evekhm/cms_iom_500 huggingface dataset:
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
1.3 - Generating Unsolicited Responses to the VA  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04- 07-08)  While the VA is entitled by law to collect the coinsurance and deductible amounts that would have been payable had the claim been a true Medicare claim, it is generally permitted to do so only to the extent that there are no true Medicare claims for coinsurance and deductible submitted to the insurer for the same beneficiary for the same year.  While the VA submits these Medicare -equivalent claims in good faith, based on the current deductible information within CWF and maintained by the shared systems, situations sometimes arise where a true Medicare claim is subsequently adjudicated and for whom the insurers' payment of deductible is owed.  When this occurs, and the supplemental insurer processes the true Medicare claim, it may deny the claim believing it has already paid the deductible, with the possible result of providers in turn billing the Medicare beneficiary for this amount.  While the VA is willing to pay back the amounts it collected in error, it will not always know that this situation has occu rred, and has asked Medicare to help it determine when this situation has transpired.  The solution is an unsolicited response, sent to the VA, indicating that a change in Medicare deductible has occurred since the adjudication of the VA claim.  The unsoli cited response will show the amount of deductible approved for the affected VA claim and the total true Medicare deductible satisfied as of the date the Medicare claim was adjudicated. There will be one unsolicited response per affected VA claim.  The unsolicited responses will be generated each time a Medicare claim affecting the deductible is adjudicated after the adjudication of a VA claim applying a deductible for the same year of service, even if the VA claim has not overapplied the deductible.  Although this provision became effective January 1, 2006, it affects claims with dates of service January 1, 2004, and later.
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
1.4 - Use of CMS Certification Numbers (CCNs) After National Provider Identifiers (NPIs) Are Fully Implemented  (Rev.  11396, Issued:05- 04-2022, Effective:10 -01-2022, Implementation:10- 03-2022)   While equivalent to Medicare claims in overall appearance and the nature of the services rendered, VA claims contain unique elements to ensure that they are processed appropriately and apart from Me dicare claims, and in particular that payment is not made.  Among these characteristics are a demo code and provider numbers which are unique to this project.   CMS has determined that it is in its best interests to have the VA continue to submit the MRA project transactions with its CMS Certification Number (CCN) instead of NPIs.   In addition, if the VA providers begin using an NPI for other purposes, Medicare -equivalent remittance advice claims must be submitted to CMS with a VA CMS Certification Number (CCN) as the provider identifier.  The demo number (31) will be assigned based on the CCN submitted and by the A/B MAC (A) or (B) number. Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11427CP  05/20/2022  Claims Processing Man ual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  01/03/2023  12734  R11414CP  05/12/2022  Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)   Rescinded and replaced by Transmittal 11427  06/13/2022  12734  R11396CP  05/04/2022  Update to  Chapters 3, 4, 27 and 37 of Publication (Pub.) 100- 04 Medicare Claims Processing Manual to Remove Reference to the Term "OSCAR"  10/03/2022  12715  R4023CP  04/20/2018  Update of Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100- 04, Chapter 37 -  Department of Veterans Affairs (VA) Claims Adjudication Services Project
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
07/20/2018  10621  R3009CP  08/01/2014  Update to Pub. 100 -04, Chapter 37 to Provide Language -Only Changes for Updating ASC X12  09/02/2014  8770  R1454CP  02/22/2008  Department of Veterans Affairs (VA) Claims Adjudication Services Project -  New IOM Chapter -  Pub. 100- 04, Chapter 37 Department of Veterans Affairs (VA) Claims Adjudication Services Project  04/07/2008  5938  Back to top of chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 38 - Emergency Preparedness Fee- For-Service Guidance   Table of Contents  (Rev. 10135, 05- 15-20)  Transmittals for Chapter 38   01  Foreward  10  Use of the CR Modifier and DR Condition Code for Disaster/Emergency -Related Claims   01  Foreward  (Rev. 1784, Issued: 07- 31-09, Effective: 08- 31-09, Implementation: 08 -31-09)  Generally, this chapter describes the guidance that may be implemented for the Medicare fee-for-service program in the event of a disaster/emergency. As part of its preparedness efforts for a disaster/emergency, the Centers for M edicare and Medicaid Services (CMS) has developed certain disaster/emergency guidance that may  be implemented for the Medicare fee- for-service program in the event of a disaster/emergency.  CMS has also developed certain additional disaster/emergency guida nce that may  be implemented if: 1. the President declares an emergency or disaster under the National Emergencies Act or the Stafford Act; and  2. the Secretary of the Department of Health and Human Services declares -  under  319 of the Public Health Servi ce Act -  that a public health emergency exists, and  3. the Secretary elects to waive one or more requirements of Title XVIII of the Social Security Act (Act) pursuant to  1135 of such Act.  Until CMS declares these guidances to be in effect, the guidances  are considered to be pending.   10  Use of the CR Modifier and DR Condition Code for Disaster/Emergency -Related Claims  (Rev.  2999, Issued; 07- 25-14, Effective: 01- 01-12, Implementation: 08- 25-14)  In order to facilitate claims processing and track services and items provided to beneficiaries during disaster/emergency situations, a modifier and condition code have been established for providers to use on disaster/emergency related claims.  The modifier and condition code have been in effect since August 21, 2005.  The codes are effective for dates of service on and after August 21, 2005.  The modifier and/or condition code can be used by providers submitting claims for beneficiaries who are emergency patients in any part of the country.
(Medicare Claims Processing Manual)
The DR Condition Code :  The title of the DR condition code is disaster related and its definition requires it to be used to identify claims that are or may be impacted by specific payer/health plan policies related to a national or regional disaster.   The DR condition code is used only for institutional billing, i.e., claims submitted by providers using the ASC X12 837 institutional claim format or on an institutional paper claim Form CMS -1450.  In previous emergencies, use of the DR condition code ha s been discretionary with the billing provider or supplier. It no longer may be used at the provider or suppliers discretion. Use of the DR condition code will be mandatory for any claim for which Medicare payment is conditioned on the presence of a form al waiver, as defined below. The DR condition code also may be required for any type of claim for which, at the A/B MAC (A)s or (HHH) s discretion or as directed by CMS in a particular disaster or emergency, the use of the DR condition code is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee- for-service program.
(Medicare Claims Processing Manual)
The CR Modifier :  Both the short and long descriptors of the CR modifier are catastrophe/disaster related .  The CR modifier is used in relation t o Part B items and services for both institutional and non- institutional billing.  Non -institutional billing, i.e., claims submitted by physicians and other suppliers, are submitted either using the ASC X12 837 professional claim format or on a professional paper claim Form CMS -1500 or, for pharmacies, in the NCPDP format.  In previous emergencies, use of the CR modifier has been discretionary with the billing provider or supplier.  It no longer may be used at the provider or suppliers discretion.  Use of the CR modifier will be mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned on the presence of a formal waiver, as defined below.  The CR modifier also may be required for any HCPCS code for which, at the A/B MAC (A)s, (B) s, or (HHH)s or DME MACs discretion or as directed by CMS in a particular disaster or emergency, the use of the CR modifier is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee- for-service program.   Formal Waivers :  A formal waiver is a waiver of a program requirement that otherwise would apply by statute or regulation.  There are two types of formal waivers.  One type is a temporary waiver or modification of a requirement under the autho rity described in 1135 of the Social Security Act (the Act).  Although Medicare payment rules themselves are not waivable under this statutory provision, the waiver authority under 1135 may permit Medicare payment in a circumstance where such payment would otherwise be barred because of noncompliance with the requirement being waived or modified.  The second type of formal waiver is a waiver based on a provision of Title XVIII of the Act or its implementing regulations.  The most commonly employed waiver in this latter category is the waiver of the 3 -day qualifying hospital stay requirement that is a precondition for Medicare payment for skilled nursing facility services.  This requirement may be waived under 1812(f) of the Act .
(Medicare Claims Processing Manual)
Several conditions must  be met for a 1135 waiver to be implemented.  First, the President must declare an emergency or disaster under the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act.  Such a declaration will specify both an ef fective date and the geographic area(s) covered by the declaration.  Second, the Secretary of the Department of Health and Human Services must declare - under 319 of the Public Health Service Act -  that a public health emergency exists within some or all of the areas covered by the Presidential declaration.  Third, the Secretary must authorize the waiver of one or more requirements specified in 1135 of the Act.  Fourth, the Secretary or the Administrator of CMS must determine which Medicare program requir ements, if any, may be waived or modified under the Secretarys authorization and whether specific conditions within the geographic area(s) specified by the Secretarys declaration warrant waiver or modification of one or more requirements of Title XVIII o f the Act.  If all of the foregoing conditions are met, the Secretary or CMS Administrator may specify the extent to which a waiver or modification of a specific Medicare requirement is to be applied within the geographic area(s) with respect to which the waiver authority has been invoked.   The waiver of a Medicare requirement based on authority included in the provision of Title XVIII of the Act or its implementing regulations may be made at the discretion of the Administrator of CMS unless otherwise speci fied.  Such a waiver does not require either a Presidential or a Secretarial declaration nor, if such declarations are made, would such a waiver be necessarily limited by the geographic boundaries specified in such declarations.  Nevertheless, the Administ rator may elect to limit the effect of Title XVIII waivers to such geographic areas and to such time frames as are specified by such declarations.   A Medicare requirement established in statute or regulation that is not subject to waiver under either of these types of formal waiver generally may not be waived as a matter of administrative discretion.  Because most Medicare requirements are not waivable, nearly all Medicare entitlement, coverage, and payment rules will remain in effect during a disaster or emergency.
(Medicare Claims Processing Manual)
Informal Waivers :  An informal waiver is a discretionary waiver or relaxation of a procedural norm, when such norm is not required by statute or regulation, but rather is reflected in CMS guidance or policy.  Such norm may be waived or r elaxed administratively if circumstances warrant.  One example of such a norm would be claims filing jurisdiction.  In the event of a disaster/emergency that impaired or limited operations at a particular Medicare Administrative Contractor (MAC), alternative claims filing jurisdictions could be established.  Informal waivers are made by the CMS Administrator or his/her delegates.   Further Instructions in the Event of a Disaster or Emergency :  In the event of a disaster or emergency, CMS will issue specific guidance to MACs via one or more Technical Direction Letter (TDL) that will contain a summary of the Secretarys declaration (if any); specify the geographic areas affected by any declarations of a disaster or emergency; specify what formal waivers and/or informal waivers, if any, have been authorized; specify the beginning and end dates that apply to the use of the DR condition code and/or the CR modifier; and specify what other uses of the condition code and/or modifier, if any, will be mandatory for the particular disaster/emergency.   Reporting Utilization of the Condition Code and Modifier :  MACs must compile reports of utilization of the use of the condition code and/or modifier as specified via any TDL as may be issued in the event of a specific disast er or emergency.   B. Policy:   The DR Condition Code :   The DR condition code is used for institutional billing only.    Use of the DR condition code is required when a service is affected by an emergency or disaster and Medicare payment for such service is conditioned on the presence of a formal waiver (as that term is described in Background, above)    Use of the DR condition code also may be required when either the A/B MAC (A) or (HHH)  or CMS determine that such use is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee -for-service program.    The DR condition code is used at t he claim level when all of the services/items billed on the claim are related to the emergency/disaster.   The CR Modifier :   The CR modifier is used for Part B items and services only but may be used in either institutional or non -institutional billing.
(Medicare Claims Processing Manual)
The CR Modifier :   The CR modifier is used for Part B items and services only but may be used in either institutional or non -institutional billing.    Use of the CR modifier is required when an item or service is impacted by an emergency or disaster and Medicare payment for such item or service is conditioned on the presence of a formal waiver (as that term is described in Background, above)   Use of th e CR modifier also may be required when either the A/B MAC (A), (B), or (HHH), or DME MAC or CMS determine that such use is needed to efficiently and effectively process claims or to otherwise administer the Medicare fee -for-service program.   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R10135CP  05/15/2020  Manual Update to Pub. 100 -04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section  06/16/2020  11778  R2999CP  07/25/2014  Update to Pub. 100 -04, Chapter 38 to Provide Language -Only Changes for Updating ASC X12 08/25/2014  8772  R2021CP  08/06/2010  National Modifier and Condition Code to Identify Items or Services Related to the 2010 Oil Spill in  the Gulf of Mexico  01/03/2011  7087  R1784CP  07/31/2009  The Use of the CR Modifier and DR Condition Code on Disaster/Emergency Related Claims -Initial re lease of chapter  08/31/2009  6451  Back to top of chapter
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Medicare Claims Processing Manual  Chapter 39  Opioid Treatment Programs (OTPs)  Table of Contents  (Rev. 12418; Issued: 12- 21-23)  Transmittals for Chapter 39   10 - General    20 - Statutory authority for OTPs billing Medicare    30 - Bundled payments for Opioid Use Disorder (OUD) treatment services    30.1 -  Duration of bundle      30.2 -  Requirements for an Episode     30.3 -  Non -drug episode of care     30.4 -  New drugs     30.5 -  Site of service (telecommunications)     30.6 -  Coding    30.6.1 -  Adjustments to Bundled Payment Rate     30.7 -  Cost Sharing   30.8 -  Locality Adjustments    30.9 -  Annual Updates   40 - Practitioner Claims submission  A/B MAC (B)   40.1 -  Place of Service    40.2 -  Date of Service      40.3 -  Prescribing Individuals   50  Institutional Opioid Treatment Program (OTP) Services  A/B MAC (A)   50.1 Special Opioid Treatment Program Billing Requirements for Hospitals, Critical Access Hospitals, and Free -Standing Opioid Treatment Program Facilities       10 - General  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  This chapter provides claims processing instructions for Opioid Treatment Programs (OTPs).   The Medicare Benefit Policy Manual, Chapter 17, provides coverage policy for OTPs.   20 - Statutory authority for OTPs billing Medicare  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)
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Section 2005 of the SUPPORT Act amended section 1861 of the Act by adding a new subsection (jjj)(2) to define an OTP as an entity meeting the definition of OTP in 42 CFR 8.2 or any successor regulation (that is, a program or practitioner engaged in opioid treatment of individuals with an opioid agonist treatment medication registered under 21 U.S.C. 823(g)(1)), that meets the additional requirements set forth in subparagraphs (A) through (D) of section 1861(jjj)(2) of the Act.  Specifically that the OTP: is  enrolled under section 1866(j) of the Act; has in effect a certification by the Substance Abuse and Mental Health Services Administration (SAMHSA) for such a program; is accredited by an accrediting body approved by SAMHSA; and meets such additional condi tions as the Secretary may find necessary to ensure the health and safety of individuals being furnished services under such program and the effective and efficient furnishing of such services.  We defined opioid treatment program at  410.67(b) as an entity that is an OTP as defined in  8.2 (or any successor regulation) that meets the applicable requirements for an OTP. For an OTP to participate and receive payment under the Medicare program, the OTP must be enrolled under section 1866(j) of the Act, have in effect a certification by SAMHSA for such a program, and be accredited by an accrediting body approved by SAMHSA.   30 - Bundled payments for Opioid Use Disorder (OUD) treatment services  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  The bundled payment rates are calculated by combining the drug component and the non- drug components.  30.1 - Duration of bundle  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)  An episode of care is defined at  410.67(b) as a 1 -week (contiguous 7- day) period.   There is no maximum number of weeks for a course of treatment for OUD.
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An episode of care is defined at  410.67(b) as a 1 -week (contiguous 7- day) period.   There is no maximum number of weeks for a course of treatment for OUD.   30.2 - Requirements for an Episode  (Rev. 12418; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 24-24)  In recognition that there is a range of service intensity depending on the severity of a patients OUD and stage  of treatment,  a full  weekly  bundle  may consist  of a very different  frequency  of services for  a patient in the initial phase of treatment compared to a patient in the maintenance phase of treatment, or based on other factors such as pregnancy or relapse.  The threshold to bill the weekly episode is the delivery of at least one service in the weekly bundle (from either the drug or non- drug component) to the patient during the week that corresponds to the episode of care.  If no drug was provided to the patient  during that episode, the OTP must  bill the G-code  describing the weekly bundle not including the drug (HCPCS code G 2074) and the threshold to bill would be at least one service in the non- drug component. If a drug was provided with or without additional non- drug component services, the appropriate  G-code  describing the weekly  bundle  that includes  the drug furnished  may be billed.
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For OTP intensive outpatient services, the threshold to bill HCPCS code G0137 for these services is a minimum of nine services furnished over a 7 -continguous day period. These services are described in  410.67(b)(ix) in the definition of OTP intensive outpatient services. A minimum of nine OTP intensive outpatient services, regardless of the length or time duration of these services, meets the threshold to bill, including if services of the same type are furnished more than once a week as long as all ser vices are medically reasonable and necessary for the treatment of OUD. However, an OTP may not count an intensive outpatient program service for the purposes of the nine -service threshold if that same service is being used to qualify for billing other week ly bundles and add- on codes under the OTP benefit. Additionally, to bill HCPCS code G0137, a physician or non-physician practitioner (as defined in section 1842(b)(18)(C) of the Act) must certify that the individual has a need for a minimum of nine hours of services per week and requires a higher level of care intensity compared to other non- intensive outpatient OTP services. A physician or non-physician practitioner, as permitted by state law and scope of practice requirements, must also meet requirements for certification, plan of treatment, and recertification requirements as set forth in  424.24(d)(1) through (3)  for the purposes of furnishing OTP intensive outpatient services.   30.3 - Non-drug episode of care  (Rev. 4524: Issued; 02- 14-20: Effective; 01 -01-20: Implementation: 03 -16-20)