evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Beginning in 2009, contractors shall maintain separate ZIP code files for each year which will be updated on a quarterly basis.  Claims shall be processed using the correct ZIP code file based on the date of service submitted on the claim.  It should be noted that though some states consist of a single pricing locality, ZIP codes can overlap states thus necessitating the submission of the 9-digit ZIP code in order to allow the process to identify the correct pricing locality.  Claims received with a 5 -digit ZIP code that is one of the ZIP codes that cross localities and therefore requires a 9 -digit ZIP code to be processed shall be treated as unprocessable.  For claims received that require a 9 -digit ZIP code with a 4 -digit extension that does not match a 4 -digit extension on file, manually verify the 4-digit extension to identify a potential coding error on the claim or a new 4-digit extension established by the U.S. Postal Service (USPS).  ZIP code and county information may be found at the USPS Web site at http://www.usps.com/, or other commercially available sources of ZIP code information may be consulted.  If this process validates the ZIP code, the claim may be processed.  The Revision to Payment Policies under the Physician Fee Schedule that is published annually in the Federal Register , or any other available resource, may be used to determine the appropriate payment locality for the ZIP code with the new 4- digit extension.  If this process does not validate the ZIP code, the claim shall be treated as unprocessable.  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 Two.  Group Code: CO CARC: 16  RARC: MA114  MSN: N/A
(Medicare Claims Processing Manual)
Should a service be performed in a ZIP code area that does not require the submission of the 9 -digit ZIP code, but the 4-digit extension has been included anyway, A/B MACs (Part B) shall price the claim using the A/B MAC (Part B) locality on the ZIP5 file and ignore the 4-digit extension.  Effective for claims processed on or after July 6, 2009, the standard system shall make revisions to allow contractors to add valid 4-digit extensions not included on the current quarter s 9-digit ZIP Code file until they  appear on  a quarterly file.   Contractors shall reprocess claims brought to their attention if the next CMS quarterly file is received and the locality determination on a new 4 -digit extension is different than that made manually by the contractor thus having inadvertently caused incor rect payment.  E.  ZIP9 Code to Locality Record Layout  Below is the ZIP9 Code to locality file layout.  Information on the naming conventions, availability, how to download the ZIP5 and ZIP9 files, and the ZIP5 layout can be found in Pub. 100-04, Chapter 15, section 20.1.6.  ZIP9 Code to Locality Record Layout  (Effective for dates of service on or after October 1, 2007.)  Field Name  Beg. Position  End Position  Length  Comments  State  1 2 2  ZIP Code  3 7 5  A/B MAC (B)  8 12 5  Pricing Locality  13 14 2  Rural Indicator     15 15 1 Blank=urban  R=rural  B=super rural  Filler   16 20 5  Plus Four Flag  21 21 1 0=no+4 extension  1=+4 extension  Plus Four  22 25 4
(Medicare Claims Processing Manual)
10.1.1.2 - Payment Jurisdiction for Services Subject to the Anti -Markup Payment Limitation  (Rev. 4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)  Diagnostic tests and their interpretations are paid on the MPFS.  Therefore, they are subject to the same payment rules as all other services paid on the MPFS.  Additional explanation is provided here due to general confusion concerning these services when they are performed or supervised by a physician or other supplier who does not meet the criteria for sharing a practice with the billing physician or other supplier, rather than rendered and billed by the billing entity.  (See 30.2.9 for additional information on sharing a practice.)  Physicians and other suppliers must meet the current enrollment criteria stated in chapter 15, of the Program Integrity Manual, in order to be able to bill for anti -markup tests.  That these services are billed by an entity that does not share a practice with the performing physician or other supplier does not negate the need for the performing physician or other supplier to follow appropriate enrollment procedures with the A/B MAC (Part B) that has jurisdiction over the geographic area where the services were rendered.   The A/B MAC (Part B) must accept and process claims for services subject to the anti -markup payment limitation when billed by physicians or other suppliers enrolled in the A/B MAC (Part B)s jurisdiction, regardless of the location where the services were furnished.  Effective for claims processed on or after April 1, 2004, in order to allow the A/B MAC (Part B) to determine jurisdiction and apply the anti- markup payment limitation correctly, global billing will not be accepted on electronic or paper claims when billing anti-markup tests. Claims received with global billings in this situation will be treated as unprocessable per 80.3.
(Medicare Claims Processing Manual)
Effective for claims submitted with a receipt date on and after October 1, 2015, billing physicians and suppliers must report the name, address, and NPI of the performing physician or supplier on all anti-markup and reference laboratory claims, even if the performing physician or supplier is enrolled in a different contractors jurisdiction.  Contractors shall return as unprocessable any anti- markup or reference laboratory claim with an NPI in Item 32a (or its electronic equivalent) that belongs to the billing physician/supplier, or that cannot be verified as a valid, Medicare enrolled entity.  A.  Payment Jurisdiction for Suppliers of Diagnostic Tests and Interpretations Performed by Other Suppliers under Contract   Effective for claims with dates of service on or after January 25, 2005, laboratories, physicians, and IDTFs must submit all claims for anti- markup tests to their local A/B MAC (Part B).  A/B MAC (Part B) must accept and process claims for services subject  to the anti -markup payment limitation when billed by suppliers enrolled in the A/B MAC (Part B) jurisdiction, regardless of the location where the services were furnished.  A/B MAC (Part B) should allow claims submitted by an IDTF for anti- markup tests if  the IDTF has previously enrolled to bill for anti-markup test components they perform.  Effective April 1, 2005, A/B MAC (Part B) must price anti -markup tests billed by laboratories and IDTFs based on the ZIP code of the location where the diagnostic test was rendered.   Effective for claims with dates of service on or after October 1, 2007 through 2013, A/B MAC (Part B) must use the national abstract file to price all claims for anti- markup tests for all supplier specialty types (including physicians), based on the ZIP code of the location where the service was rendered. Beginning in 2014, A/B MAC (Part B) must refer to an Anti -markup Test Indicator, to identify HCPCS codes payable under the MPFS as anti -markup tests for the year.   10.1.1.3 - Payment Jurisdiction for Reassigned Services (Rev. 1987, Issued: 06- 11-10, Effective: 08 -12-10, Implementation: 08- 12-10)
(Medicare Claims Processing Manual)
10.1.1.3 - Payment Jurisdiction for Reassigned Services (Rev. 1987, Issued: 06- 11-10, Effective: 08 -12-10, Implementation: 08- 12-10)  Though a supplier or provider may reassign payment for his services to another entity, suppliers are still required to bill the correct B/MAC for reassigned services when they are paid under the MPFS. The billing entity must submit claims to the B/MAC that has jurisdiction over the geographic area where the services were rendered.  Suppliers and providers must also meet current enrollment criteria stated in chapter 10 of the Program Integrity Manual in order to be able to bill for reassigned services.   10.1.3 - Exceptions to Jurisdictional Payment  (Rev. 1, 10- 01-03) B3-3100.6, R1813B3  Exceptions to billing the area carrier are:    A claim for covered services performed in the United States by a legally authorized Canadian or Mexican physician is within the jurisdiction of the carrier servicing the location where the services were rendered.    Because coverage of Part B services furnished in Canada or Mexico is contingent upon coverage of related inpatient hospital services, carriers designated to process foreign claims identified in  10.1.4.2 will receive such claims from the FI servicing the foreign hospital only after the FI has determined that the Part A services are covered. (If the request is for payment of medical services performed outside the United States by a physician or supplier whose office is located in the United States, the carrier servicing the physicians or suppliers office has jurisdiction. This carrier issues the denial determination and handles any resultant appeal.)    If a claim by an individual who resides outside the United States involves both medical services performed within the United States and medical services performed outside the United States the carrier will process both segments of the claim.   10.1.5 - Domestic Claims Processing Jurisdictions  (Rev. 1, 10- 01-03) B3-3102, B3- 3116  10.1.5.1 - Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN)  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  B3-3116, B -3102
(Medicare Claims Processing Manual)
B3-3116, B -3102  Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).   To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table of services by HCPCS code that indicates who to bill for which services. The CMS updates this list by a special One -Time Special Notification as needed. In general, claims for DMEPOS, other than implanted durable medical equipment and implanted prosthetic devices, are processed by the appropriate DME MAC. The appropriate A/B MAC processes claims for implanted durable medical equipment and implanted pr osthetic devices, as well as DMEPOS items incident to a physicians service.   Note that surgical procedures  for implantable DME or for prosthetic devices, performed in an inpatient or outpatient hospital setting include the cost of the device in the Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) rate. However, there are some implantabl e devices that are eligible for separate pass through under Outpatient Prospective Payment System (OPPS). DME MACs do not process claims for DMEPOS items that are subject to consolidated billing or bundled payment under Prospective Payment System (PPS) or in a DRG.   Claims from parenteral and enteral nutrition (PEN) suppliers are processed by the DME MAC.   Method II ESRD claims for dates of service prior to January 1, 2011, are also processed by the DME MAC.  For dates of service on and after January 1, 2011, refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis.  The claims processing jurisdiction among DME MACs  is determined by the beneficiarys permanent address. A beneficiarys permanent address is determined by where the beneficiary resides for more than six months of a year. See the CMS Web site at http://www.cms.hhs.gov/contacts/incardir.asp for a list of St ate jurisdictions by DME MAC.
(Medicare Claims Processing Manual)
10.1.5.2 - Supplier of Portable X -Ray, EKG, or Similar Portable Services  (Rev. 1, 10- 01-03)  If a supplier operates mobile units in geographic areas served by more than one carrier, the carrier serving the area where the service was performed must process the claims.   10.1.5.3 - Ambulance Services Submitted to Carriers  (Rev. 1, 10- 01-03)  Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.   A.  One Ambulance Vehicle Used   If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point of origin, i.e., home station of the vehicle. This carrier has qualification information on t he ambulance supplier and in most cases all other pertinent details necessary to adjudicate a claim.   EXAMPLE:  A patient is picked up at the Johns Hopkins Hospital in Baltimore, Maryland and transported to his home in West Virginia by an ambulance dispatched from the area of the patients home.  The carrier serving the point of origin of the ambulance, Nationwide M utual Insurance Company, Part B carrier for the State of West Virginia, has jurisdiction of any claim filed.  In this case Nationwide should have all the data necessary to make proper payment, i.e., certification of the ambulance company, price i nformation and data pertaining to the nearest appropriate company, price information and data pertaining to the nearest appropriate facility. Had an ambulance whose home station was in Baltimore been used, the carrier servicing Baltimore, Maryland would ha ve had jurisdiction. The Baltimore carrier would then have had to obtain data concerning the nearest appropriate facility to the patients home from Nationwide   B.  More Than One Vehicle Used   If more than one vehicle is used in transporting the patient to their destination, jurisdiction of the claim lies with:  The carrier serving the home base of the ambulance taking the patient on the first leg of the trip , on a trip to  a distant institution more remote than the nearest appropriate facility; or    The carrier serving the home base of the ambulance taking the patient on the final leg of the trip home, on a trip from  an institution more remote than the nearest appropriate facility.    If there is no  claim for the final leg of the trip, the carrier serving the patients home area handles any resulting claims or disallowance actions.
(Medicare Claims Processing Manual)
 If there is no  claim for the final leg of the trip, the carrier serving the patients home area handles any resulting claims or disallowance actions.   EXAMPLE:  A patient is transported by ambulance from a hospital in Miami Beach, Florida to Miami International Airport and from there by air ambulance to LaGuardia Airport in Queens, New York City. At the airport he is picked up by an ambulance (based in Yonkers, Ne w York) and taken to his home in Yonkers, New York. The carrier that handles the adjudication is the carrier whose area of responsibility includes Yonkers, New York, since partial reimbursement is based upon the nearest appropriate facility to his residence when he is being returned home from a distant institution.  In rules A and B above, the principle followed is that the carrier having the information to determine the nearest appropriate facility is the one to adjudicate the claim. In any event, before any partial reimbursement can be made, the carriers as designated in rules A and B, must have all the information concerning the patients transportation, from initial pickup to final destination .  10.1.5.4 - Independent Laboratories  (Rev. 1, 10- 01-03)  Jurisdiction of claims for laboratory services furnished by an independent laboratory normally lies with the carrier serving the area in which the laboratory test is performed. However, there are some situations where a regional or national lab chain juris diction is with a single carrier.   10.1.5.4.1 - Cases Involving Referral Laboratory Services  (Rev. 1, 10- 01-03)  If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by the other laboratory.   Examples of Independent Laboratory Jurisdiction   EXAMPLE 1:   An independent laboratory located in Oregon performs laboratory services for physicians whose offices are located in several neighboring States.  A physician from Nevada sends specimens to the Oregon laboratory.  If the laboratory sends the results to the physician and accepts assignment, the carrier in Oregon has jurisdiction.  EXAMPLE 2:
(Medicare Claims Processing Manual)
American Laboratories, Inc., is an independent laboratory company with branch laboratories located in Philadelphia, Pennsylvania, and Wilmington, Delaware, as well as regional laboratories located in Millville, New Jersey, and Boston, Massachusetts.  The Philadelphia laboratory receives a blood sample from a patient whose physician ordered a complete blood count, an SMAC T -4, and a B12 and folate. The Philadelphia lab performs the complete blood count, but the SMAC T -4 is performed at the Millville lab, while the B12 and folate is performed at the Boston Lab. The Pennsylvania carrier retains jurisdiction for processing the claims if they have certification information and the appropriate fee schedule allowance in house . Otherwise, the local carrier serv icing Boston and/or Millville has jurisdiction for processing their claims.   The Wilmington laboratory draws a blood specimen from a patient whose physician has ordered a blood culture. The Wilmington lab then sends the specimen to the Boston laboratory, which performs the required test. American Laboratories accepts an assignment for the service.   If the Delaware carrier has the capability of comparing the Wilmington labs charge for the blood culture against the appropriate reasonable charge screens for the Boston lab, the Delaware carrier will retain jurisdiction for processing the claim. If the D elaware carrier does not have this capability, the claim should be transferred to the Massachusetts carrier for processing.  10.1.6 - Railroad Retirement Beneficiary Carrier  (Rev. 142, 04- 16-04) B3-3103  Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:    The services are furnished by a M+C organization which deals directly with CMS on a cost basis;    The QRRB is enrolled under a buy- in agreement involving a State  agency that has entered into an agreement to act as a carrier with respect to such individuals; or;    The medical services were provided outside the United States, in which case the RRB handles the claim.  (See 10.1.4.6 for handling claims for services in Mexico.)
(Medicare Claims Processing Manual)
 The medical services were provided outside the United States, in which case the RRB handles the claim.  (See 10.1.4.6 for handling claims for services in Mexico.)   If a claim involves medical services provided both within and outside the United States, Palmetto GBA processes the claim for the medical services provided within the United States.  If the claimant raises a question as to why the medical services provided  outside the United States were not paid, Palmetto GBA directs the claimant to contact the RRB and forwards the claims to them at:   Railroad Retirement Board  Division of Disability and Health Insurance  844 Rush St.  Chicago, IL 60611   10.1.7 - Welfare Carriers  (Rev. 1, 10- 01-03) B3-3104, B3- 3060 for buy- in definition   Section 1843(f)  of Title XVIII permits a State agency that administers a plan under Titles I, XVI, or XIX to become the carrier for individuals enrolled in the States Buy In agreement. Currently there are no State agencies that are serving as carriers.   10.1.9 - Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  A misdirected claim is a claim that has been submitted to the wrong place.  This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.   Each fee- for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing.   Physicians and other suppliers are required to submit claims to the contractor having the appropriate jurisdiction.  Jurisdictional rules are specified in this Chapter at Section 10.   A contractor may not knowingly adjudicate a misdirected claim and, as such, upon receipt of such a claim, must dispose of the claim in accordance with the specifications of this section or other relevant instructions.  This section addresses the following types of misdirected claims:   1. a CMS -1500 or electronic claim submitted to the wrong local contractor (Part B MAC or carrier);   2. a CMS -1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to a DME MAC;
(Medicare Claims Processing Manual)
2. a CMS -1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to a DME MAC;   3. a CMS -1500 or electronic claim submitted to a DME MAC that should have been submitted to a local contractor (Part B MAC or carrier);   4. a CMS -1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to the Railroad Retirement Board (RRB);   5. a CMS -1500 or electronic claim submitted to a DME MAC or a local contractor (Part B MAC or carrier) that should have been submitted the United Mine Workers of America (UMWA);   6. a CMS -1500 claim that should be submitted to a DME MAC that is submitted to the wrong DME MAC, and  This subsection does not apply to:   1. misdirected beneficiary -submitted claims.  See Section 80.3.2 of this Chapter regarding handling of such claims;   2. electronic claims for durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) that are submitted to the incorrect DME MAC (misdirected DMEPOS claims are automatically routed to the appropriate DME MAC jurisdiction for processing);   3. a claim submitted to the wrong Part A MAC or fiscal intermediary (FI), including a regional home health intermediary (RHHI).   10.1.9.1  An A/B MAC (B) Receives a Claim for Services that are in Another A/B MAC (B)s Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a CMS -1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.   NOTE:  This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, but are billed to the wrong B MAC/carrier payment jurisdiction.  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 Three.