evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual Crosswalk)
A2.2809 Intermediary Relationshi ps With Providers Serviced by Another Intermediary 1 20.5.1     Solicitation of a Provider to Secure a Change of Intermediary 1 20.5.2 Communications1 30 A2-2810 Provider Participation1 30.1 A2-2840,    RHC-320 Content and Term s of Provider Participation Agreements 1 30.1.1    RHC-321 Provider Charges to Beneficiaries 1 30.1.2    RHC-322 Provider Refunds to Beneficiaries 1 30.1.3    RHC-323 Provider Treatment of Beneficiaries 1 30.2 A3-3488,A3- 3703.1 B3-3060   Assignment of Provider's Right to Payment 1 30.2.1     Exceptions to Assignment of Provider's Right to Payment - Claims Submitted to FIs and Carriers 1 30.2.2  B3-3045.1   Background and Purpose of Reassignment Rules - Claims Subm itted toCarriersChap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description Submitted to Carriers 1 30.2.2.1 A3-3005    Reassignments by Nonphysician Suppliers - Claims Submitted to FIs 1 30.2.3     Effect of Payment to Ineligible Recipient 1 30.2.4 A3-3488.1 B3-3060.10   Payment to Agent - Claims Submitted to Carriers 1 30.2.5 A3-3488.2 B3-3060.11   Payment to Bank 1 30.2.6  B3-3060.1   Payment to Employer of Physician - Carrier Claims Only - Carrier Claims Only 1 30.2.7  B3-3060.2   Payment to Facility in Which Services Are Performed 1 30.2.8  B3-3060.3   Carrier Payment to Health Care Delivery System - Claims Submitted to Carriers 1 30.2.8.1  B3-3060.3C   Definition of Health Care Delivery System 1 30.2.8.2  B3-3060.3D   University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers 1
(Medicare Claims Processing Manual Crosswalk)
30.2.8.3 B3-3060.3E,B3-7065   Managed Care Organization, including HCPPs, Cost-Contracting HMOs, CMPs, and Medicare + Choice Organizations - Claims Submitted to Carriers 1 30.2.9 B3-3060.4,R1813B3   Payment to Physician for Purchased Diagnostic Tests - Claims Submitted to Carriers 1 30.2.9.1  B3-3060.5   Payment to Supplier of Diagnostic Tests for Purchased Interpretations Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1 30.2.10  B3-3060.6   Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers 1 30.2.11  B3-3060.7   Payment Under Locu m Tenens Arrangements - Claims Submitted to Carriers 1
(Medicare Claims Processing Manual Crosswalk)
30.2.12 B3-3060.8 Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims 1 30.2.13  B3-3060.9   Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for Carrier Processed Claims 1 30.2.14 A3-3488.3 B3-3060.6E.B3-3060.12   Correcting Unacceptable Payment Arrangements 1 30.2.14.1 Questionable Payment Arrangements1 30.2.15 A3-3488.4 B3-3060.13,B3-3060.14   Sanctions for Prohibited Payment Arrangement 1 30.2.16 A3-3488.5 B3-3060.15,B3-7065 partial   Prohibition of Assignments by Beneficiaries 1 30.3 A3-3005 B3-17000 Physician/Practitione r/Supplier Participation Agreement and Assignment - Carrier Claims 1 30.3.1  B3-3040.4   Mandatory Assignment on Carrier Claims 1 30.3.1.1  B-3040.3   Processing Claims for Services of Participating Physicians or Suppliers by Carriers 1 30.3.2  B3-3045.1   Nature and Effect of Assignment on Carrier Claims Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1 30.3.3  B3-3045.2   Physician's Right to Collect from Enrollee on Assigned Claim Submitted to Carriers 1 30.3.4  B3-3045.3   Effect of Assignment Upon Rental or Purchase of Durable Medical Equipment on Claims Submitted to Carriers 1 30.3.5  B3-3045.4   Effect of Assignment Upon Purchase of Cataract Glasses from Participating Physician or Supplier on Claims Submitted to Carriers 1 30.3.6  B3-3045.5   Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers 1 30.3.7  B3-3045.6   Physicians Billing fo r Purchased Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) on Claims Submitted to Carriers 1 30.3.8  B3-3045.7   Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers 1 30.3.9  B3-3040   Filing Claims to a Carrier For Nonassigned Services 1
(Medicare Claims Processing Manual Crosswalk)
Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers 1 30.3.9  B3-3040   Filing Claims to a Carrier For Nonassigned Services 1 30.3.10  B3-3040.1   Carrier Submitted Bills by Beneficiary 1 30.3.11  B3-3040.2   Carrier Receipted Bill - Definition 1
(Medicare Claims Processing Manual Crosswalk)
30.3.12 B3-17001 Carrier Annual Participation Program 1 30.3.12.1 B3-17001.1 Carrier Pa rticipation and Billing Limitations 1 30.3.12.2  B3-17001.1   Carrier Participation Agreement Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1 30.3.12.3  B3-17002   Carrier Rules for Limiting Charge 1                                          40 A3-3008,A2-2800    Termination of Provider Agreement 1 40.1 A3-3008.1,A2-2800.1 RHC-330,OPT-124   Voluntary Termination 1 40.1.1 A2-2800.2   RHC-330 Close of Business 1 40.1.2 HHA-145,HO-145;  SNF-145;  RHC-331,  RHC-332 Change of Ownership 1 40.1.3  A3-3008.3 Expiration and Renewa l-Nonrenewal of SNF Term Agreements 1 40.2 A3-3008.2 RHC-331 Involuntary Terminations1 40.2.1  A2-2800.3 Processing Involuntary Terminations1 40.2.2 A2-2801,A2-2801.1    Intermediary Report on Provider Deficiencies 1 40.2.2.1 A2-2801.2    Subsequent Communications With Provider 1 40.3 A2-2804    Readmission to Medicare Program After Involuntary Termination 1 40.3.1 A2-2804.1    Effective Date of Provider Agreement 1 40.3.2 A2-2805 RHC-334 Fiscal Considera tions In Provider Readmission To Medicare Program After Involuntary Termination Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1 40.4 A3-3008.4    Payment for Services Furn ished After Termination, Expiration, or Cancellation of Provider Agreement 1 40.4.1  A3-3600.3
(Medicare Claims Processing Manual Crosswalk)
Reviewing Inpatient  Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions 1 40.4.2  A3-3699.3.C Status of Hospital or SNF After Termination, Expiration, or Cancellation of Its Agreement 1 40.5 A3-3600.7    Intermediary/Carrier/DMERC Responsibilities for Informing Providers of Changes 1 50 A3-3301    Filing a Request for Payment With the Carrier or Intermediary 1 50.1 A3-3302    Request for Payment from the Carrier or Intermediary 1 50.1.1 A3-3302.1,A3-3602.4     Billing Form as Request for Payment 1 50.1.2 A3-3302.2    Beneficiary Request for Payment on Provider Record - UB-92 and Electronic Billing (Part A and Part B) 1 50.1.3 A3-3302.5 B3-3008   Signature on the Request for Payment by Someone Other Than the Patient 1 50.1.4 A3-3302.6    Request for Payment as a Claim for HI Entitlement 1 50.1.5 A3-3302.7    Refusal by Patient to Request Payment Under the Program 1 50.1.6  B3-3057   When Beneficiary Statement is Not Required for Physician/Supplier Claim Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1
(Medicare Claims Processing Manual Crosswalk)
50.1.7 A3-3305.1,A3-3312.2,   B3-3004,  B3-3000 partial   Definition of a Claim for Payment 1 50.1.8 A3-3305.2,A3-3305.3     Establishing Date of Filing - Postmark Date Carriers 1 50.2 A3-3603 Frequenc y of Billing for Providers 1 50.2.1     Inpatient Billing from Hospitals and SNFs 1 50.2.2     Frequency of Billing for Outpatient and Services to Intermediaries 1 50.2.3 A3-3603.1    Submitting Bills In Seque nce Ffor a Continuous Inpatient Stay or Outpatient Course of Treatment 1 A3-3603.2,Definition of spell of illness from MIM-3035    Reprocess Inpatient or Hospice Claims in Sequence 1 60    No Pay Bills 1 70 A3-3600.2    Time Limitations for Filing Provider Claims 1 70.1 A3-3600.2A Determining Start Date of Timely Filing Period--Service Date 1 70.2 A3-3600.2B Definition of Claim1 70.2.1  A3-3600.2B1 Appropriate Medicare Contractor1 70.2.2 A3-3600.2B2    Form Prescribed by CMS Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1 70.2.3 A3-3600.2B3    In Accordance with CMS Instructions 1
(Medicare Claims Processing Manual Crosswalk)
70.2.3.1 A3-3600.2B3a    Incomplete or Invalid Submissions 1 70.2.3.2 A3-3600.2B3b    Handling Incomplete or Invalid Submissions 1 A3-3600.2B3c 1 70.3 A3-3600.2C Determining End Date  of Timely Filing PeriodReceipt Date 1 1 70.4 A3-3600.2D Determination of Timely Filing and Resulting Actions 1 70.4.1     Part A Institutional Provider Services and Part A and Part B Home Health Services 1 70.5 A3-3600.2E    Application to Special Claim Types 1 70.6 A3-3600.2F    Filing Claim Where Usual Time Limit Has Expired 1 70.7 A3-3600.2G    Exceptions Allowing Extension of Time Limit 1 70.7.1  A3-3600.2G1 Administrative Error1 70.7.2  A3-3600.2G2 Statement of Intent1 70.7.3  A3-3600.2G3 Reopening of Determinations Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1
(Medicare Claims Processing Manual Crosswalk)
80 A3-3600,A3-3600.1 B3-13306, B2-5240.11 HO-401,HO-401A,  HH-462  Carrier and Intermediary Claims Processing Timeliness 1 80.1     Control and Counting Claims 1 80.2 A3-3600.1 B2-5240.11A  HO-401D Definition of Clean Claim 1 80.2.1 A3-3600.1-Item 7 Receipt Date1 80.2.1.1 A3-3600.1A.1 B2-5240.11D   Payment Ceiling Standards 1 80.2.1.2 A3-3600.1   HO-401B Payment Floor Standards 1 80.2.2 A3-3600.1-Item 5   HO-401C Interest Payment on Clean Non-PIP Claims Not Paid Timely 1 80.2.2.1  B2-5240.11C   Determining and Paying Interest 1 80.2.2.2     Preparation of IRS Form 1099-INT 1 80.3 A3-3600.1-Item 4 B2-5240.11B  HO-401E Other Claims (Other Than Clean) 1 80.3.1 A3-3605.1 B3-3005.1   Incomplete or Invalid Claims Processing Terminology 1 80.3.2 A3-3605.2 B3-3005.2B   Handling Incomplete or Invalid Claims 1 80.3.2.1 A3 3605.3 B3-3005.3,   Data Element Requirements Matrix Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1
(Medicare Claims Processing Manual Crosswalk)
80.3.2.1.1  B3-3005.4,R1813B3   Carrier Data Element Requirements 1 80.3.2.1.2  B3-3005.4,R1813B3   Conditional Data Element Requirements for Carriers and DMERCs 1 80.3.2.1.3     Carrier Specific Requirements for Certain Specialties/Services 1 80.3.2.2  A3-3606 Intermediary Consistency Edits1 80.4 A3-3676    Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment) 1 80.5     Do Not Forward Initiative (DNF) 1 80.5.1  B3-4021,  B-02-023  Carrier DNF Requirements 1 80.5.1.1   B-02-11  Reporting Requirements - Carriers 1 80.5.2 A-02-12 Intermediary DNF Requirements1 80.5.2.1     Reporting Requirements - Intermediaries 1 90 HO-408,HH-412 Patient Is a Member of an M+CO for Only a Portion of the Billing Period 1 100 HO-301,HO-469,  42 CFR 411.32 Medicare as a Secondary Payer 1 110 HO-413,HH-480,  SNF 545 Provider Retention of Health Insurance Records Chap Sect Int. Pub. 13 Carrier Pub. 14 PMs Other Description 1                    110.1 HO-413,HH-480,  SNF 545.1 Categories of Health Insuran ce Records to Be Retained 1 110.2    SNF 545.3,  HO-413,  HH-480 Microfilming Records 1 110.3  Retention Period1 110.4 HO-413.1,HH-480.1,  SNF 545.4 Destruction of Records 1 130 A3-3670  AB-00-38  Detection of Duplicate Claims 1   B3-3999   Exhibit 1 - Data Element Requirements Matrix (Carrier)
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 2 - Admission and Registration Requirements   Table of Contents  (Rev. 12423; Issued: 12- 20-23)
(Medicare Claims Processing Manual)
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.  Transmittals for Chapter 2  01 - Purpose of Chapter  05 - Definition of Provider and Supplier  10 - General Admission and Registration Rules  10.1 -  Medicare beneficiary identifiers  10.1.1 -  Changes to Medicare beneficiary identifier s 10.1.2 -  Contractor Procedures for Obtaining Missing or Incorrect Medicare beneficiary identifiers  10.1.3 -  Importance of Medicare beneficiary identifiers  10.2 -  Prohibition Against Waiver of Health Insurance Benefits as a Condition of Admission  10.3 -  Requiring Prepayment as a Condition of Admission is Prohibited 10.4 -  When Prepayment May Be Requested  10.5 -  Hospital and Skilled Nursing Facility (SNF) Verification of Prior Hospital Stay Information for Determining Deductible and Benefit Period Status  10.6 -  Hospitals May Require Prepayment for Noncovered Services  10.7 -  Compliance With Agreement  10.8 -  Request for Payment Should Be Obtained in All Cases as Protective Application for Hospital Insurance Benefits  10.9 -  A/B MAC (A) or (HHH)  Requests to Verify Patients  Medicare beneficiary identifier  10.10 -  A/B MAC (A) or (HHH)  Learns Beneficiary is an HMO Enrollee  10.11 -  Retroactive Entitlement 10.12 -  SNF Verification of Prior Hospital Stay and Transfer Requirements  20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer  20.1 -  Provider Development of Medicare Secondary Payer  30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier and Entitlement Status  30.1 -  Cross -Reference of  Medicare beneficiary identifier  30.2 -  Health Insurance (HI) Card  30.3 -  Temporary Eligibility Notice  30.4 -  Certificate of Social Insurance Award  30.5 -  Medicare Summary Notice (MSN)  30.6 -  Provider Access to CMS and A/B MAC
(Medicare Claims Processing Manual)
-  Health Insurance (HI) Card  30.3 -  Temporary Eligibility Notice  30.4 -  Certificate of Social Insurance Award  30.5 -  Medicare Summary Notice (MSN)  30.6 -  Provider Access to CMS and A/B MAC (A) or (HHH)  Eligibility Data  30.6.1 -  Reserved  30.6.1.1 -  Part A Inquiry (HIQA) Screen Display  30.6.1.2 -  Part A Inquiry Reply (HIQAR) Screen Display 30.6.1.3 -  Part A Inquiry (HUQA) Data  30.6.1.4 -  Part A Inquiry Reply (HUQAR) Data  30.6.1.5 -  Health Insurance Query for Home Health Agencies (HIQH)  30.6.2 -  Reserved  30.6.3 -  Reserved  30.6.4 -  Reserved  30.6.5 -  Reserved  30.6.6 -  Reserved  30.8 -  Reserved  30.10 -  Reserved  30.11 -  Reserved  30.12 -  Reserved  30.13 -  Reserved  30.14 -  Reserved  30.15 -  Reserved  30.16 -  Reserved  30.17 -  Reserved  30.18 -  Reserved  30.19 -  Reserved  30.19.1 -  Reserved  30.19.2 -  Reserved  30.19.3 -  Reserved  30.19.4 -  Reserved  30.20 -  Reserved  30.21 -  Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry Response Procedures  30.21.1 -  HMO- Related Master File Corrections  30.22 -  Provider Problems Obtaining Entitlement Information 50 - Critical Case Procedures -  Establishing Entitlement Under Part A and B  60 - Reserved  60.1 -  Reserved  60.2 -  Reserved  70 - SSO Assistance in Resolving Entitlement Status Problems  90 - Outpatient Hospital Registration Procedures  90.1 -  Patient Identification  90.2 -  Determining Whom to Bill  90.3 -  Source of Admission -  Outpatient Hospital 90.4 -  Type of Bill  90.5 -  Definition of Diagnostic Services  90.6 -  Definition of Encounter  100 -  Reserved  100.1 -  Reserved  110 -  Reserved  110.1 -  Reserved  120 -  Reserved  01 - Purpose of Chapter  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)
(Medicare Claims Processing Manual)
This chapter describes general requirements with respect to verifying an individuals Medicare eligibility and entitlement status for providers, suppliers, A/B MACs (A), (B), and (HHH), and DME MACs.  It also includes general requirements for hospitals for  determining the source admission for use later in the claims process.  05 - Definition of Provider and Supplier  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    This chapter uses the definition of provider and supplier found in 42 CFR 400.202.  These are:    Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech -language pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitaliz ation or intensive outpatient  services.    Supplier  means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.    Note that while rural health clinics, Federally qualified health centers, and renal dialysis facilities are suppliers under the regulation, they submit most claims to A/B MACs (A).   10 - General Admission and Registration Rules  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)
(Medicare Claims Processing Manual)
The following is a general description of requirements and prohibited activities that apply to admission for inpatient services or registration for other healthcare services.  Upon admission, Prospective Payment System (PPS) hospitals and acute care hospitals in areas with waivers from PPS are required to give the notice, An Important Message from Medicare, to beneficiaries (available at www.cms.gov/Medicare/Medicare -General -Information/BNI/downloads/RevisedImportantMessageFromMedicare05_2007.pdf ).  The facility inserts its Quality Improvement Organizations (QIO) name, address, and phone number.  It provides this notice to each Medicare patient or the patients representative.  The CMS does not supply copies of the notice.   Upon admission of a Medicare beneficiary to an institution that bills Medicare, or as soon thereafter as practical, the provider must verify a patients eligibility in order to process the bill.  The provider may obtain this eligibility information directly from the patient or through the providers A/B MAC (A)s limited Medicare eligibility data.  See 30.6.  The provider contacts its A/B MAC (A) to obtain technical instructions regarding how this access may be implemented along with hardware/software compatibility details.   This information does not represent a definitive eligibility status.  If the individual is not on file, the provider uses the usual admission and billing procedure in effect, independent of this data access.   Disclosure of CMS eligibility data is restricted under the provisions of the Privacy Act of 1974.  This information is confidential, and may be used only for verifying a patients eligibility to benefits under the Medicare program.  Penalties for misuse by anyone may result in being found guilty of a misdemeanor and paying a fine not more than $5,000.  10.1 - Medicare beneficiary identifiers                                                        (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)
(Medicare Claims Processing Manual)
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.   The CMS maintains the electronic records for individuals enrolled in the health insurance program.  The CMS issues health insurance cards where entitlement is established through the Social Security Administration (SSA), and the Railroad Retirement Board (RRB) issues health insurance cards where entitlement is established through RRB.   See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual (Pub. 100- 01) for an extended discussion of HI cards and Medicare beneficiary identifiers.
(Medicare Claims Processing Manual)
See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual (Pub. 100- 01) for an extended discussion of HI cards and Medicare beneficiary identifiers.                                                                    10.1.1 - Changes to Medicare beneficiary identifier  (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 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.   Changes in an individuals entitlement to Medicare benefits may result in an individual being assigned a completely different HICN.  For example, an individual not entitled to monthly benefits (000- 00-0000T) marries and becomes entitled to wifes benefits on her husbands account (111- 11-1111B).  If a claim is submitted under the old HICN, the Common Working File (CWF) disposition code 51 will notify the A/B MAC (A), (B), (HHH), or DME MAC (whom we will refer to as the MAC when all are meant) of the new HIC N.  The MAC will annotate its records and use the new HICN when submitting future bills or claims.   10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect Medicare beneficiary identifier s  (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 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.