x history claim admission date.  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7258 and 7259 when a therapy claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates of an occurrence Span code date of 74 reported on a SNF inpatient claim 21x in history.  This will allow for services to be separately payable outside of SNF consolidated billing during non- covered periods in the SNF.
(Medicare Claims Processing Manual)
Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on April 7, 2008 to modify the existing therapy edit for Part B claims processing for non -covered SNF stays to read claims history to look for a 21x (SNF Inpati ent) bill type that contains an Occurrence Code 22 (Date Active Care Ended) and a Patient Status Code 30 (Still patient or expected to return for outpatient services) where there is no subsequent 21x (SNF inpatient) bill type discharge claim from the same provider.  As therapy services provided in a SNF must be consolidated when a beneficiary is in either a covered or non- covered stay, CWF will reject claims with dates of service after the posted SNF claim containing Occurrence Code 22 (Date Active Care Ended) and Patient Status 30 (Still patient or expected to return for outpatient services) until a 21x (SNF inpatient) bill type discharge claim is processed.  The entity furnishing the therapy services must look to the SNF for reimbursement rather than the A/B MAC (A) or (B).  For claims processed on or after January 5, 2009, this edit shall no longer be functional.  A/B MACs (A) and (B) shall re- open and- re-process claims previously denied due to this edit when brought to their attention should they determine that the beneficiary was not in a SNF stay during the period the therapy service was rendered.   B. Edits 7260 and 7261 - Part B Claim Without Therapy Against an Inpatient SNF  Reject if a Part B claim is received with From/Thru Dates overlapping or are within the From/Thru Dates on an SNF Inpatient claim (21x).  If the SNF 21x claim on history has patient status 30 and  occurrence code 22 (Date Active Care Ended), use occurrence 22 date instead of the through date.  Use separate error codes where (1) dates are within (A/B MAC (B) will reject claim); or (2) where dates overlap (A/B MAC (B) will automate a separate denial message to provider).  Bypass the edit in the following situations:   The 21x history claim contains a cancel date.
(Medicare Claims Processing Manual)
 The incoming A/B MAC (B) claim from date equals the SNF 21x history claim discharge date.  The incoming A/B MAC (B) claim through date equals the SNF 21x history claim admission date.   A diagnosis code in any position on the incoming claim is for renal disease.   The A/B MAC (B) claim contains ambulance codes per the files supplied to CWF in the annual and quarterly updates with modifiers other than N (SNF) in both the origin and destination on the same claim.   The A/B MAC (B) claim is a CANCEL ONLY (Action Code 4) claim.    The A/B MAC (B) claim is denied.    The A/B MAC (B) service has a Payment Process Indicator other than A (allowed).    The A/B MAC (B) claim contains only separately payable services per the files supplied to CWF in the annual and quarterly updates.  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass the edits 7260 and 7261 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thru dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A 3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non- covered periods in the SNF.   110.2.3 - Duplicate Edits  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  Effective April 1, 2002, CWF implemented the following duplicate edits for A/B MAC (B) submitted claims.   A. Edit 7253 -  Part B Ambulance Claim Against an Outpatient Part B SNF Ambulance Claim on History
(Medicare Claims Processing Manual)
Effective April 1, 2002, CWF implemented the following duplicate edits for A/B MAC (B) submitted claims.   A. Edit 7253 -  Part B Ambulance Claim Against an Outpatient Part B SNF Ambulance Claim on History   Reject if a Part B claim is received with ambulance codes per the files supplied to CWF in the annual and quarterly updates and the Date of Service equals the Date of Service on an outpatient Part B SNF (23x) claim with revenue code 54x (ambulance).   Bypass the edit if either the incoming or history claim contains any of the following situations:    The claim is a CANCEL ONLY (Action Code 4) claim.   The claim is denied.   The incoming claim payment process indicator is other than A (allowed).   B. Edit 7257 -  A/B MAC (B) or DME MAC  or A/B MAC (A) Part B Claim Against An Inpatient B SNF (22x) Claim on History   Reject as a duplicate claim if an A/B MAC (B) or DME MAC Part B claim or A/B MAC (A) Part B claim (12x, 13x, 14x, 23x, 33x, 71x, 73x, 74x, 75x, 76x, 83x or 85x) is received containing date of service, HCPCS code and modifier if present, equal to the date o f service, HCPCS code and modifier, if present, on an inpatient Part B SNF (221, 222, 223, 224 or 225) claim.  Bypass the edit if either the incoming or history claim contains any of the following situations:    The claim is a CANCEL ONLY (Action Code 4) claim.   The claim is denied.   HCPCS code is not present on the A/B MAC (A) claim.  The A/B MAC (B) Part B claim payment process indicator is other than A (allowed).   For the A/B MAC (B)/DME MAC claim only, the Part B claim contains only separately payable services per the files supplied to CWF in the annual and quarterly updates.  110.2.4 - Edit for Ambulance Services  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)
(Medicare Claims Processing Manual)
When a medically necessary transport from one SNF to another SNF occurs when the beneficiary is discharged from the first SNF and admitted to the second, this transport is included in consolidated billing.  The first SNF is responsible for the ambulance se rvice and the cost is included in the Part A rate.  It is not separately billable.  CWF will reject these services to the A/B MAC (B).  The A/B MAC (B) must deny the service with appeals rights.   Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass edit 7275 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thr u dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.   110.2.5 - Edit for Clinical Social Workers (CSWs)  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  Per the Balanced Budget Act, services provided by CSWs to beneficiaries in a Part A SNF stay may not be billed separately to the A/B MAC (B).  Payment for these services is included in the prospective payment rate paid to the SNF by the A/B MAC (A) .  Though the policy was in effect since April 1, 2001, there were no corresponding edits. With the April 2003 release, CWF implemented a new SNF consolidated billing edit to prevent payment to CSWs for services rendered to beneficiaries in a Part A SNF st ay.