evekhm/cms_iom_500 huggingface dataset:
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 Monitor IOCE software to determine when the impediment to processing is removed.    Consider the claim processed for workload and expenditure reports when it is paid.   Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a monthly report of all outpatient claims paid without processing through the IOCE.  The list of claims paid outside of the IOCE is to include the following information:   o Mbi o DCN o TOB  o DOS (From/Through)  o Provider Number  o MCE/OCE OVR (Claim/Line)  o Reimbursement Amount  o Receipt Date  o Process Date  o Paid Date   Also, include summary data for each edit code showing claim volume and payment.  Any override approvals received and/or relev ant JSM references should be annotated on the reports.    40.5 - Transitional Pass-Throughs for Designated Drugs or Biologicals  (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  Certain current designated drugs and biologicals are assigned to special APCs.  I/OCE identifies these and assigns the appropriate APC.  Fiscal Intermediary Shared System (FISS) establishes payment at the average sales price (ASP) drug fee amount minus the  portion of the otherwise applicable APC payment amount.  I/OCE and FISS will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.   All related payment calculations will be returned by the I/OCE and F ISS, identified as a designated drug and biological with status indicator (SI) K.  Certain new designated drugs and biologicals may be approved for payment, and their payment will be calculated in the same manner as listed above for current designated dr ugs and biologicals.  IOCE identifies these new designated drugs and biologicals (SI G) separately from the current designated drugs and biologicals (SI K).  Note:   See section 40.1 for the I/OCE instructions and specifications   50 - Outpatient Pricer (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  Outpatient Pricer determines the amount to pay as well as deductions for deductible and coinsurance.
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Outpatient Pricer determines the amount to pay as well as deductions for deductible and coinsurance.   This CMS -developed software is updated on a quarterly basis to determine the APC line item price (as well as applicable coinsurance/deductible) based on data from the Outpatient Provider Specific File (OPSF), the beneficiary deductible record and the OCE output file.  Pricer prepares an output data record with the following inf ormation:    All information passed from the OCE;    The APC line item payment amount;   The APC line item deductible;   The APC line item coinsurance amount;    The total cash deductible applied to the OPPS services on the claim;    The total blood deductible applied to the OPPS services on the claim;    The APC line item blood deductible;    The total outlier amount for the claim to be paid in addition to the line item APC payments.  This amount is to be reported to CWF via value code 17 as is the process for inpatient outlier payments; and   A Pricer assigned review code to indicate why or how Pricer rejected or paid the claim.   The Pricer implementation guide has information concerning Pricer processing reports, input parameters, and data requirements.   50.1 - Outpatient Provider Specific File  (Rev. 10121, Issued: 05-08-2020, Effective: 10-01- 2020, Implementation: 10-05-2020)    The Outpatient Provider Specific File (OPSF) contains the required information about each provider to enable the pricing software to calculate the payment amount. Data elements and formats are shown below. Contractors must maintain the accuracy of the data , and update the file as changes occur in data element values, e.g., changes in metropolitan statistical area (MSA), bed size, cost to charge ratio. An update is accomplished by preparing and adding an additional complete record showing new current values and the effective date of the change. The old record is retained without change.    Contractors must also furnish CMS a quarterly file in the same format.     NOTE : All data elements, whether required or optional, must have a default value of 0 (zero) if  numerical, or blank if alphanumerical.
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Contractors must also furnish CMS a quarterly file in the same format.     NOTE : All data elements, whether required or optional, must have a default value of 0 (zero) if  numerical, or blank if alphanumerical.    File Position     Format    Title     Description   1-10   X(10)   National Provider Identifier (NPI)   Alpha -numeric 10 character provider number.   11-16   X(6)   Provider Oscar Number   Alpha -numeric 6 character provider number.   17-24   9(8)   Effective Date   Must be numeric, CCYYMMDD. This is the effective date of the provider's first OPPS period. For subsequent OPPS periods, the effective date is the date of a change to the PROV fil e. If a termination date is present for this record, the effective date must be equal to or less than the termination date.     25-32   9(8)   Fiscal Year  Beginning Date   Must be numeric, CCYYMMDD.   Month: 01-12   Day: 01 -31   The date must be greater than 19990630.     33-40   9(8)   Report Date   Must be numeric, CCYYMMDD.   Month: 01-12   Day: 01 -31   The created/run date of the PROV report for submittal to CO.      41-48   9(8)   Termination Date   Must be numeric, CCYYMMDD. Must be zeroes or contain a termination date. (Once the official tie-out notice from CMS is received). Must be equal to or greater than the effective date. (Termination date is the date on which the reporting contractor ceased servicing the provider in question).    49   X(1)   Waiver Indicator   Enter a Y or N.   Y = waived (provider is not under OPPS)         For End Stage Renal Disease (ESRD) facilities provider waived blended payment, pay full PPS.   N = not waived (provider is under OPPS)        For ESRD facilities provider did not waive blended payment. Pay according to transitional payment method for ESRD PPS through 2013.     50-54   9(5)   Intermediary Number   Enter the Contractor #.    55-56   X(2)   Provider Type   This identifies providers that require special handling. Enter one of the following codes as appropriate.     00 or blanks = Short Term Facility   02 Long Term   03 Psychiatric   04 Rehabilitation Facility   05 Pediatric   06 Hospital Distinct Parts
(Medicare Claims Processing Manual)
00 or blanks = Short Term Facility   02 Long Term   03 Psychiatric   04 Rehabilitation Facility   05 Pediatric   06 Hospital Distinct Parts        (Provider type 06 is effective until July 1, 2006. At that point, provider type 06 will no longer be used. Instead, contractors will assign a hospital distinct part as one of the following provider types: 49, 50, 51, 52, 53, or 54)   07 Rural Referral Center   08 Indian Health Service   13 Cancer Facility   14 Medicare Dependent Hospital (during cost reporting periods that began on or after April 1, 1990.   15 Medicare Dependent Hospital/Referral Center (during cost reporting periods tha t began on or after April 1, 1990. Invalid October 1, 1994 through September 30, 1997).   16 Re-based Sole Community Hospital   17 Re-based Sole Community Hospital /Referral Center   18 Medical Assistance Facility  21 Essential Access Community Hospital   22 Essential Access Community Hospital/Referral Center   23 Rural Primary Care Hospital   32 Nursing Home Case Mix Quality Demonstration Project  Phase II   33 Nursing Home Case Mix Quality  Demonstration Project  Phase III  Step 1  34 Reserved   35 Hospice   36 Home Health Agency   37 Critical Access Hospital        38 Skilled Nursing Facility (SNF)  For non-demo PPS SNFs  effective for cost reporting periods beginning on or after July 1, 1998   40 Hospital Based ESRD Facility   41 Independent ESRD Facility   42 Federally Qualified Health Centers   43 Religious Non-Medical Health Care Institutions   44 Rural Health Clinics-Free Standing   45 Rural Health Clinics-Provider Based   46 Comprehensive Outpatient Rehab Facilities   47 Community Mental Health Centers   48 Outpatient Physic al Therapy Services   49 Psychiatric Distinct Part   50 Rehabilitation Distinct Part   51 Short-Term Hospital  Swing Bed   52 Long -Term Care Hospital  Swing Bed   53 Rehabilitation Facility  Swing Bed   54 Critical Access Hospital  Swing Bed    57  X(1)  Special Locality Indicator  Indicates the type of special locality provision that applies.    For End Stage Renal Disease (ESRD) facilities value Y equals low volume adjustment applicable.    58  X(1)  Change Code For Wage Index  Reclassification  Enter Y if the hospitals wage index location has been reclassified for the year.  Enter N if it has not been reclassified for the year. Adjust annually. Does not apply to ESRD Facilities.
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Reclassification  Enter Y if the hospitals wage index location has been reclassified for the year.  Enter N if it has not been reclassified for the year. Adjust annually. Does not apply to ESRD Facilities.    59-62  X(4)  Actual  Geographic  LocationMSA   Enter the appropriate code for MSA, 00409965, or the rural area, (blank) (blank)  2-digit numeric State code, such as _ _ 3 6  for Ohio, where the facility is physically located.    63-66  X(4)  Wage Index  LocationMSA   The appropriate code for the MSA, 0040-9965, or the rural area, (blank)(blank) (2 digit numeric State code) such as _ _ 3 6 for Ohio, to which a hospital has been reclassified for wage index. Leave blank or enter the actual location MSA if not reclassified. Does not apply to ESRD Facilitie s.    67-70  9V9(3)  Payment -to-Cost Ratio  Enter the providers payment -to-cost ratio. Does not apply to ESRD Facilities.     71-72  9(2)  State Code  Enter the 2-digit state where the provider is located. Enter only the first (lowest) code for a given state.  For example, effective October 1, 2005, Florida has the following State Codes: 10, 68 and 69. Contractors shall enter a 10 for Floridas State C ode.      List of valid State Codes is located in Pub. 10007, Chapter 2, Section 2779A1.  73  X(1)  TOPs Indicator  Enter the code to indicate whether TOPs applies or not.    Y = qualifies for TOPs   N = does not qualify for TOPs
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74  X(1)  Quality Indicator Field  Hospital:  Enter the code to indicate whether the hospital meets data submission criteria per HOP QDRP requirements.   1 = Hospital quality reporting standards have been met or hospital is not required to submit quality data (e.g., hospitals that are specifically excluded from the IPPS or which are not paid under the OPPS, including psychiatric, rehabilitation, long -term care and childrens and cancer hospitals, Maryland hospitals, Indian Health Service hospitals, or hospital units;  or hospitals that are located in Puerto Rico or the U.S. territories). The reduction does not apply to hospices, CORFs, HHAs, CMHCs, critical access hospitals or to any other provider type that is not a hospital.      Blank = Hospital does not meet criteria.     Independent and Hospital -based End Stage Renal Disease (ESRD)Facilities:  Enter the code applicable to the ESRD Quality Incentive Program (QIP):    Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent payment reduction     * Please refer to file position 101 for ESRD Childrens Hospitals Quality Indicator.    75  X(1)  Filler  Blank.  76-79  9V9(3)  Outpatient Cost -to-Charge Ratio  Derived from the latest available cost report data.  See 10.11 of this chapter for instructions on how to calculate and report the Cost-to -Charge Ratio.      Does not apply to ESRD Facilities.    80-84  X(5)  Actual  Geographic  Location CBSA  00001-89999, or the rural area, (blank) (blank)  (blank) 2 digit numeric State code such as _ _ _ 3 6 for Ohio, where the facility is physically located.     85-89  X(5)  Wage Index  Location CBSA  Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates. Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities.    90-95  9(2) V9(4)  Special Wage Index
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90-95  9(2) V9(4)  Special Wage Index  Enter the special wage index that certain providers may be assigned. Enter zeroes unless the Special Payment Indicator equals a 1 or 2.    96  X(1)  Special Payment Indicator  The following codes indicate the type of special payment provision that applies.    Blank = not applicable  Y = reclassified  1 = special wage index indicator  2 = both special wage index indicator and reclassified  D = Dual Reclassified    97-100  9(4)  Reduced  Coinsurance  Trailer Count  Enter the number of APCs the provider has elected to reduce coinsurance for. The number cannot be greater than 999.  101  X(1)  Quality Indicator  ESRD Childrens  Hospitals  Childrens Hospitals for End Stage Renal Disease (ESRD) Facilities:  Enter the code applicable to the ESRD Quality Incentive Program (QIP):    Blank = no reduction  1 =  percent payment reduction  2 = 1 percent payment reduction  3 = 1  percent payment reduction  4 = 2 percent payment reduction    102-105  9V9(3)  Device departments Cost-to-Charge Ratio  Derived from the latest available cost report data.      Does not apply to ESRD Facilities.     106-112  X(7)  Carrier/Locality code  The carrier/locality code for the provider service facility.  The first five positions represent the carrier code and the last two positions represent the locality code.  113-117  9(5)  County Code  Enter the County Code.    Must be 5 numbers.    118-122  X(5)  Payment CBSA   Enter the appropriate code for the CBSA, 0000189999, or the rural area, (blank)(blank)(blank) (2 digit numeric State code) such as _ _ _ 3 6 for Ohio, to which a hospital has been reclassified due to its prevailing wage rates.  Leave blank or enter the Actual Geographic Location CBSA, if not reclassified. Pricer will automatically default to the actual location CBSA if this field is left blank. Does not apply to ESRD Facilities.   123-128  9V9(5)   Payment Model Adjustment (PMA)   Derived from payment model Technical Direction Letter.   129-133   9V9999   Medicare Performance Adjustment (MPA)   Enter the MPA percentage calculated and published by the Centers for Medicare & Medicaid Services (CMS).   134-139 9(2) V9(4)
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9V9999   Medicare Performance Adjustment (MPA)   Enter the MPA percentage calculated and published by the Centers for Medicare & Medicaid Services (CMS).   134-139 9(2) V9(4)  Supplemental Wage Index  Enter the supplemental wage index that certain providers may be assigned.  Enter zeroes if it does not apply. 140-140 X(1)  Supplemental Wage Index Flag Enter the supplemental wage index flag:  1=Prior Year Wage Index 2=Future use 3=Future use  Enter blank if it does not apply.  141-162 X(22)  FILLER     The contractor enters the number of APCs for which the provider has elected to reduce coinsurance. Cannot be greater than 999. Reduced Coinsurance Trailer Record - Occurs 0-999 times depending on the  reduced Coinsurance Trailer Count in positions 97-100. Due to systems capacity limitations the maximum number of reduced coinsurance trailers allowable is 999 at this time.     1-4   9(4)   APC Classification - Enter the 4-digit APC classification for which the provider has elected to reduce coinsurance.   5-10   9(4)V9(2)   Reduced Coinsurance Amount - Enter the reduced coinsurance amount elected by the provider
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The Shared system will verify that the last position of the record is equal to the number in file positions 97 through 100 multiplied by 10 plus 100 (last position of record = (# in file position 97-100)(10) + 100).     50.2 - Deductible Application  (Rev. 1, 10-03-03) A-03-066  Pricer determines the deductible for OPPS services on a claim, and the A/B MAC (A) determines the deductible for other services on the same claim.  Pricer will automatically apply the deductible to the APC line item with the largest national unadjusted coinsurance as a percent of the APC payment.  Pricer then goes to the next largest coinsurance as a percent of the APC payment and so on until the deductible is met or no other payments can be used to satisfy the deductible.  This method of applying the deductible is the most advantageous for the beneficiary.  If less than $100, or less than the beneficiarys remaining deductible amount is applied, an additional deductible amount from other services, if applicable, is applied to the clai m for other types of payments on the same claim before submitting to CWF.  The deductible does not apply to the influenza virus vaccines, pneumococcal pneumonia vaccine, clinical diagnostic laboratory services (which include screening pap smears), screening mammographies, screening pelvic examinations, and screening prostate examinations.  Only influenza virus vaccine, pneumococcal pneumonia vaccine, screening pelvic examinations and screening prostate examinations are subject to OPPS.  50.3 - Transitional Pass Through Payments for Designated Devices  (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)
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Certain designated new devices are assigned to APCs and identified by the OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for devices used with the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.  All related payment calculations will be returned on the same APC line and identified as a designated new device.   Refer to https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html  for the most current OPPS APC Offset File.   50.4  Changes to Pricer Logic Effective April 1, 2002  (Rev. 3941; Issued: 12- 22-17; Effective: 01- 01- 18; Implementation: 01 -02-18)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.   A. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  C. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.  D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient deductible of $812 remains effective January 1, 2002.  E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.
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E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.  F. If a claim has more than 1 service with a status indicator (SI) of S or T and any lines with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will be summed and the charges will then be divided up proportionately to the payment rate for each S or T line.  The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation.   EXAMPLE:   SI Charges  Payment Rate  New Charges  Amount  S $19,999 $6,000 $12,000 T $1 $3,000 $6,000 S $0 $1,000 $2,000  $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.  G. All charges on lines with a SI of N (bundled services) on the claim will be summed and the charges will then be divided up proportionately to the payment rate for each S, T, V or X line.  This proportional amount will be added to the new charges amount from item F above or, if that doesn't apply, they will be added to the actual submitted charges for each S, T, V or X before making a line item outlier calculation.   H. Outliers will be calculated at a line item level.  No outlier payment will be calcu lated for SIs of G, N or H, although charges for packaged services (SI=N) will be used in calculating outlier payments for other services as described in G. above.  Pricer will use submitted charges as modified by items F and G above.  The CMS changed the factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to  multiply the difference between claim payments and costs from .75 to .50.  Pricer will keep the cost to charge ratio adjustment factor at .981956.  Pricer will sum all line  item outlier amounts and output them as a single total claim outlier amount, just as it outputs the outlier amount that contractors are to place in value code 17.
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I. Any claim with one or more APCs that match those listed in Table 1 of the March 1, 2002, F ederal Register will have all applicable APC offset amounts summed and wage adjusted.  The total wage adjusted offset amount will be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C, i.e., C1713 through C2631.  J. A pro rata reduction of 63.6 percent applies to all SI G and/or H payments.  For H, devices, the offset (or reduction) is applied to the final payment amount after all device offset amounts (see item I above) have been taken.  For SI G, pass thru drugs, CMS determines the pass-through amount (PTA) by subtracting 5 times the minimum coinsurance from the Medicare payment amount.  The CMS will multiply .364 times the PTA and add that amount to 5 times the minimum coinsurance to get the new Medicare payment amount.  K. The provider specific file for SNFs and HHAs that may be reimbursed for splints, casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or 0.001 if the shared system will not allow 0.000.  Pricer will not pay outliers for these services.  L. Pricer Drug Copayment Changes   M. APC  N. Drug Name  O. Corrected Copayment P. 726 Q. Dexrazoxane  R. $27.85 S. 1607 T. Eptifibatide  U. $1.62  50.5 - Changes to Pricer Logic Effective April 1, 2002  (Rev. 1, 10-03-03) A-02-026  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  V. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.  W. Inpatient  hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.