evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
-  Close of Business  40.1.2 -  Change of Ownership 40.1.3 -  Expiration and Renewal -Nonrenewal of SNF Term Agreements  40.2 -  Involuntary Terminations  40.2.1 -  Processing Involuntary Terminations  40.2.2 -  FI Report on Provider Deficiencies  40.2.2.1 -  Subsequent Communications With Provider  40.3 -  Readmission to Medicare Program After Involuntary Termination  40.3.1 -  Effective Date of Provider Agreement  40.3.2 -  Fiscal Considerations in Provider Readmission to Medicare Program After Involuntary Termination 40.4 -  Payment for Services Furnished After Termination, Expiration, or Cancellation of Provider Agreement  40.4.1 -  Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions  40.4.2 -  Status of Hospital or SNF After Termination, Expiration, or Cancellation of Its Agreement  40.5 -  FI/Carrier/DMERC Responsibilities for Informing Providers of Changes  50 - Filing a Request for Payment With the Carrier or FI  50.1 -  Request for Payment From the Carrier or FI  50.1.1 -  Billing Form as Request for Payment  50.1.2 -  Beneficiary Request for Payment on Provider Record - ASC X12 837 Institutional Claim Format and Form CMS -1450 50.1.3 -  Signature on the Request for Payment by Someone Other Than the Patient  50.1.4 -  Request for Payment as a Claim for HI Entitlement 50.1.5 -  Refusal by Patient to Request Payment Under the Program  50.1.6 -  When Beneficiary Statement is Not Required for Physician/Supplier Claim  50.1.7 -  Definition of a Claim for Payment 50.1.8 -  Establishing Date of Filing -  Postmark Date -  Carriers  50.2 -  Frequency of Billing for Providers  50.2.1 -  Inpatient Billing From Hospitals and SNFs  50.2.2 -  Frequency of Billing for Providers Submitting Institutional Claims  With Outpatient Services  50.2.3 -  Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment  50.2.4 -  Reprocess Inpatient or Hospice Claims in Sequence  50.3 -  When an Inpatient Admission May Be Changed to Outpatient Status  50.3.1 -  Background  50.3.2 -  Policy and Billing Instructions for Condition Code 44 60
(Medicare Claims Processing Manual)
-  Reprocess Inpatient or Hospice Claims in Sequence  50.3 -  When an Inpatient Admission May Be Changed to Outpatient Status  50.3.1 -  Background  50.3.2 -  Policy and Billing Instructions for Condition Code 44 60  Provider Billing of Non- covered Charges on Institutional Claims  60.1 -  General Information on Non- covered Charges on Institutional Claims  60.1.1 -  Basic Payment Liability Conditions  60.1.2 -  Billing Services Excluded by Statute  60.1.3 -  Claims with Condition Code 21  60.1.3.1  Provider -liable Fully Noncovered Outpatient Claims  60.2 -  Noncovered Charges on Inpatient Bills  60.2.1  Billing for Noncovered Procedures in an Inpatient Stay 60.3 -  Noncovered Charges on Institutional Demand Bills  60.3.1 -  Background on Institutional Demand Bills (Condition Code 20)  60.3.2 -  Inpatient and Outpatient Demand Billing Instructions  60.4 -  Noncovered Charges on Outpatient Bills  60.4.1 -  Outpatient Billing With an ABN (Occurrence Code 32)  60.4.2 -   Line -Item Modifiers Related to Reporting of Non- covered Charges When Covered and Non- covered Services Are on the Same Outpatient Claim 60.4.3  Liability Considerations for Bundled Services  60.5 -  Coding That Results from Processing Noncovered Charges  70 - Time Limitations for Filing Part A and Part B Claims  70.1 -  Determining Start Date of Timely Filing Period --Date of Service  70.2 -  Definition of a Claim for Payment 70.2.1 -  Appropriate Medicare Contractor  70.2.2 -  Form Prescribed by CMS  70.2.3 -  In Accordance with CMS Instructions  70.2.3.1 -  Incomplete or Invalid Submissions  70.2.3.2 -  Handling Incomplete or Invalid Submissions  70.3 -  Determining End Date of Timely Filing Period Receipt Date  70.4 -  Determination of Untimely Filing and Resulting Actions  70.5 -  Application to Special Claim Types  70.6 -  Filing Claim Where General Time Limit Has Expired  70.7 -  Exceptions Allowing Extension of Time Limit  70.7.1 -  Administrative Error  70.7.2  Retroactive Medicare Entitlement  70.7.3  Retroactive Medicare Entitlement Involving State Medicaid Agencies  70.7.4 -  Retroactive Disenrollment from a Medicare Advantage Plan or Program of All -Inclusive Care for the
(Medicare Claims Processing Manual)
Retroactive Medicare Entitlement  70.7.3  Retroactive Medicare Entitlement Involving State Medicaid Agencies  70.7.4 -  Retroactive Disenrollment from a Medicare Advantage Plan or Program of All -Inclusive Care for the Elderly (PACE) Provider Organization  70.8 -  Filing Request for Payment to Carriers Medicare Part B  70.8.1 -  Splitting Claims for Processing  70.8.2 -  Replicating Claims for Processing  70.8.3 -  Methods of Claiming Benefits for Services by Physicians and Suppliers  70.8.4 -  Claims Forms  CMS -1490S and CMS -1500 70.8.5 -  Photocopies  70.8.6 -  Penalty for Filing Claims after One Year  70.8.8 -  Penalty for Filing Claims after One Year  70.8.8.6  Monitoring Claims Submission Violations  70.8.8.7  Notification Letters  70.8.8.8  Violations That Are Not Developed For Referral  80 - Carrier and FI Claims Processing Timeliness  80.1 -  Control and Counting Claims  80.2 -  Definition of Clean Claim  80.2.1 -  Receipt Date  80.2.1.1 -  Payment Ceiling Standards  80.2.1.2 -  Payment Floor Standards  80.2.2 -  Interest Payment on Clean Non- PIP Claims Not Paid Timely  80.2.2.1 -  Determining and Paying Interest  80.2.2.2 -  Preparation of IRS Form 1099- INT 80.3 -  Other Claims (other than clean)  80.3.1 -  Incomplete or Invalid Claims Processing Terminology 80.3.2 -  Handling Incomplete or Invalid Claims  80.3.2.1.1 -  A/B MAC (B) Data Element Requirements  80.3.2.1.2 -  Conditional Data Element Requirements for A/B MACs (B) and DME  MACs  80.3.2.1.3 -  A/B MAC (B) Specific Requirements for Certain Specialties/Services  80.3.2.2 -  Consistency Edits for Institutional Claims  80.3.3  Timeliness Standards for Processing Other -Than -Clean Claims  80.4 -  Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment)  80.5 -  Do Not Forward Initiative (DNF)  80.5.1 -  Carrier DNF Requirements  80.5.1.1 -  Reporting Requirements -  Carriers  80.6 -  Processing All Diagnosis
(Medicare Claims Processing Manual)
Continue PIP (Periodic Interim Payment)  80.5 -  Do Not Forward Initiative (DNF)  80.5.1 -  Carrier DNF Requirements  80.5.1.1 -  Reporting Requirements -  Carriers  80.6 -  Processing All Diagnosis Codes Reported on Claims Submitted to Carriers  90 - Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period  91 - Moral and Religious Fee for Service Claims for Medicare Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans  100 -  Medicare as a Secondary Payer  110 -  Provider Retention of Health Insurance Records  110.1 -  Categories of Health Insurance Records to Be Retained  110.2 -  Microfilming Records  110.3 -  Retention Period 110.4 -  Destruction of Records  120 -  Detection of Duplicate Claims  120.1 -  Overview  120.2 -  Exact Duplicates  120.3 -  Suspect Duplicates  130 -  Adjustments and Late Charges  130.1 -  General Rules for Submitting Adjustment Requests  130.1.1 -  Adjustment Bills Involving Time Limitation for Filing Claims  130.1.2 -  Claim Change Reasons  130.1.2.1 -  Claim Change Reason Codes  130.1.2.2 -  Edits on Claim Change Reason Codes  130.1.2.3 -  Additional Edits  130.1.3 -  Late Charges  130.2 -  Inpatient Part A Hospital Adjustment Bills  130.2.1 -  Tolerance Guidelines for Submitting Inpatient Part A Hospital Adjustment Requests  130.3 -  SNF Part A Adjustments  130.3.1 -  Tolerance Guides for Submitting SNF Inpatient Adjustment Requests  130.3.2 -  SNF Inpatient Claim Adjustment Instructions  130.3.3 -  Patient Does Not Return From SNF Leave of Absence, and Last Bill Reported Patient Status as Still Patient (30)  130.4 -  Hospital and SNF Part B Adjustment Requests  130.4.1 -  Guidelines for Submitting Adjustment Requests  130.5 -  Home Health Adjustments  130.5.1 -  Submitting Adjustment Requests  130.6 -  Adjustments to Reprocess Certain Claims Denied Due to an Open Common Working File (CWF) Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record Was Subsequently Deleted  or Terminated  130.7 -  MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims  140  Fiscal Intermediary (FI) Edits Affecting Multiple Bill Types  140.1 -  Threshold Edit for Outpatient and Inpatient Part B
(Medicare Claims Processing Manual)
Record Was Subsequently Deleted  or Terminated  130.7 -  MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims  140  Fiscal Intermediary (FI) Edits Affecting Multiple Bill Types  140.1 -  Threshold Edit for Outpatient and Inpatient Part B Claims  140.2  Systematic Validation of Claims Information Using Patient Assessments  140.3 -  Verification Edit for Claims with OPPS Payments  150  Limitation of Liability Notification and Coordination With Quality Improvement Organizations (QIOs)  150.1 -  Limitation on Liability -  Overview  150.2  Hospital Claims Subject to Hospital Issued Notices of Noncoverage  150.2.1  Scope of Issuance of Hospital Issued Notices of Noncoverage (HINNs)  150.2.2 -  General Responsibilities of QIOs and Fiscal Intermediaries (FIs) Related to HINNs  150.2.3  Billing and Claims Processing Requirements Related to HINNs  150.3 Skilled Nursing Facility (SNF), Home Health Agency (HHA), Hospice and Comprehensive Outpatient Rehabilitation Facility (CORF) Claims Subject to Expedited Determinations  150.3.1  Scope of Issuance of Expedited Determination Notices  150.3.2 -  General Responsibilities of QIOs and FIs Related to Expedited Determinations  150.3.3  Billing and Claims Processing Requirements Related to Expedited Determinations  160 -  Identifying Institutional Providers  160.1 -  Reporting of Taxonomy Codes (Institutional Providers)  170 -  Payment Bases for Institutional Claims  170.1 -  Services Paid on the Medicare Physician Fee Schedule (MPFS)  170.1.1 -  Payments on the MPFS for Providers With Multiple Service Locations  180 -  Denial of Claims Due to Violations of Physician Self -Referral Prohibition  180.1 -  Background and Policy 180.2 -  Denial Code  190  Payer Only Codes Utilized by Medicare  200 -  Qualified Medicare Beneficiary (QMB)  01 - Foreword  (Rev. 3086, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD-10; ASC X12: November 4, 2014)
(Medicare Claims Processing Manual)
Generally, this chapter describes policy applicable to Medicare fee- for-service claims, or what is known as the original or traditional Medicare program.  See the Medicare Managed Care Manual for services to enrollees in managed care plans.   Unless specified otherwise the instructions in this chapter apply to both providers and suppliers, and to the contractors that process their claims.  In this chapter the terms provider and supplier are used as defined in 42 CFR 400.202.   Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech-language pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitaliz ation services.    Supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.  A supplier must meet certain requirements and enroll as described in Chapter 10 of the Medicare Program Integrity Manual.  A provider that meets the applicable conditions may also enroll as a supplier of a particular service and may bill separately for that service where Medicare payment policy allows separate payment for the service.   In this chapter and in subsequent chapters of Pub. 100- 04, the terms institutional claim and professional claim are defined by the submission format of the claim.   Institutional claim means any claim submitted using the Health Insurance Portability and Accountability Act (HIPAA) mandated transaction ASC X12 837  institutional claim or the paper Form CMS -1450.   Professional claim means any claim submitted using the HIPAA mandated transaction ASC X12 837 professional claim or the CMS-1500 paper claim form.  01.1  Remittance Advice Coding Used in this Manual  (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08-31-2020)
(Medicare Claims Processing Manual)
01.1  Remittance Advice Coding Used in this Manual  (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08-31-2020)   When Medicare denies coverage or adjusts the payment amount for items or services, these actions are documented using codes reported on the providers remittance advice.  Medicare, like all other health insurance payers, uses remittance advice codes in combination to create one message.  This combination includes a Claim Adjustment Group Code (Group Code) and a Claim Adjustment Reason Code (CARC).  Frequently, payers also use one or more Remittance Advice Remark Codes (RARC) to add additional detail.  RARC coding is optional unless the CARC definition requires an accompanying RARC, s o RARCs may not appear on all remittance advice messages.  Each of the codes in the message communicates different information:    Group Codes assign financial responsibility to the provider or the beneficiary   CARCs communicate the general reason why the payment is different from the billed amount   RARCs, when used in combination with CARCs,  provide additional or more specific payment adjustment information
(Medicare Claims Processing Manual)
 RARCs, when used in combination with CARCs,  provide additional or more specific payment adjustment information   In certain cases, RARCs may also be used alone to provide information unrelated to the difference between the amount billed and the amount paid.  In these cases, the RARC definition always begins with the word Alert.  Remittance advice codes are identified in standard code sets that are used by all payers, as required by HIPAA.  Since the definitions of the codes are an industry standard, the instructions in this manual refer only to the code values.  Providers and cont ractors can access the definitions of the codes at the official Washington Publishing Company website.   Section 1171 of the Social Security Act requires a standard set of operating rules to regulate the health insurance industrys use of electronic data interchange (EDI) transactions.  Operating Rule 360: Uniform Use of CARCs and RARCs, regulates the way in which group codes, CARCs and RARCs may be used.  The rule requires specific codes which are to be used in combination with one another if one of the named business scenarios applies.  This rule is authored by the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE).  Medicare and all other payers must comply with the CAQH CORE-developed code combinations. The business scenario for each payment adjustment must be defined, if applicable, and a valid code combination selected for all remittance advice messages.  Providers and contractors can access t he business scenarios and code combinations at: caqh.org/CORECodeCombinations.php.  When remittance advice messages are used to explain payments to providers, Medicare Summary Notice (MSN) messages are used to explain payments to beneficiaries.  In order to provide remittance advice codes and MSN messages consistently throughout the Medicare Claims Processing Manual, the one of the following standard language statements will be included as necessary.    If the CARC/RARC being reported is included in the CAQH CORE list of valid combinations:   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario [Insert Business Scenario number].
(Medicare Claims Processing Manual)
The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario [Insert Business Scenario number].   Group Code: [Insert Group Code]  CARC: [Insert CARC number or N/A if the RARC is an Alert message]  RARC: [Insert RARC number(s) or N/A if a RARC is not needed]  MSN: [Insert MSN message number(s)]    If the CARC is not included in the CAQH CORE publication and therefore, standard business scenarios do not apply:   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: [Insert Group Code]  CARC: [Insert CARC number or N/A if the RARC is an Alert message]  RARC: [Insert RARC number(s) or N/A if a RARC is not needed]  MSN: [Insert MSN message number(s)]    02.1.1 - HIPAA Standards for Claims  (Rev. 10236, Issued: 07 -31-2020, Effective: 08 -31-2020, Implementation: 08- 31-2020)   The standards adopted under HIPAA include both a transaction standard and an implementation guide.  The following are the claims transactions and the implementation guides adopted as standards under HIPAA:   Standard Claim Transaction  Short Reference  Implementation Guide  Type of Claim  ASC X12 Health Care Claim:  Professional (837)  ASC X12 837  professional claim  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Health Care Claim: Professional (837)   Professional services and supplies, including  retail pharmacy  ASC X12 Health Care Claim:  Institutional (837)  ASC X12 837  institutional claim  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Health Care Claim: Institutional (837)   Institutional  Standard Claim Transaction  Short Reference  Implementation Guide  Type of Claim  Telecommunication Standard, National Council for Prescription Drug Programs and equivalent Batch Standard, National Council for Prescription Drug Programs Depending upon context: NCPDP claim; NCPDP transaction; NCPDP batch transaction; NCPDP batch claim  Telecommunication Standard Implementation Guide and equivalent Batch Standard  Implementation Guide, National Council for Prescription Drug Programs.
(Medicare Claims Processing Manual)
Retail pharmacy professional services and supplies; retail pharmacy drugs   Claims sent electronically to Medicare must abide by the HIPAA standards listed above.  The current versions of these HIPAA standards are listed in chapter 24 of this manual.  More information about HIPAA can be found at www.cms.gov, under the Regulations and Guidance tab.  More information about these transactions and implementation guides can be found, as appropriate, at the official ASC X12 website and www.NCPDP.org .  In addition, chapter 24 of this manual provides more information regarding Medicares requirements for electronic data interchange (EDI), such as EDI enrollment and trading partner agreements.   Note that HIPAA standard implementation guides provide comprehensive directions regarding how to submit a claim on the transactions they support.  Therefore, there is no separate guidance in this claim processing manual as to how to submit a claim using these transactions.  However, there may be situations where the Medicare requirements require additional clarification, description, or guidance. In such cases, there will be additional instructions in the appropriate subject area section.   02 - Formats for Submitting Claims to Medicare  (Rev. 3086, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD-10; ASC X12: November 4, 2014)  02.1 - Electronic Submission Requirements  (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08-31-2020)   The standards adopted under HIPAA include both a transaction standard and an implementation guide.  The following are the claims transactions and the implementation guides adopted as standards under HIPAA:  Standard Claim Transaction  Short Reference  Implementation Guide  Type of Claim  ASC X12 Health Care Claim:  Professional (837)  ASC X12 837  professional claim  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Professional services and supplies, including  Standard Claim Transaction  Short Reference  Implementation Guide  Type of Claim  Health Care Claim: Professional (837)  retail pharmacy  ASC X12 Health Care Claim:  Institutional (837)  ASC X12 837  institutional claim  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Health Care Claim: Institutional (837)
(Medicare Claims Processing Manual)
retail pharmacy  ASC X12 Health Care Claim:  Institutional (837)  ASC X12 837  institutional claim  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Health Care Claim: Institutional (837)  Institutional  Telecommunication Standard, National Council for Prescription Drug Programs and equivalent Batch Standard, National Council for Prescription Drug Programs Depending upon context: NCPDP claim; NCPDP transaction; NCPDP batch transaction; NCPDP batch claim  Telecommunication Standard Implementation Guide and equivalent Batch Standard  Implementation Guide, National Council for Prescription Drug Programs.  Retail pharmacy professional services and supplies; retail pharmacy drugs   Claims sent electronically to Medicare must abide by the HIPAA standards listed above.  The current versions of these HIPAA standards are listed in chapter 24 of this manual.  More information about HIPAA can be found at www.cms.gov, under the Regulations and Guidance tab.  More information about these transactions and implementation guides can be found, as appropriate, at the official ASC X12 website and www.NCPDP.org .  In addition, chapter 24 of this manual provides more information regarding Medicares requirements for electronic data interchange (EDI), such as EDI enrollment and trading partner agreements.   Note that HIPAA standard implementation guides provide comprehensive directions regarding how to submit a claim on the transactions they support.  Therefore, there is no separate guidance in this claim processing manual as to how to submit a claim using these transactions.  However, there may be situations where the Medicare requirements require additional clarification, description, or guidance. In such cases, there will be additional instructions in the appropriate subject area section.   02.1.2 - Where to Purchase HIPAA Standard Implementation Guides  (Rev. 10236, Issued: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08-31-2020)   ASC X12 implementation guides (technical report 3s) may be purchased from the official Washington Publishing Company website.   NCPDP implementation guides may be purchased from the NCPDP at www.NCPDP.org   02.2 - Paper Claims (Rev. 3086, Issued: 10- 03-14, Effective:  ICD -10: Upon Implementation of ICD -10, ASC X12: January 1, 2012, Implementation  ICD- 10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)