evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
40.3.2.1  Payment for C apped Rental Items  (Rev.  3593, Issued: 08- 17-16, Effective: 10- 01-16, Implementation: 10- 03-16)  For rented, grandfathered equipment in the capped rental payment class (e.g., CPAP device or manual wheelchair), after the rental payment cap for the grandfathered equipment and after the rental payment cap on the accessory (when applicable, e.g., elevating leg rests) is reached, the beneficiary must obtain covered accessories and supplies (e.g., CPAP masks) only from a contract supplier.  The supplier of the grandfathered equipment is no longer permitted to furnish the covered accessories and supplies once the rental payment cap on the grandfathered equipment is reached, with the exception of completing the rental period for accessories whose first month rental began during the rental period for the grandfathered equipment (e.g., the addition of elevating leg rests during the third rental month for a grandfathered manual wheelchair).   40.3.2.2  Payment for Inexpensive or Routinely Purchased Items (Rev.  3593, Issued: 08- 17-16, Effective: 10- 01-16, Implementation: 10- 03-16)  For rented, grandfathered equipment in the inexpensive or routinely purchased payment class, after the total payments for the rented, grandfathered equipment (e.g., folding walker) rea ch the purchase fee schedule amount for the grandfathered equipment and after the rental payment cap on the accessory (when applicable), the beneficiary must obtain covered accessories (e.g., seat attachment) and supplies only from a contract supplier.  The supplier of the grandfathered equipment is no longer permitted to furnish the covered accessories and supplies once the capped rental payment cap on the equipment is reached, with the exception of completing the rental period for accessories whose first month rental began during the rental period for the grandfathered equipment.  40.3.3 - Accessories and Supplies for Grandfathered Items  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)
(Medicare Claims Processing Manual)
Accessories and supplies that are used in conjunction with and are necessary for the effective use of a grandfathered item may be furnished by the same grandfathered supplier that furnishes the grandfathered item.  Examples of medically necessary accessori es and supplies used in conjunction with DMEPOS items include tubes, hoses, and masks with respiratory equipment and administration sets with infusion pumps.  Payment for these items to a grandfathered supplier is based on the single payment amount if the item is a competitive bid item for the CBA in which the beneficiary maintains a permanent residence (see 36.40.1 of chapter 20 in this manual).  If the item is not a competitive bidding item, payment will be made in accordance with the standard payment rules.   40.4 - Payment for Rental of Inexpensive or Routinely Purchased DME  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The monthly rental payment amounts for inexpensive or routinely purchased DME (identified using HCPCS modifier RR) are equal to 10 percent of the single payment amount established for purchase of the item.   40.5 - Payment for Oxygen and Oxygen Equipment  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The monthly payment amounts for oxygen and oxygen equipment are equal to the single payment amounts established for the following classes of items:    Stationary oxygen equipment (including stationary oxygen concentrators) and oxygen contents (stationary and portable)    Portable equipme nt only (gaseous or liquid tanks)    Oxygen generating portable equipment (OGPE) only (used in lieu of traditional portable oxygen equipment/tanks)    Stationary oxygen contents (for beneficiary -owned stationary liquid or gaseous equipment)    Portable oxygen contents (for beneficiary -owned portable liquid or gaseous equipment)   In cases where a supplier is furnishing both stationary oxygen contents and portable oxygen contents, the supplier is paid both the single payment amount for stationary oxygen contents and the single payment amount for portable oxygen contents.  The payment amounts for purchase of supplies and accessories used with beneficiary -owned oxygen equipment are equal to the single payment amounts established for the supply or accessory.
(Medicare Claims Processing Manual)
40.5.1 - Change in Suppliers for Oxygen and Oxygen Equipment  (Rev.  3953, Issued: 01- 19-18, Effective: 07 -01-18, Implementation: 07- 02-18)  The following rules apply when the beneficiary switches from one supplier of oxygen and oxygen equipment to another supplie r after the beginning of each round of competitive bidding:   Noncontract supplier to contract supplier   In general, monthly payment amounts may not exceed a period of continuous use of longer than 36 months.  However, if the beneficiary switches from a noncontract supplier to a contract supplier before the end of the 36- month period, at least 10 monthly payment amounts would be made to a contract supplier that begins furnishing oxygen and oxygen equipment in these situations provided that medical necessity for oxygen continues.   For example, if a contract supplier begins furnishing oxygen equipment to a beneficiary in months 2 through 26, payment would be made for the remaining number of months in the 36-month period, because the number of payments to the contract supplier would be at least 10 payments.  To provide a more specific example, a contract supplier that begins furnishing oxygen equipment beginning with the 20th month of continuous use would receive 17 payments (17 for the remaining number of months  in the 36- month period).  However, if a contract supplier begins furnishing oxygen equipment to a beneficiary in month 27 or later, no more than 10 monthly payments would be made assuming the oxygen equipment remains medically necessary.   Contract supplie r to another contract supplier  This rule does not apply when a beneficiary switches from a contract supplier to another contract supplier to receive his/her oxygen and oxygen equipment. In this scenario, the new contract supplier is paid based on the sing le payment amount for the remaining number of months in the 36-month period assuming the oxygen equipment remains medically necessary.   Grandfathered item where there was a noncontract to contract supplier switch in a prior round
(Medicare Claims Processing Manual)
Grandfathered item where there was a noncontract to contract supplier switch in a prior round   This rule does not apply  to grandfathered items in subsequent competitive bidding rounds when there was a previous noncontract to contract supplier switch in the prior round and the same supplier has elected to continue furnishing the oxygen equipment.  In this case, the grandfat hered supplier would be eligible to continue billing for the remaining number payments left in the oxygen rental period at the start of the competitive bidding round.  The maximum number of monthly rental payments may not exceed 45 rental payments.    40.6 - Payment for Capped Rental DME Items (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The monthly rental payment amounts for capped rental DME (identified using HCPCS modifier RR) are equal to 10 percent of the single payment  amount established for purchase of the item for each of the first 3 months and 7.5 percent of the single payment amount established for purchase of the item for months 4 through 13.   40.6.1 - Change in Suppliers for Capped Rental DME Items (Rev. 1532, Issued: 06 -11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The following rules apply when the beneficiary switches from one supplier of capped rental DME to another supplier after the beginning of each round of competitive bidding:   Noncontract supplier to contract supplier
(Medicare Claims Processing Manual)
The following rules apply when the beneficiary switches from one supplier of capped rental DME to another supplier after the beginning of each round of competitive bidding:   Noncontract supplier to contract supplier   In general, rental payments may not exceed a period of continuous use of longer than 13 months.  However, if the beneficiary switches from a noncontract supplier to a contract supplier before the end of the 13- month rental period, a new 13- month period begins and payment is made on the basis of the single payment amounts described in section 40.6. The contract supplier that the beneficiary switches to is responsible for furnishing the item until medical necessity ends, or the 13-month period of continuous use ends, whichever is earlier.  On the first day following the end of the new 13- month rental period, the contract supplier is required to transfer title of the capped rental item to the beneficiary.  Once the beneficiary switches from a noncontract supplier to a contract supplier, they may not switch back to a noncontract supplier if he/she continues to maintain a permanent residence in a CBA.  If, however, the beneficiary relocates out of the CBA to a non- CBA, then he/she may sw itch to a noncontract supplier and a new 13- month rental period does not begin. See section 40.3 for instructions for payment of grandfathered items.  Contract supplier to another contract supplier  If the beneficiary switches from a contract supplier to a  contract supplier before the end of the 13-month rental period, a new 13- month period does not begin.  This provision applies in situations where the beneficiary changes suppliers within a CBA and in situations where the beneficiary relocates and switches  from a contract supplier in one CBA to contract supplier in another CBA.  The contract supplier that the beneficiary switches to is responsible for furnishing the item until medical necessity ends, or the 13 -month period of continuous use ends, whichever is earlier.  On the first day following the end of the 13 -month rental period of continuous use, the contract supplier is required to transfer title of the capped rental item to the beneficiary.
(Medicare Claims Processing Manual)
40.7 - Payment for Purchased Equipment  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The payment amount for the purchase of new equipment (identified using HCPCS modifier NU), including inexpensive or routinely purchased DME, power wheelchairs, and enteral nutrition equipment, is equal to 100 percent of the single payment amounts established for these items.  This payment amount for the purchase of used equipment (identified using HCPCS modifier UE), including inexpensive or routinely purchased DME, power wheelchairs, and enteral nutrition equipment, is equal to 75 percent of the single payment amounts established for new purchase equipment items.  40.8 - Payment for Repair and Replacement of Beneficiary -Owned Equipment  (Rev.  3593, Issued: 08- 17-16, Effective: 10- 01-16, Implementation: 10- 03-16)  Beneficiaries who maintain a permanent residence in a CBA may go to any Medicare- enrolled supplier (contract or noncontract supplier) for the maintenance or repair of beneficiary -owne d equipment, including parts that need to be replaced in order to make the equipment serviceable.  Labor to repair equipment is not subject to competitive bidding and, therefore, will be paid in accordance with Medicares general payment rules.  Payment fo r replacement parts that are part of the competitive bidding program for the area in which the beneficiary resides is based on the single payment amount for that replacement part in the CBA in which the beneficiary lives.  Payment is not made for parts and labor covered under a manufacturers or suppliers warranty.
(Medicare Claims Processing Manual)
Beneficiaries must obtain replacements of beneficiary -owned competitively bid items that are part of the competitive bidding program for the areas in which the beneficiary resides from a contract supplier unless the item is a replacement part or accessory that is replaced as part of the service of repairing beneficiary -owned base equipment (e.g., wheelchair, walker, hospital bed, continuous positive pressure airway device, oxygen concentrator, etc.).  All base equipment that is replaced in its entirety because of a change in the beneficiarys medical condition or because the base equipment the beneficiary was using was either lost, stolen, irreparably damaged, or used beyond the equipments reasonable useful lifetime (see section 110.2.C of chapter 15 of the  Benefit Policy Manual) must be obtained from a contract supplier in order to receive Medicare payment.  The contract supplier is not required to replace an entire competitively bid item with the same make and model as the previous item unless a physician or treating practitioner prescribes that make and model.  (See section 30.4 of this chapter.).   If beneficiary -owned oxygen equipment or capped rental DME that is a competitively bid item for the CBA in which the beneficiary maintains a permanent residence  has to be replaced prior to end of its reasonable useful lifetime, then the replacement item must be furnished by the supplier (contract or noncontract supplier) that transferred ownership of the item to the beneficiary.   Payment for replacement of items that are part of the competitive bidding program for the area in which the beneficiary resides is based on the single payment amount for that item.  For additional information regarding payment of a part of a DMEPOS Item, please see Pub.100-04 chapter 20, section 50.5.  40.9 - Payment for Rental Enteral Nutrition Equipment  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The monthly rental payment amounts for enteral nutrition equipment (identified using HCPCS modifier RR) are e qual to 10 percent of the single payment amount established for purchase of the item for each of the first 3 months and 7.5 percent of the single payment amount established for purchase of the item for months 4 through 15.
(Medicare Claims Processing Manual)
40.9.1 - Maintenance and Servici ng of Enteral Nutrition Equipment  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The contract supplier that furnishes the equipment to the beneficiary in the 15th month of the rental period must continue to furnish, maintain, and service the equipment after the 15 month rental period is completed until a determination is made by the beneficiarys physician or treating practitioner that the equipment is no longer medically necessary.  The payment for maintenance and servicing enteral nutrition equipment is 5 percent of the single payment amount established for purchase of the item .  40.10 - Traveling Beneficiaries  (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation: 07-07-08)  Beneficiaries may travel, for example,  to visit family members or reside in a State with warmer climates during winter months. As a result, beneficiaries will need to consider the following three factors when traveling: (1) where to go to obtain a DMEPOS item; (2) identify whether the item is a competitively bid item or not; and (3) determine the Medicare payment amount for that item. Depending on where the beneficiary travels (whether to a CBA or a non-CBA), the beneficiary may need to obtain DMEPOS from a contract supplier in order for Medica re to cover the item.  For example, a beneficiary who travels to a non -CBA may obtain DMEPOS, if medically necessary, from any Medicare-enrolled supplier. On the other hand, a beneficiary who travels to a CBA should obtain competitively bid items in that C BA from a contract supplier in that CBA in order for Medicare to cover the item. The chart below shows whether a beneficiary should go to a contract supplier or any Medicare- enrolled supplier when the beneficiary travels.   Beneficiary Permanently Resides  Travels to  Type of Supplier  a CBA
(Medicare Claims Processing Manual)
Beneficiary Permanently Resides  Travels to  Type of Supplier  a CBA   a CBA  The beneficiary should obtain competitively bid items in that CBA from a contract supplier located in that CBA if the beneficiary wants Medicare to cover the item.  a non -CBA  Medicare will cover DMEPOS, if medically necessary, from any Medicare -enrolled DMEPOS supplier.  Non-CBA   a CBA  The beneficiary should obtain the competitively bid item from a contract supplier in the CBA if the beneficiary wants Medicare to cover the item.  Non-CBA  Medicare -enrolled DMEPOS supplier   Suppliers that furnish DMEPOS items to Medicare beneficiaries who maintain a permanent residence in a CBA and who travel to a non-CBA need to be aware of the public use files on the CBIC Web site at: http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home. The public use files contain the ZIP Codes for the CBAs, the HCPCS for competitively bid items, and the single payment amounts for these items. Suppl iers will be able to use these files to identify if the beneficiary traveling to the area maintains a permanent residence in a CBA, determine whether the beneficiary is obtaining a competitively bid item, and determine the single payment amount for those i tems.   The Medicare payment amount is always based on the location in which the beneficiary maintains a permanent residence. For example:   a. If a beneficiary maintains a permanent residence in a CBA and travels outside of the CBA, payment for a competitively  bid item for the CBA in which the beneficiary maintains a permanent residence is the single payment amount for that item in the beneficiarys CBA.   b. When a beneficiary maintains a permanent residence in an area that is not in a CBA and travels to CBA or non- CBA, the supplier that furnishes the item will be paid the fee schedule amount for the area where the beneficiary maintains a permanent residence.
(Medicare Claims Processing Manual)
40.10.1 - Traveling Beneficiaries and Transfer of Title of Oxygen Equipment or Capped Rental Items  (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation: 07-07-08)  If a beneficiary has two residences in different areas and uses a local supplier in each area or if a beneficiary changes suppliers during or after the rental period, this does not result in a new rental episode. The supplier that provides the item in the 36th month of a rental episode for oxygen equipment or the 13th month of a rental episode for capped rental DME is responsible for transferring title to the equipment to the beneficiary . This applies to snow bird or extended travel patients and coordinated services for patients who travel after they have purchased the item.   40.11 - Billing Procedures Related to Advance Beneficiary Notice (ABN) Upgrades under the Competitive Bidding Pr ogram  (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation: 07-07-08)  In general, an item included in a competitive bidding program must be furnished by a contract supplier for Medicare to make payment.  This requirement applies to situations where the item is furnished directly or indirectly as an upgrade.  An upgrade is an item with features that go beyond what is medically necessary.  An upgrade may include an excess component.  An excess component may be an item feature or service, which is in addition to, or is more extensive than, the item that is reasonable and necessary under Medicare coverage requirements.  An item is indirectly furnished if Medicare makes payment for it because it is medically necessary and is furnished as part of an upgraded item.   The billing instructions for upgraded equipment found in section 120 of chapter 20 of the Medicare Claims Processing Manual (Pub. 100 -04) continue to apply under the DMEPOS Competitive Bidding Program.   The following scenarios and chart des cribe situations where a beneficiary, residing in a competitive bidding area, elects to upgrade to an item with features or upgrades that are not medically necessary.    Upgrades from a bid item to a non- bid item  In this situation, Medicare payment will only  be made to a contract supplier on an assignment -related basis.  Medicare payment will be equal to 80 percent of the single payment amount for the medically necessary bid item.
(Medicare Claims Processing Manual)
 Upgrades from a non- bid item to a bid item  When upgrading from a non- bid to a bid item, Medicare payment is made to a contract supplier on either an assigned or unassigned basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary non -bid item.    Upgrades from a bid item in one product category (category S) to a bid item in another product category (category U) In this case, Medicare payment is only made to a contract supplier for the product category U on an ass ignment-related basis.  Medicare payment would be equal to 80 percent of the single payment amount for the medically necessary bid item in product category S.   Upgrade Scenarios for Beneficiaries Residing in a Competitive Bidding Area (CBA)  From  the Medically Necessary Item To the Upgraded Item Must be Furnished by Assignment Mandatory (Y/N)  Medicare Payment Based Upon  Bid Item  Non-Bid Item Contract Supplier Y Single Payment Amount for the Medically Necessary Item  Non-Bid Item Bid Item  Contract Supplier N Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Bid Item in Product Category S Bid Item in Product Category U Contract Supplier for Category U Y Single Payment Amount for Category S for the Medically N ecessary Item   The following scenarios and chart describe situations where a beneficiary, who does not reside in a competitive bidding area, but travels to a competitive bidding area, elects to upgrade to an item with features that are not medically neces sary.    Upgrades from a bid item to a non- bid item  In this situation, Medicare payment is only made to a contract supplier on an assignment-related basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary bid item.    Upgrades from a non- bid item to a bid item  When upgrading from a non- bid to a bid item, Medicare payment is made to a contract supplier on either an assigned or unassigned basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary non -bid item.