evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The RO provides information as to the overall success of the complaint validation and referral procedure including the extent of cooperation among CMS, OIG, State Insurance Departments, and the U.S. Attorneys.  This information will be used to correct or strengthen existing procedures.  This report should be submitted by the 15th of the month following the report quarter.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11939CP  04/05/2023  Process Improvements for the National Coordination of Benefits Agreement (COBA) Detailed Error Reporting Notification Process  07/06/2023  13154  R10638CP  03/09/2021  Modernization of the Electronic Files Transfer (EFT) Associated with the National Coordination of Benefits Agreement (COBA) Crossover Process 04/05/2021  12053  R10559CP  01/20/2021  Modernization of the Electronic Files Transfer (EFT) Associated with the National Coordination of Benefits Agreement (COBA) Crossover Process - Rescinded and replaced by Transmittal  10638 04/05/2021  12053  R4281CP  04/19/2019  Update to Chapter 28 in Publication (Pub.) 100-04 to Provide Language-Only Changes for the New Me dicare Card Project  05/20/2019  11261  R4243CP  02/15/2019  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  04/01/2019  10961  R4160CP  11/02/2018  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process - Rescin ded and replaced by Transmittal 4243  04/01/2019  10961  R4157CP  11/02/2018  Hospital and Critical Access Hospital (CAH) Swing -Bed Manual Revisions and Shared Systems Changes 04/01/2019  10961  R4069CP  06/08/2018  Alignment of Coordination of Benefits Agreement (COBA) Internet Only Manual References  07/09/2018  10737  R3714CP  02/03/2017  Changes to the National Coordination of Benefits Agreement (COBA) Crossover 07/03/2017  9885  Rev #  Issue Date  Subject  Impl Date  CR#  Process as a Result of the Social Security Number Removal Initiative (SSNRI)  R3004CP  08/01/2014  Modification to the National Coordination of Benefits Agreement (COBA) Crossover Process  01/05/2015  8731 R2906CP  03/14/2014  Pub
(Medicare Claims Processing Manual)
Number Removal Initiative (SSNRI)  R3004CP  08/01/2014  Modification to the National Coordination of Benefits Agreement (COBA) Crossover Process  01/05/2015  8731 R2906CP  03/14/2014  Pub 100-04, Chapter 28 language-only update for ASC X12 version 5010, implementation of MACs, and MAC coordination with Medigap, Medicaid and Other Complementary Insurers 04/14/2014  8540 R2904CP  03/14/2014  Pub 100-04, Chapter 28 language-only update for ASC X12 version 5010, implementation of MACs, and MAC coordination with Medigap, Medicaid and Other Complementary Insurers 04/14/2014  8540 R2810CP  11/07/2013  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  04/07/2014  8454 R2569CP  10/26/2012  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  04/01/2013  8071 R2215CP  05/13/2011  Modifications to the COBA Process for Other Federal Payer Payment Order and Other Issues  10/03/2011  7393 R2189CP  04/04/2011  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process Stemming Principally From the Affordable Care Act (ACA)  04/04/2011  7136 R2181CP  03/25/2011  Medicare Claims Processing Pub. 100-04 Chapter 24 Update for HIPAA 5010 and EDI Enhancements 04/25/2011  7269 R2090CP  11/10/2010  Implementation of Errata for Version 5010 of Health Insurance Portability and 04/04/2011  7202  Rev #  Issue Date  Subject  Impl Date  CR#  Accountability Act (HIPAA) Transactions, and Updates in 837I, 837P, and 835 Flat Files  R2087CP  11/05/2010  Implementation of Errata for Version 5010 of Health Insurance Portability and Accountability Act (HIPAA) Transactions, and Updates in 837I, 837P, and 835 Flat Files  Rescinded and replaced by Transmitta l 2090 04/04/2011  7202 R2076CP  10/28/2010  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  Stemming Principally From the Affordable Care Act (ACA)
(Medicare Claims Processing Manual)
replaced by Transmitta l 2090 04/04/2011  7202 R2076CP  10/28/2010  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  Stemming Principally From the Affordable Care Act (ACA)   Rescinded and replaced by Transmittal 2189 04/04/2011  7136 R1920CP  02/19/2010  Modifications to Gap- Filling Requirements for the Health Insurance Portability Accountability Act (HIPAA) 837 version 5010 Coordination of Benefits (COB) Claims Transactions and National Council for Prescription Drug Programs (NCPDP) Version D.0 Claim Files  07/06/2010  6816 R1844CP  11/06/2009  Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Process 04/05/2010  6658 R1841CP  10/29/2009  National Council for Prescription Drug Programs (NCPDP) Version D.0. Coordination of Benefits (COB) Requirements for the National C laims Crossover Process 04/05/2010  6664 R1727CP  05/01/2009  Coordination of Benefits Agreement (COBA) Repair and Claims Recovery Requirements Stemmin g from the Health 10/05/2009  6420  Rev #  Issue Date  Subject  Impl Date  CR#  Insurance Portability and Accountability Act (HIPAA) 5010 Claims Transactions R1720CP  04/24/2009  Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) 837 5010 Coordination of Benefits (COB) Requirements --Part II  07/06/2009  6374 R1704CP  03/20/2009  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover 07/06/2009 and 10/05/2009  6343 R1640CP  11/21/2008  Modifications to the National Coordination of Benefits Agreement (COBA) Process  04/06/2009  6234 R1568CP  08/01/2008  Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12- N 837 version 5010 Changes Necessary for Coordination of Benefits (COB) and other Coordination of Benefits Agreement (COBA) Process Revisions  01/05/2009  6103 R1507CP  05/16/2008  Coordination of Benefits Agreement (COBA) and Affiliate National Provider Identifier
(Medicare Claims Processing Manual)
of Benefits (COB) and other Coordination of Benefits Agreement (COBA) Process Revisions  01/05/2009  6103 R1507CP  05/16/2008  Coordination of Benefits Agreement (COBA) and Affiliate National Provider Identifier (NPI) Process Modifications  10/06/2008  6024 R1497CP  05/02/2008  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  07/07/2008  6037 R1436CP  02/05/2008  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  Replaced by Transmittal 1497 07/07/2008  5866 R1420CP  01/25/2008  Clarification Regarding the Coordination of Benefits Agreement (COBA) Medigap Claim- Based Crossover Process  02/01/2008  5837 R1332CP  08/31/2007  Transitioning the Mandatory Medigap (Claim Based) Crossover Process to the 10/01/2007  5601  Rev #  Issue Date  Subject  Impl Date  CR#  Coordination of Benefits Contractor (COBC)  R1296CP  07/18/2007  Modifications to the National Coordination of Benefits Agreement (COBA) Crossover Process  10/01/2007  5569 R1282CP  07/06/2007  Medicare Contractors Use of the Coordination of Benefits Agreement (COBA) Problem Inquiry Request Form and Send COBA Related Issues  to the COB Contractor 08/06/2007  5656 R1242CP  05/18/2007  Transitioning the Mandatory Medigap (Claim Based) Crossover Process to the Coordination of Benefits Contractor (COBC)  10/01/2007  5601 R1232CP  04/27/2007  Modification to the Coordination of Benefits Agreement (COBA) Crossover Process - Replaced by Transmittal 1296 10/01/2007  5569 R1189CP  02/28/2007  Differentiating Mass Adjustments From Other Types of Adjustments and Claims for Crossover Purposes and Revising the Detailed Error Report Special Provider Notification Letters  Replaced by Transmittal 1189  07/02/2007  5472 R1179CP  02/02/2007  Differentiating Mass Adjustments From Other Types of Adjustments and Claims for Crossover Purposes and Revising the Detailed Error Report Special Provider Notification Letters  Replaced by Transmittal 1189  07/02/2007  5472 R1110CP  11/09/2006  Excluding Sanctioned Provider Claims from the Coordination of Benefits Agreements (COBA) Crossover Process
(Medicare Claims Processing Manual)
Revising the Detailed Error Report Special Provider Notification Letters  Replaced by Transmittal 1189  07/02/2007  5472 R1110CP  11/09/2006  Excluding Sanctioned Provider Claims from the Coordination of Benefits Agreements (COBA) Crossover Process  04/02/2007  5353  Rev #  Issue Date  Subject  Impl Date  CR#  R1038CP  08/25/2006  COBC Sending Copy of Trading Partner's Eligibility File to Medicare Contractor for Use in Recovery Process  01/02/2007  5250 R1006CP  07/21/2006  Modification to the Coordination of Benefits Agreement (COBA) Claims Selection Criteria and File Transfer Protocols  10/02/2006  5094 R967CP  05/26/2006  Modification to the Coordination of Benefits Agreement (COBA) Claims Selection Criteria and File Transfer Protocols  10/02/2006  5094 R837CP  02/03/2006  Coordination of Benefits Agreement (COBA) Full Claim File Repair Process  07/03/2006  4277 R666CP  09/02/2005  Updates to the Coordination of Benefits Contractor (COBC) Detailed Error Report File Layouts 10/03/2005  4042 R586CP  06/17/2005  Modification to the National Coordination of Benefits Agreement (COBA) File Transfer and Financial Reporting Processes 10/03/2005  3906 R474CP  02/11/2005  Detailed Error Report Notification Process to COBA Partners  07/05/2005  3709 R448CP  01/21/2005  Timeframe for Execution of Crossover Agreements and Update on the Transition to the National Coordination of Benefits Agreement (COBA ) Program  02/22/2005  3658 R250CP  07/23/2004  Update of CWF Procedures 01/03/2005  3404 R158CP  04/30/2004  Transition to Medicare Coordination of Benefits Contractor (COBC) 10/04/2004  3273 R138CP  04/09/2004  Transition to Medicare Coordination of Benefits Contractor (COBC)  07/06/2004  3218 R098CP  02/06/2004  Transition to Medicare Coordination of Benefits Contractor (COBC)  07/06/2004  3109  Rev #  Issue Date  Subject  Impl Date  CR#  R001CP  10/01/2003  Initial Publication of Manual NA NA Back to top of Chapter
(Medicare Claims Processing Manual Crosswalk)
Medicare Claims Processing Manual  Chapter 28 - Coordination With Medigap, Medicaid, and Other Complementary Insurers Crosswalk Chap.                                                 Sect. Int.Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. ROOffice  Manual Description 28 10 B3-4700 Medigap - Definition and Scope 28 20 B3-4702,B3-3047    Assignm ent of Claim s and Transfer Policy  28 20.1 B3-4702.1,B3-3047, B4-2110.1    Beneficiary  Insurance Assignm ent Selection 28 30 B1-2010,B3-4702 A-01-20,A-01-63  Com pletion of the Claim  Form  28 30.1 B1-2010,B3-4702 A-01-20,A-01-63  Form  CMS-1500 (ANSI X12N 837 COB (Version 4010)) 28 30.2 A3-3604  HO-460   UB-92 (Form  CMS-1450) 28 40 B3-4703 AB-99-3,AB-01-155 MSN Messages28 50 B3-4704 AB-99-3,B-01-35, A-01-57  Rem ittance Notice Messages 28 60  B3-4705  AB-99-3  Returned Medigap Notices  Chap. Sect. Int.  Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. RO  Office  Manual Description 28
(Medicare Claims Processing Manual Crosswalk)
Chap. Sect. Int.  Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. RO  Office  Manual Description 28                          70 A1-1601,A3-3768 - A3-3769 B1-4607, B3-4701, B3-4706    Coordination of Medicare with Medigap and Other Com plementary  Health Insurance Policies 28 70.1 A1-1600-A1-1602.5, A3-3768, A3-3769  B1-4600 - B14602.5, B3-10010    Authorization for Release of Inform ation 28 70.1.1      Requests for Additional Inform ation 28 70.1.2   HO-91.3   Release of Title XVIII Claim s Inform ation for Medigap Insurance Purposes by  Providers 28 70.2 A3-3769     Integration of Title XVIII Claim s Processing with Com plementary  Insurance Claim s Processing 28 70.2.1 Program  Recognition28 70.2.2 A3-3769C Records and Inform ation28 70.2.3 A3-3769D     Matching Files Against Medicare Claim s Files 28 70.3 A1-1600 B1-4601    Standard Medicare Charges for COB Records 28 70.4  B1-4607    General Guidelines for Interm ediary  or Carrier Transfer of Claim s Inform ation to Medigap Insurers 28 70.5 A1-1601C B1-4601 Audits Chap. Sect. Int.  Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. RO  Office  Manual Description 28
(Medicare Claims Processing Manual Crosswalk)
Chap. Sect. Int.  Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. RO  Office  Manual Description 28                                             80 B3-4707 A-01-20,A-01-63, B-01-06  Electronic Transm ission - General Requirem ents 28 80.1 A-01-20 HIPPA Provisions  Affecting Medigap Transactions 28 80.2      ANSI X12N 837 COB (Version 4010) Transaction Fee Collection 28 80.3 B3-4709,B4-2110.1    Medigap Electronic Claim s Transfer Agreem ents 28 80.3.1 A-01-20,A-02-069,  A-02-077,  A-02-078,  AB-02-20  Interm ediary  Crossover Claim  Requirem ents 28 80.3.2 B-01-32,B-01-06  Carrier/DMERC Crossover Claim  Requirem ents 28 90 B3-4708 Paper Subm ission28 100 A-00-23 RO-2700 Mediga p Insurers Fraud Referral 28 110 RO-2700 Medigap Crim inal Penalties/Ty pes of Com plaints under Subsection 1882(d) 28 110.1     RO-2700 Outline of Com plaint Referral Process  Chap. Sect. Int.  Pub.13. Carrier Pub. 14 HO Pub. 10 P.M. RO  Office  Manual Description 28 110.2                 RO-2700 Prelim inary  Screen ing and Referral to Regional Office of the Inspector General 28 110.3     RO-2700 CMS Regional Office Quarterly  Report on Medicare Supplem ental Health Insurance Penalty  Provision Activity  28 110.3.1 RO-2700 Statistics28 110.3.2 RO-2700 Narrative
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual            Chapter 29 - Appeals of Claims Decisions            Table of Contents              (Rev. 12423; Issued:  12-20-23)  Transmittals for Chapter 29
(Medicare Claims Processing Manual)
110 -  Glossary  200 -  CMS Decisions Subject to the Administrative Appeals Process  210 -  Who May Appeal  210.1 -  Provider or Supplier Appeals When the Beneficiary is Deceased  220 -  Steps in the Appeals Process:  Overview  230 -  Where to Appeal  240 -  Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals  240.1 -  Good Cause  240.2 -  Conditions and Examples That May Establish Good C ause for Late Filing by B eneficiaries 240.3 -  Conditions and Examples That May Establish Good Cause for Late Filing by  Providers, Physicians or Other Suppliers  240.4 -  Good Cause   Administrative Relief Following a Disaster  240.5 -  Procedures to Follow When a Party Fails to Establish Good Cause  250 -  Amount in Controversy (AIC) Re quirements 250.1 -  Amount in Controversy General Requirements  250.2 -  Principles for Determining Amount in Controversy  250.3 -  Aggregation of Claims to Meet the Amount in Controversy 260 -  Parties to an Appeal  270 -  Appointment of Representative  270.1 -  Appointment of Representative - Introduction 270.1. 1 - Who May  be an Appoin ted or Authorized Representative 270.1.2 -  How to Make and Re voke a n App ointment 270.1.3 -  When and Where to Submit the A ppoin tment 270.1.4 -  Rights and Respons ibilities of a Representative 270.1.5 -  Duration of Appointment 270.1.6 -  Curing a D efective Ap pointment of Representative 270.1.7 -  Incapacitation or Death of B eneficiary 270.1.8 -  Disclosure of Indi vidually Identifiable Beneficiary Inf ormation t o an Ap pointed Representative 270.2 -  Assignment of Appeals Rights  270.2.1 -  Assignment of Appeal Rights -  Introduction 270.2.2 -  Who May be an Assignee  270.2.3 -  How to Make and Revoke a Transfer of Appeal Rights  270.2.4 -  When to Submit the Transfer of Appeal Rights  270.2.5 -  Where to Submit the Transfer of Appeal Rights  270.2.6 -  Rights of the Assignee of Appeal Rights  270.2.7 -  Duration of Transfer of Appeal Rights  270.2.8 -  Curing a Defective Transfer of Appeal Rights  270.2.9 -  Disclosure of Indi vidually Identifiable Beneficiary Inf ormation t o Assignees  270.3 -
(Medicare Claims Processing Manual)
Duration of Transfer of Appeal Rights  270.2.8 -  Curing a Defective Transfer of Appeal Rights  270.2.9 -  Disclosure of Indi vidually Identifiable Beneficiary Inf ormation t o Assignees  270.3 -  Medicare Secondary Payer (MSP) Specific Limitations or Additional Requirements with  Respect to the Appointment of Representatives  280 -  Fraud and Abuse  280.1 -  Fraud and Abuse - Authority 280.2 -  Inclusion and Consideration of Evidence of Fraud and/or Abuse  280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed  280.4 -  Responsibilities of Adjudicators  280.5 -  Requests to Suspend the Appeals Process  280.6 -  Continuing Appeals of Providers, Physicians, or Other Suppliers Who Are Under Fraud or Abuse Investigations  280.7 -  Appeals of Claims Involving Excluded Providers, Physicians, or Other Suppliers  290 -  Guidelines for Writing Appeals Correspondence  290.1 -  General Guidelines  290.2 -  Letter Format  290.3 -  How to Establish Reading Level  290.3.1 -  Writing in Plain Language  290.4 -  Required Elements in Appeals Correspondence  300 -  Disclosure of Information 300.1 -  General Information  300.2 -  Disclosure of Information to Third Parties  300.3 -  Fraud and Abuse Investigations  300.4 -  Medical Consultants Used 300.5 -  Appeal Decision Involving M ultiple Bene ficiaries 310 -  Redetermination -  The First Level of Appeal  310.1 -  Filing a Request for Redetermination  310.2 -  Time Limit for Filing a Request for Redetermination  310.3 -  Reporting Redeterminations on the Appeals Report  310.4 -  The Redetermination  310.5 -  The Redetermination Decision  310.6 -  Dismissals  310.6.1 -  Dismissal Letters 310.6.2 -  Model Dismissal Notices
(Medicare Claims Processing Manual)
310.6.3  Processing Request to Vacate Dismissals     310.7 -  Medicare Redetermination N otice (For Pa rtly or Fully Unfavorable Redeterminations) 310.8 -  Medicare Redetermination N otice (for Fully Favorable Redeterminations) 310.9 -  Effect of the Redetermination  310.10 -  System and Processing Requirements for Use of Secure Internet Portal/Application to Support Appeals Activities  310.11 -  Effectuation of the Redetermina tion Decision 310.12 - QIC R emands 320 -  Reconsideration -  The Second Level of Appeal  320.1 -  Filing a Request for a Reconsideration  320.2 -  Time Limit for Filing a Request for a Reconsideration  320.3 -  MAC  Responsibilities -  General  320.4 -  QIC Case File Development  320.5 -  QIC Case File Preparation  320.6 -  Forwarding QIC Case Files  320.7 -  QIC Jurisdictions  320.8 -  Tracking Cases  320.9 -  Effectuation of Reconsiderations  330 -  Administrative Law Judge ( ALJ) Hearing or Attorney Adjudicator Review at Office of Medicare            Hearings and Appeals (OMHA) - The Third Level of Appeal  330.1 -  Requests for an ALJ H earing 330.2 -  Forwarding Requests to OMHA  330.3 -  Review and Effectuation of  OMHA D ecisions 330.4 -  Effectuation Time Limits & Responsibilities 330.5 -  Duplicate OMHA D ecisions 330.6 -  Payment of Interest on OMHA Decisions 340 -  Departmental Appea ls Board - Appeals Counc il - The Fourth Level of Appeal 340.1 -  Recommending Agency Referral of OMHA Decisions or Dismissals  340.2 -  Effectuation of Appeals Council Orders and Decisions  340.3 -  Requests for Case Files  340.4 -  Payment of Interest on Appeals Council Decisions  345 -  U.S. District Court Review -  The Fifth Level of Appeal  345.1 -  Requests for U.S. District Court Review by a Party 345.2 -  Effectuation of U.S. District Court Decisions  345.3 -  Payment of Interest of U.S. District Court Decisions  350 -  Workload Data Analysis 360 -  Managing Appeals Workloads  360.1 -  Standard Operating Procedures  360.2 -  Execution of Workload Prioritization 360.3 -  Workload Priorities
(Medicare Claims Processing Manual)
110 - Glossary  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Adjudicator  The entity responsible for making the decision at any level of the Medicare claim decision making process, from initial determination to the final level of appeal, on a specific claim.    Administrative Law Judge (ALJ)  Adjudicator employed by the Department of Health and Human Services (HHS), Office of Medicare Hearings and Appeals (OMHA) that holds hearings and issues decisions related to level 3 of the appeals process.    Affirmation -  A term used to denote that a prior claims determination has been upheld by the current claims adjudicator. Although appeals through the OMHA level are de novo, CMS and its contractors often use this term when an adjudicator reaches the same conclusion as  that in the prior determination, even though he/she is not bound by the prior determination.    Amount in Controversy (AIC) -  The dollar amount required to be in dispute to establish the right to a particular level of appeal.  Congress establishes the amount in controversy requirements.    Appeals Council  The Medicare Appeals Council (herein Appeals Council), a division within the  Departmental Appeals Board, provides the final level of administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment. (See also Departmental Appeals Board.)    Appellant -  The term used to designate the party (i.e., the beneficiary, provider, supplier, or other person showing an interest in the claim determination) or the representative of the party that has filed an appeal.  The adjudicator determines if a particular appellant is a proper party or representative of a proper party.    Applicable plan   Applicable plan means liability insurance (including self -insurance), no- fault insurance, or a workers' compensation law or plan.    Appointed representative  The individual appointed by a party to represent the party in a Medicare claim or claim appeal.    Assignee  (1) With respect to the assignment of a claim for items or services, the assignee is the supplier who has furnished items or services to a beneficiary and has accepted a valid assignment of a claim;    OR