evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
(a). Contents  Each directory has two parts. Part I shows the correct Specialty, Name, Address and Telephone Number of each participating Physician, Supplier and Group by geographic area.  The address in the directory must be the address of the physician's/supplier's place of business and not a Post Office box number.  Part II includes only the name and telephone number of all Physicians, Suppliers and Groups contained in Part I listed in alphabetic sequence.  Telephone numbers may not be omitted.  Edit the listings to assure that everyone listed in Part I is also listed in Part II (multiple addresses may be included if appropriate); physicians are listed only once by name in Part II.  When you have only the group name for participating group practices, you may list the names of physician(s) within the group, but only at the group's request.  For groups which so request, list the physicians under the group name in alphabetical sequence.  Indicate an individual physician's specialty if it differs from other specialties.  Show only the group address and telephone number. ( NOTE:   A group practicing physician who also has solo practices may appear more than once if he is participating in more than on entity.)  Do not list the names of hospital based physicians.  Where a beneficiary would not have personal choice access to a group, (e.g., the group accepts patients by referral only), list only the group name and address. Note that it accepts patients by referral only.   If a physician or supplier has multiple service locations, accommodate this in the directories to the extent possible with the information on the provider file and information obtained during the participation enrollment process.  List all independent RHCs in your area, not necessarily jurisdiction, in the MEDPARD. They are required to accept Medicare payment on claims as payment in full and, therefore, meet the acceptance criteria for a MEDPARD listing even though a participating agreement has not been signed.  Do not group independent RHCs with physicians in the directory.  List them separately on a full or partial page under the wording shown below.  Show the name, address and telephone number of each.  Treat the RHC as a group and list only the clinic name and telephone number in Part II of the MEDPARD (the alphabetical listing).  Use an indicator so the beneficiary can distinguish between a group and a RHC.  The following wording must appear above the list of independent RHCs:
(Medicare Claims Processing Manual)
Rural Health Clinics (RHCs) agree to accept payment by the Medicare program as full payment for their services, except for the applicable deductible and coinsurance amounts for which the beneficiary is responsible.  The independent RHCs in the area are li sted below:   (b). Organization (Geographic, Physician/Supplier/Group, Alphabetic)   Prepare a separate MEDPARD for each geographic area, e.g., depending upon size, one for each metropolitan area or one for each county or group of counties.  Your plan must be submitted to RO for approval prior to production.  Divide each MEDPARD into two parts.   Divide Part I first alphabetically by geographical location. Within each location, list each specialty. Under the specialty, alphabetically list Physicians, Suppliers and Groups with their addresses and telephone numbers.  Include optometry and podiatry as  specialties and not as suppliers.  Add lay terminology to all specialty headings, e.g., ophthalmology (eye disease), so that they are easily understood by the beneficiary.  Do not list any "miscellaneous" or "unknown" specialties.  These should default to "General Practice" or "Other."   Part II is a straight alphabetical listing of all Physicians, Suppliers and Groups in the directory, with their telephone numbers.  If a physician's or supplier's name and address are the same and listed more than once in Part I, list that individual only once in Part II.   (c). Paper, Print, Binding   Carriers with regional office prior authorization and advanced funding can prepare the MEDPARD in hardcopy (booklet) form on white offset book paper. Size the directory by the number of participating physicians/suppliers in your area.  Do not exceed 8 1/2 by 11 inches.  Use print comparable to 10 point type or larger which improves the readability of the directory.  Use type set print rather than computer listings.  Put all geographical location and specialty headings in bold, uppercase lettering.  Bind the directory in an attractive and distinctive cover which displays the red, white and blue emblem of the Medicare participating physician.  This emblem must show association with U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. clearly indicate on the front cover that this is a Medicare directory of participating physicians/suppliers.  Date the MEDPARD so that older editions will not be confused with subsequent ones.
(Medicare Claims Processing Manual)
The back cover should function as an envelope for the directory.  Put your name and return address in the upper left corner.  Reserve the upper right corner for 3rd class postage.  Use address labels, generated from your records of directory requests, to m ake the directory a self -mailer.   Carriers with regional office prior authorization and advanced funding for the MEDPARD in booklet form must produce it within 45 days following the close of the annual participation enrollment process.  (d). Interpretive Information  Each directory must have a Table of Contents.  Include detailed instructions on the organization of the directory.  Place your name and toll- free telephone number at the bottom of the instructions in the front of the directory.  Include detailed instructions on "how to use the directory," i.e., to locate a participating physician or supplier in a specific area:  first, find the correct county in the table of contents; second , look below the county for the city name and find the city's page number; third , turn to the appropriate page and look for the physician or supplier specialty you need; fourth , look for the names of physicians or suppliers in that specialty.  At the top of the instruction page, include the statement:  This directory contains the names, addresses, telephone numbers, and specialties of MEDICARE PARTICIPATING physicians and suppl iers.  MEDICARE PARTICIPATING physicians and suppliers have agreed to accept assignment on all Medicare claims for covered items and services.   (e). Dissemination of MEDPARD Information   Within your Medicare service area, inform the following groups how to access the MEDPARD on the carrier Web site:    Beneficiaries who request to view the MEDPARD; and    Physicians, suppliers, groups, and clinics listed in the directory who request to view the MEDPARD.   Within 30 days after the close of the annual participation enrollment period, carriers inform the following individuals/groups of the availability of their local MEDPARD on the carrier Web site:    Congressional offices;   Quality Improvement Organizations;   Senior citizen groups and other beneficiary advocacy organizations;   Social Security Offices;    State area agencies of the Administration on Aging; and   Hospitals.   If you receive inquiries from a customer who does not have access to your Web site, ascertain the nature and scope of each request and furnish the desired MEDPARD participation information via telephone or letter.   (f). Alternative Method
(Medicare Claims Processing Manual)
If you receive inquiries from a customer who does not have access to your Web site, ascertain the nature and scope of each request and furnish the desired MEDPARD participation information via telephone or letter.   (f). Alternative Method   You may produce the MEDPARD on diskettes or transmit it electronically.  Send alternative mediums to those entities or individuals who wish to receive them in forms other than paper.   Carriers add their local MEDPARDs to their Web sites and inform the various organizations who use the directory of its availability.  Publicize Web site MEDPARD access information at least annually in your regularly scheduled newsletters.  (g). Reporting Requirements   Carriers with regional office prior authorization and advanced funding for the MEDPARD in hardcopy form must maintain a record of all hardcopy directories that were distributed.  Submit an initial printing/distribution/cost report within 90 days after the close of the annual participation enrollment period.  Send the report to your RO and copy CO at the following address:   Director, Division of Practitioner Claims Processing  Centers for Medicare & Medicaid Services  7500 Security Blvd. Baltimore, MD 21244  Include the following information in your initial report: (1) the number of MEDPARDs initially printed; (2) the number of MEDPARDs distributed to each category in (e) above within 60 days after the close of the annual participation enrollment period; and (3) the cost per directory distributed (e.g., printing and distribution costs).  Submit a year end report no later than 45 days after the end of the fiscal year.  On the year end report, include the actual number of MEDPARDs printed and the number of MEDPARDs distributed to each category during the fiscal year.  Include the cost per directory distributed on your initial report and include an explanation as to the reason for the adjusted year end cost figure.   J.  Furnishing Participating Physician/Supplier Data to Railroad Retirement Board (RRB)   (a).  Furnishing RRB with participating information for the general enrollment period:   Within 30 days after the annual participation enrollment period has closed, all carriers must furnish their entire physician/supplier file.  The file is to be transmitted to RRB at the same time the MEDPARD is being posted on the carrier Web site.  Submit the file in the following format:  1.  File Specifications
(Medicare Claims Processing Manual)
Carriers send the Provider Participation File (PPF) via CD or cartridge to the RRB carrier.  Enter the external label for the file as follows:     FROM:    TO:   DATE:    DATA SET NAME:  Provider Participation File (PPF).   A. Header Type Specifications    Field  Position  Picture  Remarks/Field Value  1. Label  1-3 x (3)  "PPF"  2. Carrier No.  4-8 9 (5)  Carrier number assigned by CMS.  3. Date File Updated  9-14 x (6)  MMDDYY   B. Detail Record Specifications. --   Field  Position  Picture  Remarks/Field Value  1. TIN/EIN  1-9 9 (9)  Tax identification number used to report income (1099).  2. UPIN  10-15 x (6)  Unique Physician Identification Number.  If not available or applicable, fill with spaces.  3. Locality  16-17 x (2)  Locality or area designation associated with TIN/EIN.  4. Current Year Par Indicator  18 x (1)  Y = Par  N = Nonpar  5. Current Year of Practice  19 9 (1)  1 = First year  2 = Second year 3 = Third year 4 = Fourth year 5 = Established Provider  6. Carrier PIN  20-29 x(10)  The provider's carrier -assigned provider identification number.  7. Physician/Supplier Name  30-54 x (25)  Last Name = 14  First Name = 10  Middle Initial = 1      or Corporate Name = 25  The format for provider name is a total of 25 bytes.  Individual providers must have a comma between last name, first name, and middle initial (i.e., Smith, John, M).  Space one position between multiple words in corporate names (i.e., Jones Medical Supply).  8. Physician/Supplier Address  55-110 x (56)  Street Address = 30  City = 15 State Code = 2  Zip Code = 9 Space between numerics and words and space between multiple words.  Left justify ZIP Codes.  The first five ZIP Code spaces must be numeric and the last four spaces can either be numeric or spaces.  Separate street address, city and state with commas, e.g. , "1234 Security Boulevard, Baltimore,MD,567891234"
(Medicare Claims Processing Manual)
Carriers send the physician/supplier file to:  Attn:  Manager, Provider Enrollment  Palmetto GBA  Railroad Retirement Board  2743 Perimeter Pkwy  Building 200, Suite 400 Augusta, GA  30909   (b).  Furnishing RRB with participating information for other than the general enrollment period:   After furnishing an annual provider file, inform the RRB carrier, on a flow -basis, of all participating doctors, practitioners and suppliers who enroll after the annual general enrollment period.  Carriers send the RRB carrier copies of participation elect ion forms received from physicians, practitioners and suppliers who enrolled after the annual enrollment and, therefore, were not included on the provider file transmitted to the RRB carrier.  Transmit copies of such participation enrollment forms via cove r letter or fax.  Include the following information in your cover letter or fax cover sheet:    Tax Identification (TIN) or Employer Identification Number (EIN);    UPIN or NPI when required;    Locality designation associated with the TIN/EIN;    Current Year of Practice;    Carrier PIN or NPI when required; and    Participation Effective Date.   NOTE:   If any of the above information is entered/displayed on the participation agreement form being transmitted, you do not need to include that piece of information in your cover letter or you may state "see attached participation agreement" for that particu lar item of information.   Carriers send photocopy participation agreements by mail to:   Attn:  Manager, Provider Enrollment  Palmetto GBA  Railroad Retirement Board  2743 Perimeter Pkwy  Building 200, Suite 400 Augusta, GA  30909   For participation agreements transmitted via fax call (706) 855- 3049.   K.  Key Implementation Dates   A detailed schedule of key implementation dates will be provided in an annual temporary instruction in advance of receiving the MPFS Database file. The following outlines significant disclosure activities and anticipated implementation dates. A detailed sc hedule is provided under separate cover by CMS.   Carriers must:   October:    Download fee schedules   Download HCPCS  November:    Release participation materials and disclosure reports;   Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;  December:
(Medicare Claims Processing Manual)
Carriers must:   October:    Download fee schedules   Download HCPCS  November:    Release participation materials and disclosure reports;   Furnish yearly physician fee schedule amounts to CMS for carrier priced codes;  December:    Furnish DMEPOS fee schedule and physician fee schedules to State Medicaid Agencies;   Furnish conversion factors and inflation indexed charge data to the carrier State Medicaid Agencies;   Process participation elections and withdrawals; and,  Send a complete fee schedule to the State medical societies and State beneficiary associations.  January:    Implement annual fee schedule amounts;   Implement annual HCPCS update;   Send an updated provider file to the Railroad Retirement Board; and   Load MEDPARD equivalent information on the carrier Web site.   February:    Submit participation counts to CMS Central Office via CROWD.   30.3.12.1.2 - Annual Medicare Physician Fee Schedule File Information  (Rev. 2799, Issued: 10- 25-13, Effective: 01 -01-14, Implementation: 01- 06-14)  The CMS transmits the annual Medicare Physician Fee Schedule (MPFS) file electronically for carriers/MACs to download each year around late -October.  The annual MPFS files (including anesthesia) are effective January 1st.  Carriers/MACs must implement these files each January, unless otherwise directed by CMS.   NOTE:   There will be an annual recurring change request for the implementation of the yearly Medicare Physician Fee Schedule Files.   The CMS will advise all contractors, via email notification, when annual MPFS files are available for download from the mainframe.  Carriers/MACs can retrieve the new files and begin the process of testing and loading the new fees into the system.  Carrier s/MACs must place the new fees, including the anesthesia conversion factor(s), on their Web site after the MPFS final rule is placed on display. (The CMS will send notification of when the MPFS final rule is put on display via email.)   In addition, there may be last minute corrections, therefore you may have to retrieve one or more MPFS corrected files. Notification of the availability of any correction files, including the file names, will be made via an email to Carriers and MACs.
(Medicare Claims Processing Manual)
In addition, there may be last minute corrections, therefore you may have to retrieve one or more MPFS corrected files. Notification of the availability of any correction files, including the file names, will be made via an email to Carriers and MACs.   30.3.12.2 - Carrier/MACs Participation Agreement  (Rev. 2221, Issued: 05- 20-11, Effective: 05 -20-11, Implementation: No later October 31, 2011)    MEDICARE  PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT   Name(s) and Address of Participant*   National Provider Identifier (NPI)*    *List all names and the NPI under which the participant files claims with the Medicare Administrative Contractor (MAC)/carrier with whom this agreement is being filed.   The above named person or organization, called the participant, hereby enters into an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment unde r the Medicare law and regulations and which are furnished while this agreement is in effect.   1.  Meaning of Assignment  - For purposes of this agreement, accepting assignment of the Medicare Part B payment means requesting direct Part B payment from the Medicare program. Under an assignment, the approved charge, determined by the MAC/carrier , shall be the full charge for the service covered under Part B. The participant shall not collect from the beneficiary or other person or organization for covered services more than the applicable deductible and coinsurance.   2.  Effective Date  - If the participant files the agreement with any MAC/carrier  during the enrollment period, the agreement becomes effective _____________________.  3.  Term and Termination of Agreement -  This agreement shall continue in effect through December 31 following the date the agreement becomes effective and shall be renewed automatically for each 12 -month period January 1 through December 31 thereafter unless one of the following occurs:   a. During the enrollment period provided near the end of any calendar year, the participant notifies in writing every MAC/carrier  with whom the participant has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the end of the current term. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calendar year, the agreement shall end on December 31 of that year.
(Medicare Claims Processing Manual)
b. The Centers for Medicare & Medicaid Services may find, after notice to and opportunity for a hearing for the participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is made, the Centers for Medicare & Medicaid Services will notify the participant in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement.    __________________________  Signature of participant  (or authorized representative  of participating organization)  _________________________  Title  (if signer is authorized  representative of organization)  _________  Date  Office phone number (including area code)_____________________  Received by    (name of carrier)  Effective date _____________   30.3.12.3 - Carrier Rules for Limiting Charge  (Rev. 1, 10- 01-03) B3-17002  Effective January 1, 1991, the maximum allowable actual charge (MAAC) for non-participating physicians is replaced by the limiting charge. The limiting charge is the maximum that the non -participating provider may charge the beneficiary.  It also effectively replaces  the special charge limits for overpriced procedure, anesthesia associated with cataract and iridectomy surgery, A -mode ophthalmic ultrasound and intraocular lenses (IOLs, and designated specialty, because the limiting charge is always less than  or equal to the special charge limits.   The limiting charge applies to all of the following services/supplies, regardless of who provides or bills for them, if the services/supplies are covered by the Medicare program and are provided:    Physicians services;    Services and supplies furnished incident to a physicians services that are commonly furnished in a physicians office;    Outpatient physical therapy services furnished by an independently practicing physical therapist;    Outpatient occupational therapy services furnished by an independently practicing occupational therapist;    Diagnostic tests; and    Radiation therapy services (including x- ray, radium, and radioactive isotope therapy, and materials and services of technicians).
(Medicare Claims Processing Manual)
 Outpatient occupational therapy services furnished by an independently practicing occupational therapist;    Diagnostic tests; and    Radiation therapy services (including x- ray, radium, and radioactive isotope therapy, and materials and services of technicians).   NOTE:  This means that, effective for services/supplies provided on or after January 1, 1994, the limiting charge applies to drugs and biologicals provided incident to Initials of carrier official__________   According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 -0373. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244 -1850.  physicians services, to physical therapy services provided by independently practicing physical therapists, and to occupational therapy services provided by independently practicing occupational therapists. These changes are made because of provisions in OBRA 1993. OBRA 1993 expanded the limiting charge to apply to services/supplies which the law permits Medicare to pay for under the physician fee schedule methodology but which Medicare has chosen to pay for under some other method. Incident to drugs and biologicals, previously excluded from the limiting charge because of their exclusion from physician fee schedule payment, are, effective January  1, 1994, still excluded from physician fee schedule payment but subject to the limiting charge. Also, OBRA 1993 applies the limiting charge to all of the above listed services/supplies, regardless of who provides or bills for the services/supplies. No longer are services of suppliers and other nonphysicians, such as physician assistants, nurse midwives, and indepe ndently practicing physical and occupational therapists, excluded from the limiting charge.   Physicians, non- physician practitioners, and suppliers must take assignment on claims for drugs and biologicals furnished on or after February 1, 2001, under 114 of the Benefits Improvement and Protection Act (BIPA).