evekhm/cms_iom_500 huggingface dataset:
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The automated MSP GHP reprocessing requirement allows CWF to alert the shared system when a MSP GHP record is deleted or a termination date added for specific beneficiaries. The shared systems and Medicare Contractors receive an IUR transaction response fr om CWF alerting the system to reprocess certain MSP GHP claims where the open GHP record was deleted /terminated by the Coordination of Benefits Contractor (COBC) or 1 -800-Medicare.  This unsolicited transaction is sent to the contractors on record at CWF who had claim history for the associated beneficiary within the 180 day period.  The CWF system is already programmed to send an updated MSP transaction (HUSC transaction) any time a change is made to an MSP record and this process does not change.       130.7 - MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims (Rev. 4415; Issued: 10- 11-19; Effective: 01 -01-20; Implementation: 01 -06-20)
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130.7 - MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims (Rev. 4415; Issued: 10- 11-19; Effective: 01 -01-20; Implementation: 01 -06-20)  The Centers for Medicare & Medicaid Services (CMS)  is refining the claim adjustment reporting process to achieve better consistency in the reporting of claim adjustments across the Medicare Administrative Contractors (MACs) and is adding new codes to address gaps in the current list of codes available.   The Shared Systems use different terminology for the adjustment codes. In FISS, the adjustment codes are called Claim Frequency Codes. In MCS, the adjustment codes are called Method of Discovery Codes.  In VMS, the adjustment codes are called Accounting Discovery Codes.  CMS is directing the A/B MACs to use claim frequency code H when CMS initiates the Part A claim adjustment, such as a mass adjustment directed by CMS to address system issues, and claim frequency code I when the A/B MAC identifies and initiates the Par t A claim adjustment.   CMS is also creating a new method of discovery code 12 to identify Part B adjustments in MCS that were initiated by CMS, and a new method of discovery code 13 for MAC initiated Part B adjustments in MCS.  The A/B MACs should use method of discovery code 12 for CMS -directed adjustments that do not fall into the C - CMS Review category or other existing CMS-related method of discovery categories.  The A/B MACs should use method of discovery code 13 for MAC identified and initiated adjustments that d o not fall into the existing method of discovery code categories, such as method of discovery code A.  The A/B MACs should use method of discovery code A for adjustments arising from MAC initiated internal review, such as adjustments to address errors the MAC identified while processing the claim or adjustments due to MAC internal quality reviews.   For provider initiated adjustments, MACs should continue with their current method of reporting (claim frequency code 7 for Part A claims, method of discovery code P for Part B MCS claims, and accounting discovery code D for Part B DME claims).
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140 - Fiscal Intermediary (FI) Edits Affecting Multiple Bill Types  (Rev. 620, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06)  140.1 - Threshold Edit for Outpatient and Inpatient Part B Claims  (Rev. 620, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06) Effective for claims received on or after January 1, 2006, intermediaries shall edit for outpatient and inpatient Part B claims that meet or exceed a reimbursement amount of $50,000.  The edit shall be applied to the following providers and bill types: Provider Type   Types of Bills   Hospitals           12X, 13X, 14X   Skilled Nursing Facilities       22X, 23X  Home Health Agencies        32X, 33X, 34X   Religious Nonmedical Health Care Institutions   43X  Rural Health Clinics         71X  Renal Dialysis Facilities        72X  Federally Qualified Health Centers     73X  Outpatient Rehabilitation Facilities     74X  Comprehensive Outpatient Rehabilitation Facilities  75X  Community Mental Health Centers     76X  Hospice Providers         81X, 82X   Non-OPPS Hospitals Ambulatory Surgery    83X  Critical Access Hospitals        85X The FIs shall suspend those claims receiving the threshold edit for development and contact providers to resolve billing errors.  If the FI determines that the reimbursement is excessive and claim corrections are required, the FI shall return the claim to the provider.  If the FI determines that the billing is accurate and the reimbursement is not excessive, the FI shall override the edit and submit the claim to the Common Working File (CWF)   140.2  Systematic Validation of Claims Information Using Patient Assessments  (Rev. 3001, Issued: 08- 01-14, Effective: 10 -01-12, Implementation: 01- 05-15)  The case- mix groups used to determine payments under several Medicare prospective payment systems (PPS) are based on clinical assessments of the beneficiary.  Each payment system uses a different patient assessment tool:   Payment System  Assessment Used  Skilled Nursing Facility  SNF PPS  Minimum Data Set  Home Health  HH PPS  Outcomes and Assessment Information Set Inpatient Rehabilitation Facility  IRF PPS  IRF Patient Assessment Instrument
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Payment System  Assessment Used  Skilled Nursing Facility  SNF PPS  Minimum Data Set  Home Health  HH PPS  Outcomes and Assessment Information Set Inpatient Rehabilitation Facility  IRF PPS  IRF Patient Assessment Instrument   In all three payment systems, the assessments are entered into software at the provider site that encodes the data into a standard transmission format and transmits the assessments to quality improvement systems.  In addition, the software runs the data fr om the assessments through grouping software that generates a case -mix group to be used on Medicare PPS claims.  These case mix groups are reported on claims using a Health Insurance PPS (HIPPS) code.   CMS provides free grouping software to perform this function, but many providers create their own software due to their need to integrate these data entry and grouping functions with their own administrative systems.  In some cases, this results in HIPPS c odes reported on claims that differ from the HIPPS code calculated by the assessment system.    In the interest of payment accuracy, Medicare claims processing systems may temporarily hold Medicare PPS claims paid under these payment systems (Medicare Advantage claims are excluded), in order to validate the claim information against the assessment re cord.  If the information found in the assessment system differs from the claim information, the assessment information will be used to pay the claim.   This process will occur within the payment floor period.   This process may be used for various purposes, including:    Validating the provider -submitted HIPPS code   Ensuring timely assessment submission requirements are met   Ensuring conditions of payment are met.  140.3 - Verification Edit for Claims with OPPS Payments  (Rev. 2463, Issued 05- 04-12, Effective: 10 -01-12, Implementation: 10- 01-12)  Effective for claims received on or after October 1, 2012, FISS shall install a verification edit for claims with OPPS payments that exceed a reimbursement amount greater than submitted charges. The edit shall be applied to the following providers and bill types:   Provider Type       Types of Bills  Hospitals        12X, 13X, 14X
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Provider Type       Types of Bills  Hospitals        12X, 13X, 14X   Contractors shall suspend those claims receiving the verification edit for development and contact providers to resolve billing errors. If the contractor determines that the reimbursement is excessive and claim corrections are required, the contractor shal l return the claim to the provider. If the contractor determines that the billing is accurate and the reimbursement is not excessive, the contractor shall override the FISS edit and submit the claim to the Common Working File (CWF).   150 - Limitation of Liability Notification and Coordination With Quality Improvement Organizations (QIOs)  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06)  The longstanding relationship between QIOs and fiscal intermediaries (FIs) is defined in regulations at 42 CFR 476.80.  Generally, these regulations require QIOs and FIs to have an agreement under which:    QIOs inform FIs of the results of DRG validation of hospital inpatient claims    QIOs inform FIs of initial determinations of cases subject to preadmission review and any changes to these determinations   FIs ensure they do not pay claims subject to initial determinations until they receive notice from the QIO    QIOs and FIs exchange data or information and otherwise coordinate to perform their functions.  More recently, this relationship was expanded by regulations regarding expedited determinations, found in 42 CFR 405, sections 1200-1208.  The following subsections provide additional detail on the coordination between these parties.  They also describe how various Medicare provider types reflect decisions of QIOs on claims they submit to Medicare FIs and how these decisions may affect the liability of Medicare beneficiaries for payment.  150.1 - Limitation on Liability - Overview  (Rev. 632, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06) A3-3674.1 HO-414.6  Chapter 30, of this manual has a complete explanation of the limitation of liability provision. However, the basic premise of the limitation on liability provision (1879
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of the Act) is that beneficiaries and providers who did not know, and could not reasonably have been expected to know, that payment would not be made for such items(s) or service(s) item(s) and/or service(s) are protected from liability.  Where the prov ider had such knowledge, such that the 1879 limitations on liability do not apply, liability falls upon the provider (i.e., the provider cannot charge the beneficiary for such services when aware no program payment will be made).  Medicare requires providers to notify beneficiaries when they face financial liability, so they can make informed choices.   150.2 - Hospital Claims Subject to Hospital Issued Notices of Noncoverage  (Rev. 632, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06)  Hospitals must issue the HINN for inpatient hospital services, form prior to delivering care, and must deliver the form properly, so that a beneficiary knowingly assumes liability.  Instructions for the HINN are found in CMS Transmittal 594, and apply in specific cases to Part A services furnished by hospitals.   150.2.1 - Scope of Issuance of Hospital Issued Notices of Noncoverage (HINNs)  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06) HO- 414.3, .4  Inpatient hospitals are required to issue HINNs to beneficiaries in a variety of circumstances defined in Chapter 30 of this manual.  Hospitals should refer to section 80 of that chapter for further instructions on HINNs.
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Inpatient hospitals are required to issue HINNs to beneficiaries in a variety of circumstances defined in Chapter 30 of this manual.  Hospitals should refer to section 80 of that chapter for further instructions on HINNs.   NOTE:   Hospitals submit bills for all inpatient stays, including those for which no payment can be made.  Although no monies are involved with no- payment bills, a claim is required because hospitalization could extend a Medicare beneficiary's benefit period, or coinsurance or deductible may be due.  The hospital is not required to issue a HINN when it does not plan to bill the beneficiary (or their representative) for item(s) or service(s).  However, applicable coinsurance and deductibles are always charged  to the beneficiary when care is provided no matter what party is liable for payment, and no liability notification is required for these collections.   150.2.2 - General Responsibilities of QIOs and Fiscal Intermediaries (FIs) Related to HINNs  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01 -03-06) A3-3674.2   Publication 100- 10, The Quality Improvement Organization Manual, Chapter 7, provides detailed instructions regarding QIO responsibilities and procedures related to HINNs.   The FI is responsible for making liability determinations in other cases (e.g., eligibility and reductions of payment).  However, the FI adjudicates claims, makes payment and sends beneficiaries Medicare Summary Notices in all cases, reflecting both QIO an d FI determinations on liability.  This joint responsibility requires that the QIO notify the FI of its denial determinations, all preadmission determinations, and diagnostic or procedural coding changes.  The FI does not issue a denial notice to the benef iciary or the hospital for cases that have been reviewed by the QIO.  The QIO notifies the beneficiary and hospital.  NOTE:   QIO determinations are binding and cannot be reversed by the FI.   150.2.3 - Billing and Claims Processing Requirements Related to HINNs  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)
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150.2.3 - Billing and Claims Processing Requirements Related to HINNs  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  Where QIO review is done prior to billing (preadmission or admission HINN), the hospital reports the results of the QIO's review on the claim using special indicators.  A set of condition codes were created to reflect these reviews.  These codes, C1 - C7, a re known as the QIO approval indicator codes. Information regarding the form locator numbers that correspond to condition codes and a table to crosswalk UB -04 form locators to the 837 transaction is found in Chapter 25.  The FI reviews these codes and makes determinations as follows:    Code C1, C3, or C6 -  Pay as billed.   Code C4 -  Do not pay, but process a no- payment bill.   Blank or Code C5 -  Return the claim to the provider for QIO review, unless the FIs agreement with the QIO requires sending it directly to the QIO.   Where the QIO review occurs after FI processing (postpayment review), the QIO reports adjustments to the FI.  Currently there is no approved electronic format for this report.  150.3 - Skilled Nursing Facility (SNF), Home Health Agency (HHA), Hospice and Comprehensive Outpatient Rehabilitation Facility (CORF) Claims Subject to Expedited Determinations  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06)
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In short, SNFs, HHAs, hospices and CORFs must give notice to Medicare beneficiaries of their right to expedited determinations when their period of covered care ends.  Expedited determinations allow beneficiaries to challenge/appeal their providers decisi ons to discharge, whereas the standard appeal process available after a claim is adjudicated allows beneficiaries to dispute payment denials.  Detailed instructions regarding expedited determination notices are found in CMS Transmittal 594.  150.3.1 - Scope of Issuance of Expedited Determination Notices  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06) Expedited determination notices are required prior to discharge when Medicare covered care has been occurring for some type of duration, such as a stay in an inpatient facility, or a period of services delivered under a plan of care supported by a physicia n order.  Generally, intermittent items or services covered under Part B do not trigger the right to expedited determinations, since there is no continuous care to end.  Expedited determinations are available to beneficiaries for each of the specified prov ider types as follows:  HHAs:  Provider initiated discharges for coverage reasons from HH services under a home health plan of care (types of bill 32x and 33x) are subject to expedited determination notices.  Home health services billed on a 34x type of bill are included if there is a therapy plan of care, but not when the HHA is acting as a durable medical equipment supplier in one -time or sporadic delivery of equipment.  SNFs:  Provider initiated discharges for coverage reasons associated with SNF and swing bed inpatient claims (types of bill 18x, 21x and 22x) are subject to expedited determination notices.  Hospices:  Provider initiated discharges for coverage reasons from hospice services (types of bill 81x and 82x), whether in inpatient or home care settings, are subject to expedited determination notices.  Even though revocation represents an end of covere d hospice care, it cannot trigger an expedited determination since it is the beneficiarys, not the providers, choice to revoke.  Hospice discharges related to qualification/coverage specific to the benefit would be rare cases where a
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care, it cannot trigger an expedited determination since it is the beneficiarys, not the providers, choice to revoke.  Hospice discharges related to qualification/coverage specific to the benefit would be rare cases where a beneficiary previously certified as terminally ill is judged no longer to be terminal.  CORFs:  Provider initiated terminations of all covered CORFs services (type of bill 75x) provided under a therapy plan of care are subject to expedited determination notices.  CORF services not provided under a plan of care, such as injections, are not inc luded.  Therapy services provided by outpatient rehabilitation facilities (type of bill 74x) or therapy services in hospital outpatient departments are not included.  Expedited determinations notices are not required when discharge is unrelated to coverage.
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150.3.2 - General Responsibilities of QIOs and FIs Related to Expedited Determinations  (Rev. 632, Issued: 07- 29-05, Effective: 01 -03-06, Implementation: 01- 03-06) A.  QIO Role  QIOs review expedited determination notices providers give beneficiaries, both as part of making decisions relative to coverage and to assure providers have given valid notice.  The QIO is responsible for establishing contact with the provider, so that the  beneficiarys medical records can used in making a determination, although QIOs can still make such decisions even if records are not available.  The QIO makes a decision on coverage in answer to the beneficiarys request for review, relaying this decision back to the involved parties.  If the beneficiary does not accept the QIO determination, they may request a reconsideration from a Qualified Independent Contractor (QIC).  B.  Intermediary Role Intermediaries support beneficiaries and providers through an awareness of the expedited determination process and by performing routine duties potentially affected by this process --liability notice oversight, claims processing and medical review.  In the initial implementation of expedited determinations, FIs need to coordinate with QIOs regarding the outcome of QIO r eviews.  As providers begin reporting the outcomes of QIO reviews on claims, the need for this coordination will diminish. Intermediary medical review should never repeat or contradict the results of QIO review regarding coverage, since this would be duplicative and QIO decisions are binding, and QIOs are bound by the same coverage policy in making their determinations --even l ocal policy.  But the scope of these QIO decisions is limited to discharge, and medical review examines a much broader range of potential issues and periods of care.  For example, a monthly SNF claim could include a discharge reviewed by a QIO, but it also contains other days of billing not related to discharge the non- discharge period is not considered by the QIO, and would still be subject to medical review.   150.3.3 - Billing and Claims Processing Requirements Related to Expedited Determinations  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)
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150.3.3 - Billing and Claims Processing Requirements Related to Expedited Determinations  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  As noted above, the outcome of expedited determinations and reconsiderations will be reported on Medicare claims to assure intermediary adjudication of claims is consistent with QIO/QIC decisions.  Note that the expedited review process is always completed  prior to billing, and therefore does not directly affect established billing procedures, even demand billing, other than the use of indicators described below.   Special indicators are used on claims to reflect the outcome of QIO expedited determinations and QIC reconsiderations.  Before the creation of the expedited review process, QIO related determinations were reflected only on hospital claims.  A set of condit ion codes were used to reflect these determinations. These codes, C1 - C7, are known as the QIO approval indicator codes.   With the advent of the expedited determination process, these QIO approval indicators are relevant to types of bill other than inpatient hospital claims.  The QIO approval indicator codes described below are valid for Medicare billing on the following type s of bill: 18x, 21x, 22x, 23x, 32x, 33x, 34x, 75x, 81x, 82x.  Since QIO expedited decisions and QIC reconsideration decisions have the same effect on providers and beneficiaries, the same QIO approval indicator codes will be used to report a decision by either entity.  Providers should note that no indicators are required on discharge claims in the case where a generic notice is provided and the beneficiary does not request an expedited determination.  A  Reporting of QIO/QIC Decisions Upholding a Discharge   Providers must also report indicators on claims when they receive notification of decisions which uphold the providers decision to discharge the beneficiary from Medicare covered care.  In these cases, providers submit a discharge claim for the billing period that precedes the determination according to all applicable claims instructions plus one additional data element. Providers must annotate these claims with condition code C4, defined as Services Denied.