evekhm/cms_iom_500 huggingface dataset:
(Medicare Program Integrity Manual)
Pursuant to 42 CFR 489.21, a provider of services shall not charge a beneficiary for services that have been denied for the reasons stated above.   3.2.3.2 - Time - Frames for Submission  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated.   In certain circumstances, the MACs, CERT, SMRC, RACs, UPICs and other contractors may not be able to make a determination on prepayment or post -payment claims they have chosen for review based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF). In those instances, the reviewer shall solicit documentation from the provider or supplier by issuing an ADR.   Contractors are authorized to collect medical do cumentation by the Social Security Act (the Act).   Section 1815(a) of the Act states that "no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period."   Section 1833(e) of the Act states that "[n]o payment shall be made to any provider of services or other person under this part unless there has bee n furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."   In addition, Contractors are required to ensure that payment is limited to those items and services that are reasonable and necessary.   Section 1862(a)(1)(A) of the Act states that [n]otwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services   which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body m ember.
(Medicare Program Integrity Manual)
Contractors are required, when authoring correspondence related to ADRs, to cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation.  A. Prepayment Review Time Frames   When requesting  documentation for prepayment review, the MACs and UPICs shall notify providers when they expect documentation to be received. The reviewer should not grant extensions to providers who need more time to comply with the re quest. Reviewers shall deny claims when the  requested documentation to support payment is not received by the expected timeframe.  B. Post-payment Review Time Frames   When requesting  documentation for post -payment review, the MACs, CERT, SMRC, UPICs and RACs shall notify  providers when they expect documentation to be received. MACs, CERT, SMRC, UPICs and RACs have the discretion to grant extensions to providers who need more time to comply with the request.   The MACs, CERT, SMRC, UPICs and RACs shall deny cla ims when the requested documentation to support payment is not received by the expected timeframe (including any applicable extensions) .  C. For esMD  submissions   The esMD  review contractor shall use the Enterprise File Transfer (EFT) system receipt date as the date the documentation was received. If the EFT receipt date is outside of the contractors normal business hours, the following business day shall be used as the rec eipt date. Contractors shall pull for esMD files at least every 4 hours (business hours) daily; including a mandatory pulling between the hours of 6- 7pm EST daily. If unforeseeable circumstances occur, in which contractors are not technically capable of re trieving documentation in a timely manner due to issues outside of their control, contractors are to notify the esMD Team and can use the date documentation was available to be retrieved once issues have been resolved in the EFT system.    3.2.3.3 - Third -party Additional Documentation Request  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, CERT and UPICs, as indicated.
(Medicare Program Integrity Manual)
This section applies to MACs, RACs, CERT and UPICs, as indicated.   Unless otherwise specified, the MAC, RAC and UPIC shall reques t information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and UPIC.   The CERT reviewer shall request medical record documentation from the referring provider as submitted/identified by National Provider Identifier/Unique Physician Identification Number on the claim when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentati on necessary to support the service billed and supported by the Local and National Coverage Determinations.  The MAC, UPIC and RAC have the discretion to send a separate ADR to third-  party entities involved in the beneficiarys care. They shall not solici t documentation from a third party unless they first or simultaneously solicit the same information from the billing provider or supplier. The following requirements also apply:    The MACs, UPICs and RACs shall notify the third party and the billing provide r or supplier that they have 30 calendar days to respond for a prepayment review or 45 calendar days for a postpayment review for MACs and RACs and 30 calendar days for  UPICs.    For prepayment review, the MACs and UPICs shall pend the claim for 45 calendar days. This 45 day time period may run concurrently as the 45 days that the billing provider or supplier has to respond to the ADR  letter;    The MACs and UPICs have the discretion to issue as many reminder notices as they deem appropriate to the third party via email, letter or phone  call prior to the 30th or 45th calendar day, as discussed  above;    When information is requested from both the billing provider or supplier and a third party and a response is received from one or both that fails to support the medical necessity of the service, the MACs and UPICs shall deny the claim, in full or in part, using the appropriate denial code. Contractors shall  count these denials as medical record  reviews.
(Medicare Program Integrity Manual)
 Contractors shall include language in the denial notice remi nding providers that beneficiaries cannot be held liable for these denials unless they received proper liability notification before services were rendered, as detailed in CMS Pub.100-  04, Medicare Claims Processing Manual, chapter  30.   Refer to3.2.3.7 for ADR to ordering providers for lab services.     3.2.3.4 - Additional Documentation Request Required and Optional Elements  (Rev. 557, Issued: 11- 26-14, Effective: 12 -29-14, Implementation: 12- 29-14)  This section applies to Medicare Administrative Contractors ( MAC), Recovery Auditors, Comprehensive Error Rate Testing ( CERT), and Supplemental Medical Review Contractors ( SMRC), as indicated.    The MAC shall use discretion to ensure that the amount of medical documentation requested does not negatively impact the providers ability to provide care.    The Recovery Auditors shall issue Additional Documentation Requests (ADR) in accordance with limits established by their Contracting Officers Representative (COR) for each calendar year.    The MACs, CERT, SMRCs, and Recovery Auditors, shall request records related to the claim(s) being reviewed and have the discretion to collect documentation related to the beneficiarys condition before and after a service.    The MACs, Recovery Auditors, and SMRCs have the discretion to issue as many reminder notices as they deem appropriate.  Reminder notices can  be issued via email, letter, or phone call.    The CERT shall issue reminder notices in accordance with its SOW.    The MACs, Recovery Auditors, and S MRCs shall not target their ADRs to providers based solely on the providers electronic health record status or chosen method of submitting records.
(Medicare Program Integrity Manual)
 The MACs, Recovery Auditors, and S MRCs shall not target their ADRs to providers based solely on the providers electronic health record status or chosen method of submitting records.  When requesting documentation for postpayment medical review, the MACs, CERT, SMRCs and Recovery Auditors shall use the unified postpayment ADR letter format. Contractors shall maintain the format of the letter, but have the discretion to insert case -specific information. In other words, contractors shall not change the order of the sections on the letter, but  should modify the text underneath each section to provide detailed information and accurately reflect the information specific to the subject of the letter. The detailed text in the Exhibit 46 templates serves only to provide an example of what types of information belong under each section heading. The templates show the format and order contractors shall use when constructing postpayment ADR letters.   If any of the elements are lengthy, contractors have the discretion to utilize an attachment to provide  the details. If a contractor does not have attachments, but has supplementary information to provide in the text of the letter, the contractor should insert the text beneath the section title Attachments / Supplementary Information).   The MACs, CERT, S MRCs and Recovery Auditors shall include the following elements in their ADRs and shall use the appropriate templates provided in Exhibit 46:   A. Introductory Paragraph   CMS as the government agency making the request;   The program making the request (e.g. the MAC program, the SMRC program, the Recovery Audit Program, the CERT program); and  The regulations and/or laws that apply to the request.  The first paragraph in the ADR may identify the following:   The program purpose;   Where additional information about the program and regulations can be found, for example, a website reference; and   Additional program information that may be helpful to the provider or supplier.  B. Reason for Selection   The reason the provider or supplier was sent the ADR le tter and notes about the claims under review.   C. Action  The action(s) the provider or supplier shall take as a result of receiving the ADR letter.   D. When  The date a provider/supplier shall reply to the ADR letter and submit the documentation to the contractor.   E. Consequences  The consequences if the provider or supplier fails to submit the requested documentation.
(Medicare Program Integrity Manual)
E. Consequences  The consequences if the provider or supplier fails to submit the requested documentation.   F. Instructions  Instructions and notes that will help the provider or supplier respond to the ADR letter.   G. Submission Methods  The methods the provider or supplier can submit the requested documentation.   H. Questions  Contractor contact information for provider inquiries related to the ADR.   I. Attachments / Supplementary Information   If there are attachments or other supplementary info rmation associated with the ADR, provide a listing of the attachment titles or provide the supplementary information.  3.2.3.5 - Acceptable Submission Methods for Responses to ADRs  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, Recovery Auditors, CERT, and UPICs, as indicated.   Reviewers shall be clear in their ADR letters about what documentation submission methods they will accept from a provider or Health Information Handler (HIH). The MACs, CERT, and Recovery Auditors shall accept documents via paper, fax, CD/DVD, and electronic submission of medical documentation (esMD).   A. Paper   The MACs, CERT, and Recovery Auditors are encouraged to state in the ADRs that paper medical documentation c an be mailed by any means including US Postal Service, FedEx, UPS, or certified mail. To facilitate delivery of documentation, MACs, CERT and Recovery Auditors should provide a physical mailing address instead of a P.O. Box.  B. Fax  If the MACs, CERT, or Recovery Auditors have the capability to offer fax confirmation, they are encouraged to send such confirmations with every successfully received fax.   C. Imaged Medical Documentation File(s) Sent on  CD/DVD   The MACs and CERT shall state in the ADR that imaged medical documentation files on CD/DVD may be mailed by any means. Recovery Auditor ADRs shall provide a Web site link or phone number that provides information regarding the requirements for submitting imaged documentation on CD or DVD.   D. Medical Documentation Sent via Electronic Submission of Medical Documentation (esMD) Transmission   Electronic Submission of Medical Documentation (esMD) is a system that allows providers/HIHs to submit medical documentation over secure electronic means. Information about the esMD system can be found at www.cms.gov/esMD.
(Medicare Program Integrity Manual)
Electronic Submission of Medical Documentation (esMD) is a system that allows providers/HIHs to submit medical documentation over secure electronic means. Information about the esMD system can be found at www.cms.gov/esMD.   MACs and CERT are encouraged to state in their ADRs how providers can get more information about submitting medic al documentation via the esMD mechanism.   Any time a new esMD service or document type is being offered, and any contractor wants to publish a public announcement (Web posting, list serve, tweet, etc.) the contractor must clear the announcement with CMS.  3.2.3.6 - Reimbursing Providers and HIHs for Additional Documentation  (Rev.  786, Issued: 04-13-18, Effective: 05-14-18, Implementation: 05-14-18)   A. General   1. Rules  for MACs,  SMRC,  CERT,  and UPICs    The MACs,  SMRC,  CERT,  and UPICs  are not required  to pay for medical  documentation for either  prepayment or post payment review.   2. Rules  for RACs    RACs  performing  post payment review  of hospital inpatient prospective payment system  (PPS)  and long term  care facilities  are required  to pay the providers for submitting requested  medical  records.  RACs  shall  pay according to  the payment  rate schedule listed  in section  B below.    RACs  performing  post payment review  of provider types other than  hospital inpatient PPS and  long term  care facilities  are required  to pay the providers for submitting  requested  medical  records,  according to  the payment rate schedule listed  in section  B below.    Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records.    RACs shall pay a maximum of $15.00 per record, including first class postage if applicable, for requested documents submitted via mail/fax/CD/DVD.    RACs shall pay a maximum of $27.00 per record, including a transaction fee of $2.00/case, for requested documents submitted via esMD.   Payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.
(Medicare Program Integrity Manual)
 Payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.    RACs shall issue documentation submission payments on at least a monthly basis and shall issue all photocopying payments within 45 calendar days of receiving the documentation.  RACs shall honor all requests from providers to issue photocopying payments to HIHs. RACs should gather, from the provider, all necessary information, such as, the HIHs name, phone number and bank routing number, etc.   Providers interested in submitting documentation via esMD can find information on the CMS esMD website at http://www.cms.gov/esMD.   B. Payment Schedule  for Requested  Medical  Records    Hospital  Inpatient  Prospective  Payment  System  (PPS)  Facilities   and Long  Term  Care  Facilities  Non-PPS Institutions  and Practitioners  Documentation  sent via mail,  fax, CD/DVD  - 12 cents per page - Plus first class postage, if applicable  - $15.00 maximum per record  - 15 cents  per page  - Plus first  class  postage, if  applicable  - $15.00 maximum per  record   Documentation  sent via esMD  - 12 cents per page  - Plus $2.00 transaction fee, per record  - $27.00 maximum per record  - 15 cents per page  - Plus $2.00 transaction  fee, per case - $27.00 maximum per record    *Note: Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records. Also, payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.   3.2.3.7 - Special Provisions for Lab Additional Documentation Requests  (Rev. 10365; Issued : 10-02-20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, RACs, UPICs, and SMRC as indicated.   ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided upon implementation of ICD -10. ICD -9-CM is used for discharges and other services before that implementation.
(Medicare Program Integrity Manual)
ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided upon implementation of ICD -10. ICD -9-CM is used for discharges and other services before that implementation.   When the MACs, CERT, RACs, and UPICs send an ADR for a lab service, the following documentation shall be requested from the billing lab:   The order for the service billed (including sufficient information to allow the reviewer to identify and contact the ordering provider);   Verification of accurate processing of the order and submission of the claim; and   Diagnostic or other medical information supplied to the lab by the ordering provider, including any diagnosis codes or narratives.   The contractor shall deny the claim if a benefit category, statutory exclusion, or coding issue is in question, or send an ADR to the ordering provider in order to determine medical necessi ty. The contractor shall review information from the lab and find it insufficient before the ordering provider is contacted. The contractor shall send an ADR to the ordering provider that shall include sufficient information to identify the claim in question.  If the documentation received does not demonstrate that the service was reasonable and necessary, the contractor shall deny the claim. These denials count as medical record reviews. Contractor denial notices shall remind providers that beneficiaries cannot be held liable for these denials unless they have received proper liability notification before services were rendered, as detailed in CMS Pub. IOM 100-04, chapter 30.  3.2.3.8 - No Response or Insufficient Response to Additional Documentation Reques ts (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated.   A. Additional Documentation  Requests
(Medicare Program Integrity Manual)
This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated.   A. Additional Documentation  Requests   The reviewer authority to request that documentation be submitted, to support claims payment, is outlined in Section 3.2.3.2 of this chapter.  If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following an extension), the MACs, RACs, SMRC, and UPICs shall deny the claim, in full or in part, as not reasonable and necessary. Contractors shall use Group Code:  CO -  Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 -  these are non -covered services because this is not deemed a medical necessity by the payer  and Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for this service.   MACs shall count these denials as automated review or non- medical reco rd review depending whether the denial is automated or requires manual intervention. For claims that had a PWK modifier, and the unsolicited documentation was reviewed, the review shall be counted as medical record review .  B. No Response   During prepayment r eview, if no response is received within the expected timeframes, the MACs and UPICs shall deny the claim.   During post -payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary. These contractors shall cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation, when denying claims for no response within the expected timeframes. The MACs shall count these denials as non- medical record reviews .  C. Insufficient  Response   If the MAC, CERT, RAC, SMRC, or UPIC requests additional documentation to verify compliance with a benefit category requirement, and the submitted documentation lacks evidence that the benefit category requirements were met, the reviewer shall issue a benefit category denial. If the submitted documentation includes defective information (the documentation does not support the physicians ce rtification), the reviewer shall deny the claim as not meeting the reasonable and necessary criteria.
(Medicare Program Integrity Manual)
3.2.3.9 - Reopening Claims with Additional Information or Denied due to Late or No Submission of Requested Information  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  Contractors shall make available general reopening process information via their website, in their ADR letters, or through remittance advice notices.  If the MACs receive the requested information from a provide r or supplier after a denial has been issued but within a reasonable number of days (generally 15 calendar days after the denial date), they have the discretion to reopen the claim. MACs who choose to reopen a specific claim shall notify the provider or supplier of their intent to reopen that claim. Notification to the provider/supplier of the intent to reopen a specific claim shall be completed through any of the following mechanisms: Interactive Voice Response (IVR), contractor website portal, telephone c ontact, by letter, fax, email or secure messaging within 3 business days of identification of the request to reopen or receipt of medical record documentation. MR will make an MR determination on the lines previously denied due to failure to submit request ed documentation, and do one of the following, within 60 calendar days of receiving documentation in the mailroom:    For claims originally selected for postpayment review, the reviewer shall issue  a new letter containing the revised denial reason and the information required by PIM chapter 3 3.6.4;    For claims originally selected for prepayment review, the MAC shall enter the revised MR determination into the shared system, generating a new Medicare Summary Notice (MSN) and remittance advice with the new denial reason  and appeals  information;    The workload, costs, and savings associated with this activity shall be allocated to the appropriate MR activity (e.g., MR  reopenings);