evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Valid codes for RNHCI claims:   3 Elective   The beneficiary's condition permitted adequate time to schedule the availability of a suitable accommodation.   9 Information   Self-explanatory   Not Available   Point of Origin for Admission   Required -  The RNHCI must enter the code indicating the beneficiarys point of origin.  The RNHCI may use any valid point of origin code that applies to the particular admission.  Patient Discharge Status   Required -  The RNHCI must enter the code indicating the patient's status as of the "Through" date of the billing period. The RNHCI may use any valid patient status code that applies to the discharge.  Condition Codes   Conditional -  The RNHCI may enter any number of condition codes to describe conditions that apply to the billing period.  If the RNHCI is submitting an adjustment or a cancellation claim, an applicable condition code from the claim change reason series ( D0 through D9 or E0) must be used.   If non -covered days are reported because the beneficiarys inpatient benefits were exhausted, the RHNCI must indicate whether the beneficiary elects to use lifetime reserve days.  The RNHCI must indicate lifetime reserve days are used on the claim by repor ting condition code 68.  If the beneficiary elects not to use lifetime reserve days, the RNHCI must report condition code 67.   Occurrence Codes and Dates   Conditional -  The RNHCI may enter any number of occurrence codes and their associated dates to define specific event(s) relating to this billing period.  Occurrence codes are 2 alphanumeric digits, and are reported with a corresponding date.  If non -covered days are reported due to days not falling under the guarantee of payment provision, the RNHCI reports occurrence code 20.   If non -covered days are reported because the beneficiarys inpatient benefits were exhausted, the RNHCI reports occurrence code A3.  Occurrence Span Code and Dates   Conditional -  The RNHCI may enter any number of occurrence span codes and their associated dates to define specific event(s) relating to this billing period.  Occurrence span codes are 2 alphanumeric digits, and are accompanied by from and through dates for the period described by the code.   If non -covered days are reported because the beneficiary was on a leave of absence and was not in the RNHCI, the RNHCI reports occurrence span code 74.
(Medicare Claims Processing Manual)
Document Control Number (DCN)   Conditional -  The RNHCI must complete this field on adjustment requests (Bill Type, FL 4 = 417).  An RNHCI requesting an adjustment to a previously processed claim must insert the ICN/DCN of the claim to be adjusted.   Value Codes and Amounts   Required -  The RNHCI must report utilization days using the value codes described below.   Covered Days - The RNHCI must use value code 80 to enter the total number of covered days during the billing period, including lifetime reserve days elected for which Medicare payment is requested.  Covered days exclude any days classified as non -covered, the day of discharge, and the day of death.   Covered days are always in terms of whole days rather than fractional days.  As a result, the covered days do not include the day of discharge, even where the discharge was late.   The RNHCI does not deduct any days for payment made under workers' compensation, automobile medical, no- fault, liability insurance, or an EGHP for an ESRD beneficiary or employed beneficiaries and spouses age 65 or over.  The specialty contractor will calc ulate utilization based upon the amount Medicare will pay and will make the necessary utilization adjustment.   Non-covered Days -  The RNHCI must use value code 81 to enter the total number of non-covered days in the billing period for which the beneficiary will not be charged utilization for Part A services.  Non -covered days include:    Days not falling under the guarantee of payment provision.  See section 40.1. E.    Days not approved by the utilization review committee when the beneficiary does not meet the need for Part A services;    Days for which no Part A payment can be made because benefits are exhausted.  This means that either lifetime reserve days were exhausted or the beneficiary elected not to use them.    Days for which no Part A payment can be made because the services were furnished without cost or will be paid for by the VA.  (Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 16, section 50);    Days after the date covered services ended, such as non- covered level of care;    Days for which no Part A payment can be made because the beneficiary was on a leave of absence and was not in the RNHCI.  See section 40.2.6;
(Medicare Claims Processing Manual)
 Days for which no Part A payment can be made because the beneficiary was on a leave of absence and was not in the RNHCI.  See section 40.2.6;    Days for which no Part A payment can be made because an RNHCI whose provider agreement has terminated may only be paid for covered inpatient services during the limited period following such termination.  All days after the expiration of this period are non -covered.  See Pub. 100- 01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, section 10.6.4;   The RNHCI enters in "Remarks" a brief explanation of any non- covered days not described in the occurrence codes.  Show the number of days for each category of non-covered days (e.g., "5 leave days").   Day of discharge or death is not counted as a non- covered day.  All hospital inpatient rules for billing non- covered days apply to RNHCI claims.  Coinsurance Days  - The RNHCI must use value code 82 to enter the number of covered inpatient days occurring after the 60th day and before the 9lst day for this billing period.  Lifetime Reserve Days  - The RNHCI must use value code 83 to enter the number of lifetime reserve days the beneficiary elected to use during this billing period.  Lifetime reserve days are not charged where the average daily charge is less than the lifetime reserve coinsurance amount.  The average daily charge consists of charges for all covered services furnished after the 90th day in the benefit period and through the end of the billing period.  The RNHCI must notify the beneficiary of their right to elect not to use lifetime reserve days before billing Medicare for services furnished after the 90th day in the spell of illness.  The determination to elect or withhold use of lifetime reserve days should be documented and kept on file at the provider.   Conditional -  The RNHCI may at their option enter any number of other value codes and related dollar amount(s) to identify data necessary for the processing of this claim.  Value codes are 2 alphanumeric digits, and a corresponding value amount.  Negative amounts are never shown.  If more than one value code is shown for a billing period, the RNHCI must show codes in ascending numeric sequence.   Revenue Code
(Medicare Claims Processing Manual)
Revenue Code   Required -  The RNHCI must enter the appropriate revenue codes to identify specific accommodation and/or ancillary charges.  This code takes the place of fixed line item descriptions.  The 4- digit numeric revenue code on the adjacent line explains each char ge.  The following revenue codes and associated descriptions are used where there are charges billed as covered by Medicare:   Code  Description   0001 Total Charges   0120 Semi -Private Room   0270  Supplies (non- religious, as covered by Medicare)   Any other revenue codes may be submitted with non- covered charges only.   Additionally, there is no fixed "Total" line in the charge area.  On paper claims, the RNHCI must enter revenue code "000l" to report a total of the charges on the claim.   The RNHCI should list revenue codes other than revenue code 0001 in ascending numeric sequence and should not repeat revenue codes on the same claim to the extent possible.  Units of Service   Required -  The RNHCI must enter the number of days for accommodations revenue codes.   Accommodation days are always in terms of whole days rather than fractional days.  The accommodation days do not include the day of discharge, even where the discharge was late.  Where a charge was made because the beneficiary remained in the RNHCI after checkout time for his own convenience, it is a non- covered charge and you can bill the beneficiary if that is your usual practice and if the beneficiary is given proper notice of their liability.  In this instance, the RNHCI will enter the additional charge  in non- covered charges.   Total Charges   Required -  The RHNCI must sum the total charges (covered and non- covered) for the billing period by revenue code and enter them on the adjacent line.  On paper claims, the last revenue code entered in revenue code "000l" represents the grand total of all c harges billed.  For all lines, the total charges minus any associated non- covered charges represent the covered charges.   Each line allows up to 9 numeric digits (0000000.00).  When submitting charges (covered/non- covered):
(Medicare Claims Processing Manual)
Each line allows up to 9 numeric digits (0000000.00).  When submitting charges (covered/non- covered):    Medicare is restricted by law and court order from paying for the religious portion of care or the training of personnel that provide that care.  Additionally Medicare does not pay either based on charges or costs for training of nonmedical personnel.  RNHCIs do not receive full Medicare payment for a beneficiarys stay since the beneficiary is fiscally responsible for the religious aspects of care.  Therefore, the original Medicare or Medicare health plan rate may be significantly lower than the RNHCI priv ate pay rate that includes religious charges.    As medical procedures are not performed in a RNHCI, the use of high cost medical supplies are not separately payable.  Supplies that require a physician order (e.g., specialty dressings, compression stockings, alternating pressure mattress pads) are not se parately payable in a RNHCI.  The use of diapers, incontinence pads, chux/underpads, feminine hygiene products, tissues, and the materials for simple dressings (cleansing and bandaging) are included in the daily room and board portion of the charges and should not be reported separately as supplies.   Medical equipment (e.g., wheelchair, walker, crutches) are institution inventory items for beneficiary use in the RNHCI.  The use of these items during the beneficiary stay is part of the daily interim payment to the RNHCI.  To receive Medicare payment for  durable medical equipment (DME) following a RNHCI stay, a beneficiary would need to meet all of the criteria, including medical necessity, and obtain a physician order or prescription.  A RNHCI is not authorized as a Medicare supplier and, therefore, may not offer DME items for purchase to beneficiaries.    Nonmedical nursing personnel, for Medicare payment purposes, perform services (e.g., serving meals, assisting with activities of daily living) that are strictly nonmedical/non- religious.  The statute and court order mandates only the coverage and payment under Part A for reasonable and necessary nonmedical/non- religious care.
(Medicare Claims Processing Manual)
 Medicare payment for religious/nonmedical nursing personnel in a RNHCI, as other inpatient facilities, is a component of the per diem rate and is not separately payable.   Non-Covered Charges   Required -  The RHNCI must enter the total non- covered charges pertaining to the related revenue code, if any (e.g., religious items/services or religious activities performed by nurses or other staff, or convenience items that are not part of the Medicare daily interim payment rate.)   Examples of non -covered charges:    Non-covered religious items include but are not limited to religious publications, religious recordings, any equipment for the use of those recordings, any reproduction costs for these materials, and attendance at religious meetings.    Religious sessions with RNHCI staff or outside associates.   Expenses related to student programs/subsistence, staff education/training, travel, or relocation to be factored into the development of charges for covered patient care services.    Stays, items, and services that are not substantiated by appropriate documentation in the beneficiarys utilization review file or care record.    Convenience items (e.g., telephone, computer, beautician/barber).   Payer Identification   Required -  If Medicare is the primary payer, the RNHCI must enter "Medicare" on line A.  If Medicare is entered, this indicates that the RNHCI has developed for other insurance and has determined that Medicare is the primary payer.   All additional entries across line A supply information needed by the payer named.  If Medicare is the secondary or tertiary payer, the RNHCI may identify the primary payer on line A and enter Medicare information on line B or C as appropriate.   National Provider Identifier   Required -  The RNHCI enters their National Provider Identifier (NPI).   During Medicare processing, the NPI is matched to the RHNCIs CMS Certification Number (CCN).  RNHCI CCNs are composed of a 2 -digit state code and a 4 -digit provider identifier in the range 1990- 99.
(Medicare Claims Processing Manual)
Insureds Unique Identification  Required -  On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown, the RNHCI must enter the beneficiary's Medicare Health Insurance Claim Number.  The RNHCI must show the number as it appears on the  beneficiary's Medicare Card, Certificate of Award, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, or as reported by the Social Security Office.   Principal Diagnosis Code   Required -  While coding of a principal diagnosis is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA.  To satisfy this requirement on claims with Statement Covers Through dates before implementation of ICD -10, the RNHCI may report ICD -9 code 799.9 (defined other unknown and unspecified cause).  To satisfy this requirement on claims with Statement Covers Through dates on or after the implementation of ICD -10, the RNHCI may report ICD -10 code R69 (defined illness, unspecified).   Other Diagnosis Codes   Required -  While coding of diagnoses is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA.  To satisfy this requirement on claims with Statement Covers Through dates before the implementation of ICD -10, the RNHCI may report ICD -9 code V62.6 (defined refusal of treatment for reasons of religion or conscience).  To satisfy this requirement on claims with Statement Covers Through dates on or after the implementa tion of ICD -10, the RNHCI may report ICD -10 code Z53.1 (defined procedure and treatment not carried out because of patient's decision for reasons of belief).   The RNHCI reports no additional diagnosis codes in the remaining fields.  Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.    The RNHCI reports no additional diagnosis codes in the remaining fields.  Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.   Attending Provider
(Medicare Claims Processing Manual)
The RNHCI reports no additional diagnosis codes in the remaining fields.  Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.   Attending Provider   Required -  While the participation of an attending provider is not consistent with the nonmedical nature of RNHCI services, reporting an attending provider is a requirement for claims transactions under HIPAA.  To satisfy this requirement, the RNHCI must r eport the name and NPI of their director of nursing.   Remarks   Conditional -  The RNHCI may enter any remarks needed to provide information that is not shown elsewhere on the bill but which is necessary for proper payment.   Provider Representative Signature and Date  Required -  If using the hard copy claim, an RNHCI representative makes sure the claim record is complete and accurate before signing Form CMS -1450.  A stamped signature is acceptable on Form CMS -1450.  170.3 - RNHCI Claims Processing By the Medicare Contractor with RNCHI Specialty Workload  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  Upon submission of a claim for RNHCI services, the contractor ensures that the submission contains the complete set of required data elements according to the instructions in 170.2.  The specialty contractor ensures that the submission does not contain da ta that is invalid, internally inconsistent or is not otherwise submitted in error.  If the submission is not found to be consistent with CMS instructions, it is returned to the RNHCI for correction.
(Medicare Claims Processing Manual)
Once the claim is found to satisfy CMS instructions, the contractor ensures the claim is not a duplicate of previously paid RNHCI services or does not demonstrate grounds for Medicare denial for any other reason.  If the claim appears appropriate for payment based on the specialty contractors initial processing, the claim is submitted to the CMS Common Working File (CWF) for approval.  The CWF system compares the claim submitted by the contractor to the eligibility and utilization data for the beneficiary that received the services.  The CWF ensures the beneficiary is eligible for Part A for the dates of service (since RNHCI services are exclusively a Part A benefit) and the beneficiary has utilization days remaining in their current inpatient spell of illness.  The CWF also compares the RNHCI claim to the beneficiarys file of RNHCI elections and claims.  If CWF does not identify any err or conditions on the RNHCI claim, an approval message is returned to the specialty contractor.   An RNHCI claim may be rejected by CWF if:    No RNHCI election period is present for the dates of service of the claim;    The RNHCI election period to which the claim would apply has been revoked (see section 180 for procedures that lead to revocation of the election);   The RNHCI election period to which the claim would apply has been cancelled; or   The service dates on the claim overlap previously paid claims for RNCHI services or other inpatient services that were processed by a Medicare contractor other than the specialty contractor.   Claims rejected for these reasons may not be corrected and returned by the RNHCI.  If the error condition can be resolved (for instance, by the resubmission of an election period cancelled in error), the RNHCI may submit a new original claim for the services.
(Medicare Claims Processing Manual)
Upon receipt of payment approval or rejection from CWF, the contractor may then process the claim to completion.  RNHCI claims are paid a daily interim rate as established for each RNHCI provider under TEFRA payment rules (see Pub. 15-2, Provider Reimbursement Manual, chapter 30).  The contractor makes RNHCI payments subject to the inpatient hospital cash deductible when applicable and, if services are for the 61st through 90th day of a benefit period or are for lifetime reserve days, subject to coinsurance (see Pub. 100- 01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Sections 10.1 and 10.2).  170.3.1 - RNHCI Claims Not Billed to Original Medicare  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Health Plans   A beneficiary covered by a Medicare Advantage plan (e.g., Medicare health maintenance organization, preferred provider organization, competitive medical plan or other health care prepayment plans.) must have prior authorization from their plan before admission to a RNHCI to assure payment for a specified time period.  Continued stay reviews must be performed, submitted, and approved at designated intervals identified by the plan to assure coverage by the Medicare health plan.   In the case of billing a Medicare health plan, the RNHCI charges for inpatient services should not exceed the established interim TEFRA per diem payment amount available under Medicare Part A.  The Medicare health plan may obtain the current TEFRA per diem  rate information by calling the specialty contractor responsible for the involved RNHCI.   Medicaid   The State agency may obtain the current Medicare rate information by calling the Medicare contractor responsible for the RNHCI.   170.4 - Informing Beneficiaries of the Results of RNHCI Claims Processing  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)
(Medicare Claims Processing Manual)
170.4 - Informing Beneficiaries of the Results of RNHCI Claims Processing  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Beneficiaries are informed of all Medicare payment determinations, including those for RNHCI services, via their monthly Medicare Summary Notice (MSN).  The complete set of messages used on the MSN can be found in chapter 21, section 50.42 of this manual.  The Medicare contractor with RHNCI specialty workload uses special messages on MSNs to reflect determinations specific to the RNHCI benefit.    If an RNHCI claim is denied because CWF did not find record of an RNHCI election in the beneficiaries record, the contractor uses MSN message 42.3.  This message reads: This service is not covered since you did not elect to receive religious nonmedical he alth care services instead of regular Medicare services.    If an RNHCI claim is denied because CWF found record of an RNHCI election in the beneficiarys record that had been revoked in writing, the contractor uses MSN message 42.5.  This message reads: This service is not covered because you requested in writing that your election to religious nonmedical health care services be revoked.   If an RNHCI claim is denied because CWF found record of an RNHCI election in the beneficiarys record that had been revoked because the beneficiary received nonexcepted medical care, the contractor uses MSN message 42.4.  This message reads: This service is not covered because you received medical health care services which revoked your election to religious nonmedical health care services.  180 - Processing Claims For Beneficiaries With RNHCI Elections by Contractors Without RNHCI Specialty Workloads  (Rev. 11963, Issued:04 -20-23, Effective: 10-01-23, Implementation, 10-02-23)