evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Upon receipt of a claim or other paper on which the Medicare beneficiary identifier is omitted, incomplete, inconsistent, or obviously incorrect, the MAC submits the claim to CWF with the best information it has available.  Depending on the CWF reply, the MAC follows the instructions in C hapter 27 for handling various disposition codes, trailers, and error codes.   10.1.3 - Importance of Medicare beneficiary identifier s                               (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The Medicare beneficiary identifier is used in Medicare records to identify the beneficiary.  The provider or supplier obtains this number before billing.  See 30 below for a description of appropriate processes for obtaining the Medicare beneficiary identifier.   10.2 - Prohibition Against Waiver of Health Insurance Benefits as a Condition of Admission  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  Providers may not require, as a condition of admission or treatment, that a patient agree to waive the right to have services paid for under Medicare.  Requiring such a waiver is inconsistent with the agreement with CMS, and the waiver is not binding upon the patient.  Providers have agreed not to charge an individual (except for specified deductible and coinsurance amounts) for services for which such individual is entitled to have payment made or for which he/she would be entitled if the provider complied with the procedural and other requirements of the program.  Further, under this provision, the provider must refund any amounts incorrectly collected.
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Where a patient who has signed such a waiver, nevertheless, requests payment under the program, the provider must bill the A/B MAC (A) and refund any payments made by the patient, or on the patients behalf, in excess of permissible charges.   10.3 - Requiring Prepayment as a Condition of Admission is Prohibited  (Rev. 1, 10- 01-03) HO- 303, SNF -317  Providers must not require advance payment of the inpatient deductible or coinsurance as a condition of admission.  Additionally, providers may not require that the beneficiary prepay any Part B charges as a condition of admission, except where prepayment from non-Medicare patients is required.  In such cases, only the deductible and coinsurance may be collected.  Where the patient does not have Part B entitlement, the provider will follow the rules in 10.6.  10.4 - When Prepayment May Be Requested  (Rev. 1, 10- 01-03) HO- 303.2  The provider may collect deductible or coinsurance amounts only where it appears that the patient will owe deductible or coinsurance amounts and where it is routine and customary policy to request similar prepayment from non- Medicare patients with similar benefits that leave patients responsible for a part of the cost of their hospital services.  In admitting or registering patients, the provider must ascertain whether beneficiaries have medical insurance coverage.  Where beneficiaries have medical insuranc e coverage, the provider asks the beneficiary if he/she has a Medicare Summary Notice (MSN) showing his/her deductible status.  If a beneficiary shows that the Part B deductible is met, the provider will not request or require prepayment of the deductible.   Except in rare cases where prepayment may be required, any request for payment must be made as a request and without undue pressure.  The beneficiary (and the beneficiarys family) must not be given cause to fear that admission or treatment will be denied for failure to make the advance payment.
(Medicare Claims Processing Manual)
Providers must insure that the admitting office personnel are informed and kept fully aware of the policy on prepayment.  For this purpose, and for the benefit of the provider and the public, it is desirable that a notice be posted prominently in the admitting office or lobby to the effect that no patient will be refused admission for inability to make an advance payment or deposit if Medicare is expected to pay the hospital cos ts.  10.5 - Hospital and Skilled Nursing Facility (SNF) Verification of Prior Hospital Stay Information for Determining Deductible and Benefit Period Status  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  If it has been determined that Medicare is the primary payer, the hospital or SNF must determine if the patient has been an inpatient in any hospital or SNF, including swing bed stays, during the prior 60 days.  If so, the hospital or SNF must determine the admission and discharge dates and the number of days of hospitalization or skilled nursing (as applicable) the patient used in the current benefit period.  The admission and discharge dates must be reported on the claim, and the number of days of hospita lization or skilled nursing (as applicable) must be used to calculate the hospital insurance copayment and the number of days remaining in the benefit period.  If the patient indicates he/she was not an inpatient within the last 60 days, the hospital applies the inpatient deductible to the current stay if it is a covered hospital admission.  The A/B MAC (A) determines the accuracy of the claim data after receipt of the claim.  The remittance advice received from the A/B MAC (A) reflects the amount of deductible (hospital claims) and coinsurance (hospital and SNF claims) applied.  If this amount is different from what was billed, the hospital/SNF must correct the r ecords accordingly.   10.6 - Hospitals May Require Prepayment for Noncovered Services  (Rev. 1, 10- 01-03) HO- 303.3
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10.6 - Hospitals May Require Prepayment for Noncovered Services  (Rev. 1, 10- 01-03) HO- 303.3  With regard to noncovered services (e.g., personal comfort items, a private duty nurse), the hospital may deny such services for which the beneficiary has not paid or offered satisfactory assurance of payment if that is the hospitals practice with nonbene ficiary patients.  For example, a private room or TV set need not be furnished to a patient who requests it but is unable to prepay or offer the assurance of payment which is usually required.   Where the individual has exhausted his/her covered inpatient hospital benefits, or cannot supply satisfactory evidence of entitlement under Part A, providers are free to apply to such persons the hospitals usual policy with respect to requiring prepayment  or other assurance of payment where the patient has no insurance.  In addition, for the beneficiaries receiving covered inpatient services who are not enrolled for medical insurance (Part B), the hospital can apply its usual policy on prepayment or assura nce of payment with regard to services of salaried physicians provided.   10.7 - Compliance With Agreement  (Rev. 1, 10- 01-03) HO- 303.4  Providers must conform to the policy set forth in this instruction.  Noncompliance will be considered in determining whether the provider is honoring its agreement, under which it may not charge for services for which payment may be made under the Medicare  program.   10.8 - Request for Payment Should Be Obtained in All Cases as Protective Application for Hospital Insurance Benefits  (Rev. 1, 10- 01-03) HO- 266, HO -307, SNF -407  To become entitled to HI benefits, an individual must not only be eligible, but must also, prior to death, have filed an application for such benefits (or for monthly social security benefits).  Even though the individual meets all eligibility requirements, if the individual does not file the necessary application before death, the individual cannot become entitled, and no payment can be made for hospital services.  The provider should obtain a written request for title XVIII payment, filed by or on behalf of a patient, upon admission as described in Chapter 1.
(Medicare Claims Processing Manual)
Occasionally, a Medicare eligible patient age 65 or over who is admitted to a hospital, has never applied for benefits.  A request for payment will protect the eligible patient, the patients estate, and the provider against the possibility that timely app lication will not be filed.  If the patient refuses to sign the request, the provider will respect the patients wishes.  The provider may then require the patient to pay or give assurance of payment in accordance with customary practice for non -beneficiar ies.  If the patient cannot sign, and is not accompanied by anyone who can sign on the patients behalf, an authorized provider official may execute the request for payment on the patients behalf.  The admission record containing the request should contai n the patients name and be signed and dated as of the signature date.   Where the Social Security Office (SSO), upon the providers inquiry for a claim number, finds that an apparently eligible inpatient has not applied for benefits; and that the filing date established by the written request might permit payment (not otherwis e possible) for the individuals inpatient services; the SSO will ask the provider for a photocopy of the admission record containing the signed request.  The SSO may ask the provider to file a prescribed application for benefits on behalf of the patient w ho is incompetent if there is no other qualified applicant.  In the case of a deceased patient, who prior to death signed a document that protected the filing date, a provider may apply on behalf of the patient if no other qualified applicant applies within six months of the date of notice of the need for application.  However, where a qualified survivor or representative of the estate refuses to file and states in writing that his/her refusal is based upon the fact that filing would be detrimental to the deceaseds estate, hospital insurance entitlement cannot be established and payment cannot be made for services.   10.9 - A/B MAC (A), (B), or (HHH), or DME MAC Requests to Verify Patients Medicare beneficiary identifier                                                  (Rev.  4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)
(Medicare Claims Processing Manual)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Where the name and Medicare beneficiary identifier information on a claim does not match the CMS central record, the A/B MAC (A), (B), or (HHH), or DME MAC will return the claim to the provider and request the provider to verify the information.  The provider will compare the name and number on the claim with that on provider records.  If the information submitted was incorrect, the provider will return the claim to the MAC with the corrected information.  If, however, the information in the providers records identifying the patient is the same as the information submitted on the claim, the provider will contact the SSO for assistance.   10.10 - A/B MAC (A), (B), or (HHH) or DME MAC  Learns Beneficiary is an HMO Enrollee  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  If the A/B MAC (A), (B), or (HHH), or DME MAC determines from its records or its query to CMS that a patient is an HMO enrollee, the MAC will return the claim to the provider with instructions to request payment from the HMO for payment, if appropriate.   10.11 - Retroactive Entitlement  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)
(Medicare Claims Processing Manual)
When an application for social security benefits is filed by a person 65 years of age or older, the person may inform the SSO that he/she received hospital services in the retroactive period of up to six months for which he/she may be entitled to benefits.  In these cases, the provider may bill for covered retroactive services but must verify the patients eligibility through the A/B MAC (A), (B), or (HHH), or DME MAC before billing.  If the patient paid, the provider must refund the appropriate amount to the patient.   10.12 - SNF Verification of Prior Hospital Stay and Transfer Requirements  (Rev. 1, 10- 01-03) SNF -414  SNFs must verify that the beneficiary was discharged from a hospital with a transfer agreement with the SNF and that:   a. The date of discharge is on or after the first day of the month in which the beneficiary became entitled to Medicare;   b. The hospital stay was at least three calendar days in duration (hospital days to which waiver of liability was applied cannot be used to satisfy the 3- day requirement); and   c. The 3 -day qualifying stay was within 30 days of the SNF admission, unless the rules for exception apply.   The hospital usually sends the SNF a patient transfer form or other record in accordance with the transfer agreement.  The dates of the hospital stay are required on the claim.   For more information on the above criteria, see Chapter 8 of the Medicare Benefit Policy Manual.   20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer  (Rev. 1, 10- 01-03) HO- 300, SNF -401
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20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer  (Rev. 1, 10- 01-03) HO- 300, SNF -401  The provider must ascertain whether the patient is a member of a Medicare + Choice organization (M+CO).  If the patient is a member of an M+CO, the provider must contact the M+CO specified by the patient or identified on the patients membership card, so the provider may determine whether to submit the claim to the M+CO.  If the patient indicates that he/she is not a member of an M+CO, the provider, in order to determine whom to bill, develops for situations where Medicare is the secondary payer by obtaining answers to the Admission Questions to Ask Medicare Beneficiaries  contained in Chapter 3 of the Medicare Secondary Payer Manual.  If another insurer is identified as primary to Medicare, the provider follows the procedures in the Medicare Secondary Payer (MSP) Manual.   20.1 - Provider Development of Medicare Secondary Payer  (Rev. 1, 10- 01-03) HO- 301, SNF -401, A -03-031  Medicare is the secondary payer under certain circumstances.  See Medicare Secondary Payer (MSP) Manual, Chapter 1, for related instructions.  30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier  and Entitlement Status  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   It is important that the patients Medicare beneficiary identifier be obtained and accurately recorded because the claim cannot be processed if the Medicare beneficiary identifier is missing or incorrect. A social security number is not sufficient.
(Medicare Claims Processing Manual)
It is important that the patients Medicare beneficiary identifier be obtained and accurately recorded because the claim cannot be processed if the Medicare beneficiary identifier is missing or incorrect. A social security number is not sufficient.   When a patient 65 years of age or over, or a younger patient who possibly has entitlement to Medicare as a disability beneficiary or under the provisions for coverage of persons needing a kidney transplantation or dialysis, is admitted or registered for se rvices, the provider asks for the health insurance card, Temporary Notice of Medicare Eligibility, or other notice the patient has received from CMS or an A/B MAC (A), (B), (HHH), or DME MAC which shows the Medicare beneficiary identifier.  If a patient or  prospective patient is within three months of age 65, or is disabled or has ESRD, and has not applied for HI entitlement, the provider advises the patient to contact the SSO, or to have someone do so on the patients behalf.  The provider may arrange with the SSO to routinely bring such cases to the SSOs attention.  This requirement also applies to inpatient services for which no payment is due because providers are required to submit inpatient claims even when benefits are exhausted or are not payable for some reason.  The CMS requires this data to record necessary benefit information on CMS records.  Where the patient refuses to request payment and refuses to furnish information about his/her Medicare beneficiary identifier, the provider documents the records accordingly and attempts to get the Medicare beneficiary i dentifier from the SSO.   30.1 - Cross-Reference of Medicare Beneficiary Identifier                      (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
(Medicare Claims Processing Manual)
If a beneficiarys entitlement to Medicare has been transferred from one Medicare beneficiary identifier to another, the CWF will cross -reference the old number to the new number.  If there has been utilization of benefits under each number, all data will be combined under the new number.  A. Disposition Code 51   1. If, after submitting the admission notice or Part B claim to CMS, the MAC receives a disposition code of 51 with trailer code 01 containing a possible Medicare beneficiary identifier, the MAC investigates the new Medicare beneficiary identifier, and if it believes the new Medicare beneficiary identifier is correct, the MAC resubmits the claim under the new Medicare beneficiary identifier.  CWF responds with an appropriate disposition code and any associated trailers for processing the claim.   2. If the MAC receives a disposition code of 51 without trailer code 01, or after investigation determines the Medicare beneficiary identifier in the 01 trailer is incorrect, it denies the claim using the following message:   Payment cannot be made for the services you received from (name of provider) because we have no record of your Medicare beneficiary identifier.  Please write your correct number on the claim and resubmit the claim to (name of provider).  If you think the n umber is right, check with your local Social Security Office.   B. Disposition Code 55   If CWF returns disposition code 55 and trailer code 08 containing an error code of 5052, indicating a mismatch in the beneficiarys personal characteristics, CWF will also return to the MAC what it believes to be the proper information on trailer code 10.  The header portion of the response also contains the corrected sex and birth date, if applicable, of the beneficiary.   The MAC investigates the information provided, corrects the information on the claim, and resubmits it to CWF.  If the MAC continues to receive a code 55, it contacts the Host through locally established procedures.  See Chapter 27.  30.2 - Health Insurance (HI) Card  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)
(Medicare Claims Processing Manual)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   As part of health insurance electronic data processing, HI cards are issued by CMS (or by the RRB where railroad retirement beneficiaries are involved) to individuals who have established entitlement to health insurance.  (See Chapter 2 of the Medicare Gen eral Information, Eligibility, and Entitlement Manual.)  The health insurance card is used to identify the individual as being entitled and serves as a source of information required to process Medicare claims or bills.  The health insurance card displays the beneficiarys name, sex, Medicare beneficiary identifier, and effective date of entitlement to hospital insurance and/or medical insurance.   If any MAC receives an inquiry about replacing a lost or destroyed HI card, it informs the inquirer to get in touch with the SSO nearest the inquirers address for assistance.  SSO addresses are generally listed in local telephone directories under Social  Security Administration.   A health insurance card is acceptable without a signature, but the provider will ask the patient to sign it.   30.3 - Temporary Eligibility Notice  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.