evekhm/cms_iom_500 huggingface dataset:
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The SSO may issue a temporary health insurance eligibility notice, pending the issuance of a health insurance card, when the beneficiary is in need of immediate medical services.  The provider may obtain the patients name and Medicare beneficiary identifi er from the temporary eligibility notice.  See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual for an example of the temporary notice.  For claims processed by the A/B MAC (B) or DME MAC, the individual, the individuals physician, or other supplier must show the Medicare beneficiary identifier on the request for Medicare payment and on other related bills and documents.  Because Health In surance records are maintained by the individuals Medicare beneficiary identifier, the Medicare beneficiary identifier must be used on all communications. claim number, the claim number must be used on all communications.   30.4 - Certificate of Social Insurance Award  (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.   Health insurance beneficiaries receive a Certificate of Social Insurance Award, SSA -30, showing the Medicare beneficiary identifier, dates of entitlement to Part A and/or Part B benefits, and the following statement:   This notice may be used if Medicare services are needed before you receive your health insurance card.  30.5 - Medicare Summary Notice (MSN)  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)
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30.5 - Medicare Summary Notice (MSN)  (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 co ntinue to use the HICN as part of their processes.   If patients cannot furnish their health insurance cards when admitted, they may have a MSN form showing the Medicare beneficiary identifier.  A notice is mailed to a beneficiary shortly after Part A or Part B benefits have been paid on the beneficiarys behalf.  Deductible status is also shown on these forms.  30.6 - Provider Access to CMS and A/B MAC (A) or (HHH)  Eligibility Data (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.
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The A/B MAC (A) or (HHH) will allow only Medicare certified providers as defined in 1861 and 1866(e)  of the Social Security Act (the Act) and their billing agents automated access to beneficiary eligibility data.  Disclosure of CWF eligibility data is restricted under provisions of the Privacy Act of 1974, 5 U.S.C 552a .  Under limited circumstances, the Privacy Act permits CMS to disclose information without consent of the individual.  One circumstance is for routine uses, that is, disclosure for purposes that are compatible with the purpose for which CMS collects the  information.  In the case of this provider access, a routine use exists which permits release of data to providers or their authorized billing agents for the purpose of verifying a patients eligibility for benefits under the Medicare program.  The use of  the data by a provider in preparing claims for hospital- based physicians would be an example of unauthorized use because the physicians are not Medicare providers as defined in the Act.   A/B MACs (A) or (HHH) will adjust their systems to accept the revised standard HIQA/HUQA records from the CMS CWF.  The standard data elements to be made available to providers are listed below:    Medicare beneficiary identifier;    Beneficiary:   o Last name (first six positions)/first initial;   o Date of birth;   o Sex;  o Date of death;   o Lifetime reserve days remaining;  o Lifetime psychiatric days remaining (requesting hospital must use a psychiatric provider number to obtain this data);   o Cross reference Medicare beneficiary identifier;   o Current and prior A and B entitlements, with start and stop dates for Part A, Part B, ESRD, HMO, and hospice; and   o Spell of illness (applicable spell based on the date entered by the provider and the next most recent spell):    Hospital full days remaining;    Hospital coinsurance days remaining;    SNF full days remaining;    SNF coinsurance days remaining;    Part A cash deductible remaining to be met;   Date of earliest billing action for indicated spell- of-illness;   Date of latest billing action for indicated spell- of-illness;    Blood deductible (combined annual Part A and B remaining to be met for applicable year entered by provider);
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 Date of latest billing action for indicated spell- of-illness;    Blood deductible (combined annual Part A and B remaining to be met for applicable year entered by provider);    Part B trailer year (applicable year based on date entered by provider);    Part B cash deductible;    Physical therapy/speech -language pathology limit (physical therapy and speech -language pathology are applicable to physical therapy limit);   Occupational therapy limit;    Hospice data (applicable periods based on the date entered by the provider and the next most recent period);    ESRD indicator (shows beneficiary is currently entitled);    REP payee indicator;    MSP indicator;    Home Health Benefit Period:  o Part A visits remaining;  o Part B visits applied;   o Date of earliest billing action for home health benefit period;   o Date of latest billing action for home health benefit period.   HMO information (applicable periods based on date entered by the provider):   o Name;   o Identification number;   o ZIP Code;   o Option code;   o Start date;   o Termination date;   o Pap smear screening risk indicator, professional date, and technical date;   o Mammography screening risk indicator (applicable to screening services prior to January 1, 1998), professional date, and technical date;   o Colorectal screening (no risk indicator); procedure code, professional date, and technical date;   o Pelvic screening risk indicator and professional date;   o Pneumococcal pneumonia vaccine (PPV) date;   o Influenza virus vaccine date; and   o Hepatitis B vaccine date.   See Chapter 10 of this manual for a complete discussion of the HIQH (Health Insurance Query for Home Health Agencies).   The A/B MAC (A) will make sure that psychiatric information is not being made available to all hospitals.  This information is to be made available only to psychiatric hospitals or hospitals that furnish inpatient psychiatric hospital services.
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The A/B MAC (A) will make sure that psychiatric information is not being made available to all hospitals.  This information is to be made available only to psychiatric hospitals or hospitals that furnish inpatient psychiatric hospital services.   Providers may use direct entry terminals or dial -up terminals to inquire about beneficiary eligibility utilization and deductible status.  The A/B MAC (A) must use either the HIQA screen display (see 30.6.1.1) or create its own Customer Information Control System (CICS) screens from the HUQA data records (see 30.6.1.2 and 30.6.1.3).  Providers may not have access to any other CWF records, e.g., the health insurance master record (HIMR).  The data must be from CWF.  The A/B MAC (A) will not substitute local history.  30.6.1 - Reserved  (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)  30.6.1.1 - Part A Inquiry (HIQA) Screen Display  (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)  All the data elements are explained in full for proper use.  A/B MACs (A) or (HHH) should access this screen to transmit data to their providers and suppliers when supplying data for 30.6.1.2.   30.6.1.2 - Part A Inquiry Reply (HIQAR) Screen Display  (Rev. 1, 10- 01-03) A3-3508.4   This screen format can be used to pass beneficiary entitlement and utilization data to the provider.  It is described in the CWF Documentation, Chapter VII, Section H, pages 1 through 24.  Refer to the CWF Documentation when providing utilization data to t he provider.   30.6.1.3 - Part A Inquiry (HUQA) Data  (Rev. 1, 10- 01-03) A3-3508.5
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30.6.1.3 - Part A Inquiry (HUQA) Data  (Rev. 1, 10- 01-03) A3-3508.5   This transaction may be used to obtain the HUQA dataset.  (See 30.6.)  Also, refer to Chapter II of the CSC maintained CWF Documentation.   30.6.1.4 - Part A Inquiry Reply (HUQAR) Data  (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)  This response can be used to create the A/B MAC (A)s or (HHH)s own screens to return beneficiary eligibility and utilization data to providers.   30.6.1.5 - Health Insurance Query for Home Health Agencies (HIQH)  (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)  This transaction, which is available through A/B MAC (HHH) remote access, is used by HHAs to ascertain whether an episode has been opened for a given beneficiary by another provider (who is the primary HHA) and to track episodes for beneficiaries for whom the inquiring HHA is the primary HHA.   30.6.2 - Reserved  (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)  30.6.3 - Reserved  (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)
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30.6.4 - Reserved  (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)  30.6.5 - Reserved  (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)  30.6.6 - Reserved  (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)  30.8 - Reserved  (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)  30.10 - Reserved  (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)  30.11 - Reserved  (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)  30.12 - Reserved  (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)  30.13 - Reserved  (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)
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30.14 - Reserved  (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)  30.15 - Reserved  (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)  30.16 - Reserved  (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)  30.17 - Reserved  (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)  30.18 - Reserved  (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)  30.19 - Reserved  (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)  30.19.1 - Reserved  (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)  30.19.2 - Reserved  (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)
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30.19.3 - Reserved  (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)  30.19.4 - Reserved  (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)  30.20 - Reserved  (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)  30.21 - Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry Response Procedures  (Rev. 1, 10- 01-03) A3-3523, 3- 6008   See 70.  30.21.1 - HMO -Related Master File Corrections  (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)  The A/B MAC (A), (B), or (HHH), or DME MAC will fully document and send to the HMO inquiries concerning problems with HMO data on the HI Master.  The HMO will resolve the problem and advise the contractor of the results.   30.22 - Provider Problems Obtaining Entitlement Information  (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)
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If after application of the above procedures, the provider encounters significant problems in obtaining information regarding Medicare entitlement or benefits in order to accurately prepare bills, the provider should contact the A/B MAC (A), (B), or (HHH), or DME MAC for assistance.  However, these requests should be on a non- routine basis.  The MAC will assist providers in obtaining entitlement information.  The MAC may temporarily refuse assistance if a pattern of abuse is discovered.  Situations that may require MAC assistance are:    When the patient dies following admission.  It may be necessary to file timely with an estate;    When the patient is not in a physical or mental condition to discuss his/her entitlement, and no other person with knowledge of the patients affairs is available;    When the provider has reason to believe the beneficiary may need lifetime reserve days, and his/her signature must be obtained if the available lifetime reserve days are not to be used for this admission and other financial arrangements must be made;    When it is suspected that the beneficiary may have exhausted his/her Medicare benefits, and timely confirmation is needed in order to file for possible supplemental benefits; and    When the patient has experienced repeated admissions during the same spell of illness, and determining available benefits for the beneficiary is difficult.   50 - Critical Case Procedures - Establishing Entitlement Under Part A and B  (Rev. 1, 10- 01-03)  See Chapter 27.   60 - Reserved  (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)  60.1 - Reserved  (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)  60.2 - Reserved  (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).
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70 - SSO Assistance in Resolving Entitlement Status Problems (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.   A. Social Security Office (SSO) Assistance   The A/B MAC (A), (B), or (HHH), or DME MAC directs initial requests for assistance to the SSO if the problem is caused by difficulties in determining the beneficiarys correct entitlement status.  Examples of situations that may require SSO assistance are:    Problems involving Railroad Retirement Board (RRB) jurisdiction;    Evidence that a beneficiary has utilization under more than one Medicare beneficiary identifier but there is no awareness of any cross -reference action taken by CMS; or    The beneficiarys name, address, sex code, date of birth, or date of death is incorrect on the HI master record.   In the event the SSO is unable to resolve the entitlement problem (e.g., cross referencing of HI records), the MAC requests assistance from the RO.   90 - Outpatient Hospital Registration Procedures  (Rev. 1, 10- 01-03) HO- 350  90.1 - Patient Identification  (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.
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Upon registration of a Medicare beneficiary, or as soon thereafter as practical, the hospital will ask the patient for his/her health insurance card to obtain the Medicare beneficiary identifier.  If the patient is unable to provide it, the hospital will c ontact the SSO for assistance.   90.2 - Determining Whom to Bill  (Rev. 1, 10- 01-03) HO- 350.B   The procedures for determining whether another payer exists are the same for outpatient situations as for inpatient.  Therefore, the hospital will follow 20 for developing other coverage.   90.3 - Source of Admission - Outpatient Hospital  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The hospitals registration process must distinguish whether the referral source for this registration/admission is from:   Its own inpatient hospital;    An encounter in another hospital (see 90.6 for definition of encounter); or    Any other source -  See chapter 25.   Hospitals must determine the appropriate source of admission from internal records or by asking the patient who referred him/her, and whether the referral took place as a result of an encounter in the servicing hospital, another hospital, or elsewhere.   The following coding must be used on the outpatient claim.  Therefore admission/registration processes must obtain the information.  1. Physician Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by his/her personal physician, or the patient independently requested outpatient services (self -referral).   2. Clinic Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by this facilitys clinic or other outpatient department physician.  3. HMO Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by an HMO physician.  4. Transfer from a Hospital -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another acute care facility.   5. Transfer from a SNF -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where the patient is an inpatient.
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5. Transfer from a SNF -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where the patient is an inpatient.   6. Transfer from Another Health Care Facility -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where the patient is an inpatient.  7. Emergency Room -  The patient was referred to this facility for outpatient or referenced diagnostic services by this facilitys emergency room physician.  8. Court/Law Enforcement -The patient was referred to this facility for outpatient or referenced diagnostic services upon the direction of a court of law, or upon the request of a law enforcement agency representative.   9. Information not available.  10. Transfer from a CAH -  The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient.   The hospital must determine the proper source of admission code based on the patients response and/or any other information the hospital may have available from its preregistration records or scheduling data.  The hospital must enter the proper source of admission code on the claim.  NOTE:  Information regarding the form locator number that corresponds to the source of admission code and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.   If the patient was referred for services by a physician at:    This hospital, the hospital enters codes 2 or 7;    Another hospital, the hospital enters code 4; or    Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate.   If the hospital is sure the admission source is not from its hospital or another hospital but cannot determine which of the codes apply, the hospital will enter code 1 on Medicare claims.  However, incorrect reporting where services were referred by staff at its own hospital or another hospital (codes 2, 4, or 7 are applicable) is considered program abuse and subject to applicable sanctions.  90.4 - Type of Bill  (Rev. 2971, Issued: 05- 23-14, Effective: 07 -01-14, Implementation, 07- 07-14)