evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
120.1 - Overview  (Rev. 2678, Issued: 03- 29-13, Effective: 04 -29-13, Implementation: 04- 29-13)  The claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims.  All exact duplicate claims or claim lines are auto -denied or rejected (absent appropriate modifiers).  Suspect duplicate claims and claim lines are suspended and reviewed by the claims administration contractors to make a determination to pay or deny the claim or claim line.   Some claims that appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances of an item or service, for which Medicare payment may be made.  Correct coding rules applicable to all billers of health care  claims encourage the appropriate use of condition codes or modifiers to identify claims that may appear to be duplicates, but, in fact, are not.  For example, there are some HCPCS modifiers that are appropriate to be appended to some services and can indicate that a claim line is not a duplicate of a previous line on the claim. Level I modifiers would typically be used by a biller to indicate that a  potential duplicate claim or claim line is not, in fact, a duplicate. Level II modifiers may also be used. The Level II modifiers RT and LT, for example, indicate that a service was performed on the right and left side of the body, respectively.  However, not every HCPCS code has an associated modifier to indicate that a claim line is not a duplicate.  In that case, the claims and claim lines are reviewed by Medicare contactors local software modules for a determination or they suspend for contrac tor review.   120.2 - Exact Duplicates  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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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Exact duplicates are controlled by the claims processing system through hard coded edits, and may not be user -controlled.  In addition, Medicare contractors cannot override or bypass exact duplicate edits.  A.  Submission of Institutional Claims   Claims or claim lines that have been determined to be an exact duplicate are rejected and do not have appeal rights.  An exact duplicate for institutional claims is a claim or claim line that exactly matches another claim or claim line with respect to the following elements:    Medicare beneficiary identifier ;    Type of Bill;   Provider Identification Number;   From Date of Service;   Through Date of Service;   Total Charges (on the line or on the bill); and   HCPCS, CPT -4, or Procedure Code modifiers.   Additional Instructions for Institutional Claims:   Whenever any of the following claim situations occur, the MAC develops procedures to prevent duplicate payment of claims.  This includes, but is not limited to:    Outpatient payment is claimed where the date of service is totally within inpatient dates of service at the same or another provider. Do not consider outpatient services provided on the day of discharge within the inpatient dates of service.    Outpatient bill is submitted for services on the day of an inpatient admission or the day before the day of admission to the same hospital.   Outpatient bill overlaps an inpatient admission period.   Outpatient bill for services matches another outpatient bill with a service date for the same revenue code at the same provider or under a different provider number.  1.  History File -  Paid Claims   The MACs and legacy claims administration contractors must maintain a history file containing information about each claim processed.  The file may consist of the claim or information from it.  It must contain the following minimum information:   o Medicare beneficiary identifier;  o Beneficiary name information;  o Provider identification (name or number); and  o Billing period from the claim.   Claims or claims information in the history file may be transferred to inactive files.  However, the MAC must have the facility to recall such claims or information if a claim for the beneficiary involving the same time period is received.   2.  History File -  Pending Claims
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2.  History File -  Pending Claims   Contractors must have controls to prevent a duplicate claim from being paid while two claims are in the process within the system at the same time.  This may be accomplished through a special check of in- process claims or in the history file for paid claims.  The file should contain the same minimum information indicated in the subsections below.  The check should be performed prior to sending the claim to CWF.   3.  Analysis of Patterns of Duplicate Claims   The contractors shall establish a system for continuing analysis of duplicate claims.  This includes the systematic evaluation of returned Medicare Summary Notices from beneficiaries and communications from providers indicating a duplicate payment has been made, as well as returned checks from any payee.   The contractors system should provide for analyzing duplicate claim receipts to determine whether certain providers are responsible for duplicates and, if so, identify those providers.  The contractor should educate such providers to reduce the number of duplicates they submit.  Should those providers continue to submit duplicate claims, the MAC should initiate program integrity action.   B.  Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers)   Claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  However, such denials may be appealed.  An e xact duplicate for physician and other supplier claims submitted to a MAC or carrier is a claim or claim line that exactly matches another claim or claim line with respect to the following elements :   Medicare beneficiary identifier ;   Provider Number;   From Date of Service;   Through Date of Service;   Type of Service;   Procedure Code;   Place of Service; and   Billed Amount.   C.  Claims Submitted by DMEPOS Suppliers   Claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  Such denials may not be appealed.  An exact duplicate for DMEPOS supplier claims submitted to a DME MAC is a claim or claim line that exactly  matches another claim or claim line with respect to the following elements:   Medicare beneficiary identifier ;   From Date of Service;   Through Date of Service;   Place of service;   HCPCS code;   Type of Service;   Billed Amount;   Supplier   D.  Claims Submitted by Multiple DMEPOS Suppliers
(Medicare Claims Processing Manual)
D.  Claims Submitted by Multiple DMEPOS Suppliers   When a second DMEPOS supplier or multiple DMEPOS suppliers submit a claim during a span date already approved for the same beneficiary for a different DMEPOS supplier, the DME MAC shall deny the second or subsequent DMEPOS suppliers claim as a duplicate not a suspect duplicate when the following conditions are met:    Same Beneficiary Medicare beneficiary identifier   Overlapping span Date of Service (DOS) (From DOS and Through DOS)   Same Healthcare Common Procedure Coding System (HCPCS) Code,  Same Type of Service on the incoming claim matches a previously approved claim in history, and  The item is a diabetic testing supply    Items Subject to Duplicate Editing   1. Diabetic Testing Supplies   120.3 - Suspect Duplicates  (Rev. 2678, Issued: 03- 29-13, Effective: 04 -29-13, Implementation: 04- 29-13)  Suspect duplicates are claims or claim lines that contain closely -aligned elements sufficient to suggest that duplication may be present and, as such, require that the suspect claim be reviewed.  Suspect duplicate edits can be hard coded in the system or l ocal edits set up by Medicare contractors.   A.  Criteria for Detecting Suspect Duplicates for Institutional Claims   A suspect duplicate claim is a claim being processed which, when compared to the history or pending file, begins with these characteristics:    Match on the beneficiary information;   Match on provider identification, and   Same date of service or overlapping dates of service.   The contractors examine and compare to the prior bill any bill that is identified as a suspect duplicate.  If the services (revenue or HCPCS codes) on a claim duplicate the services for the other, contractors should check the diagnosis.  If the diagnosis c odes are duplicates, obtain an explanation from the provider before making payment.  B.  Suspect Duplicate Claims Submitted by Physicians and other Suppliers (including DMEPOS Claims)
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The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers are not published and vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.  The denial of claim as  a duplicate of another claim may be appealed when the denial is based on criteria other than those specified above for exact duplication.   A/B MACs, Part B legacy contractors, and DME MACs must add an informational indicator to the Common Working File (CWF) transaction record when, as a result of a contractor audit/edit or CWF reject, the contractor examines what appears to be a duplicate item or service and approves it for payment.  130 - Adjustments and Late Charges  (Rev. 1, 10- 01-03) A3-3664, HO -411.1, HO -IM411.1, HH -445, A3- 3610.8, HO -415.11  130.1 - General Rules for Submitting Adjustment Requests  (Rev.11794, Issued:01- 19-23, Effective: 04 -01-23, Implementation:04 -03-23)  Adjustment requests are the most common mechanism for changing a previously accepted bill.  They are required to reflect the results of QIO medical review.  CMS may also require adjustments if it discovers that bills have been accepted and posted in error to a particular record.  Adjustments that only recoup or cancel a prior payment are credits and must match the original in the following fields:   Intermediary control number (ICN/DCN);   Surname;   Medicare beneficiary identifier   When a definite match cannot be made on the three fields above, the providers MAC will use the fields below as needed.  Note that for older claims, ICN/DCN probably will not match.   Date of birth;   Admission Date for inpatient, (Date of First Service for outpatient) unless changed by this adjustment requests; and   From/thru dates for inpatient, (Date of First Service/Date of Last Service for Outpatient), unless changed by this adjustment request.  Cancel -only adjustment requests are not acceptable, except in cases of incorrect provider identification numbers and incorrect Medicare beneficiary identifier.  The provider must submit a corrected replacement bill (bill type xx1) to its MAC after submitting the cancel -only request for the incorrect bill.
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The provider must submit all other adjustment requests as debits only.  It shows the ICN/DCN of the bill to be adjusted as described above, with the bill type shown as xx7.  It submits adjustment requests to its MAC either electronically or on hard copy.  Electronic submission is preferred.  The ICN/DCN of an associated claim shall only be reported on adjustments.  The MAC shall return to the provider any original claim reporting information in this field.   The MAC must enter the following bill types that relate to the entity generating the adjustment request:   xx7 Provider (debit)  xx8 Provider (cancel)  xxF Beneficiary  xxG CWF  xxH CMS  xxI MAC  xxM  MSP  xxP QIO xxJ Other  xxK OIG/GAO   The provider submits all adjustment requests as bill type xx7 or xx8.  Since several different sources can initiate an MSP adjustment (e.g., the provider, CWF, or the MAC), the MSP designation, xxM, takes priority over any other source of an adjustment exc ept OIG/GAO.  When the provider submits an MSP adjustment request, the MAC will change the bill type to xxM.  These priorities refer only to the designation of the source of the adjustment.  The difference between CWF generating the adjustment request and CMS generating the adjustment request is: An adjustment request is CWF -generated if the MAC receives a CWF unsolicited response, alert or a CMS -L1002.   The MAC prepares an adjustment if instructed by CMS CO or CMS RO to make a change.  Typically, such direction from CMS is to retroactively change payment for a class or other group of bills.  Occasionally, CMS will discover an error in the processing of a single bill and direct the MAC to correct it.   If adjustments are rejected by CWF for additional corrections, they must be corrected and resubmitted.  Even if a letter from CMS requests the adjustment action, the MAC must submit the adjustment request in its CWF record.  If a rejected adjustment reques t is determined to be unnecessary, the MAC stops the adjustment action upon receipt of correction.  Where an adjustment request changes subsequent utilization, the MAC notes this and processes adjustments to subsequent bills if it services the provider.
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130.1.1 - Adjustment Bills Involving Time Limitation for Filing Claims  (Rev. 1, 10- 01-03) A3-3664.D  If a provider fails to include a particular item or service on its initial bill, an adjustment request(s) to include such an item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim.  However, to the extent that an adjustment request otherwise corrects or supplements information previously submitted on a timely claim about specified services or items furnished to a specified individual, it is subject to the rules governing administrative finality, rather than the  time limitation for filing.   130.1.2 - Claim Change Reasons  (Rev. 1, 10- 01-03) HO- 411.2, HO -IM411.2, HH -445  130.1.2.1 - Claim Change Reason Codes  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The provider submits one of the following claim change reason codes to its FI with each debit -only or cancel -only adjustment request:
(Medicare Claims Processing Manual)
The provider submits one of the following claim change reason codes to its FI with each debit -only or cancel -only adjustment request:   Bill Type  Reason Code  Explanation  Xx7 D0 (zero)  Change to service dates  Xx7 D1 Change in charges  Xx7 D2 Change in revenue codes/HCPCS - HIPPS  Xx7 D3 Second or subsequent interim PPS bill - PPS inpatient hospital only  Xx7 D4 Change in GROUPER input (diagnoses or procedures) - PPS inpatient hospital).  Xx8 D5 Cancel -only to correct a Medicare beneficiary identifier or provider identification number  Xx8 D6 Cancel -only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill.)  Xx7 D7 Change to make Medicare the secondary payer  Xx7 D8 Change to make Medicare the primary payer  Xx7 D9 Any other change  Xx7 E0 (zero)  Change in patient status   The provider may not submit more than one claim change reason code per adjustment request.  It must choose the single reason that best describes the adjustment it is requesting.  It should use claim change reason code D1 only when the charges are the only change on the claim.  Other claim change reasons frequently change charges, but the provider may not add reason code D1 when this occurs.   The claim change reason code is entered as a condition code on the hard copy Form CMS -1450 or the electronic equivalent.  For reason codes D0- D4 and D7- D9, the biller submits a debit -only adjustment request, bill type xx7.  For reason codes D5 and D6, it submits a cancel -only adjustment request, bill type xx8.
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130.1.2.2 - Edits on Claim Change Reason Codes  (Rev. 1, 10- 01-03) The following edits are based on the claim change reason code.  The FI must apply them to each incoming adjustment request.   If the type of bill is equal to xx7 and the claim change reason code is not equal to D0-D4, D7 -D9, or E0, the FI rejects the request back to the provider with the following error message, Claim change reason code must be present and equal to D0-D4, D7 -D9, or E0 for a debit -only adjustment request.   If the type of bill is equal to xx8 and the claim change reason code is not equal to D5-D6, the FI rejects the request back to the provider with the following error message, Claim change reason code must be present and equal to D5 -D6 for a cancel -only adj ustment request.   If the type of bill is equal to xx7 or xx8 and the ICN/DCN of the claim being adjusted is not present, the FI rejects the request back to the provider with the following message,  ICN/DCN of the claim being adjusted is required for an adjustment request.   If more than one claim change reason code is present on the providers request, the FI rejects the request back to the provider with the following message; only one claim change reason code may apply to a single adjustment request from a provider.  The FI  chooses the single claim change reason code that best describes the reason for the providers request and resubmit.   If the provider submits an adjustment request as type of bill not equal to xx7 or xx8, the FI rejects the request back to the provider with the message, Provider submitted adjustment request must use type of bill equal to xx7 or xx8.   If the claim change reason code is equal to D0, the FI compares the beginning and ending dates on the providers request to those on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the provider with the message, Dates of service must change for claim change reason code D0.   If the claim change reason code is equal to D1, the FI compares the total and line item charges on the
(Medicare Claims Processing Manual)
rejects the request back to the provider with the message, Dates of service must change for claim change reason code D0.   If the claim change reason code is equal to D1, the FI compares the total and line item charges on the providers request to those on the claim to be adjusted on its history.  If these changes are the same, the FI rejects the request back to the provider w ith the message, Charges must be changed for claim change reason code D1.   If the claim change reason code is equal to D2 (revenue code/HCPCS or HIPPS), the FI compares revenue codes/HCPCS or HIPPS on the providers request to those on the claim to be adjusted on its history.  If these codes are the same, it rejects the request b ack to the provider with the message, Revenue codes/HCPCS or HIPPS must change for claim change reason code D2.   If the claim change reason code is equal to D3 (PPS inpatient hospital only), the FI compares the ending date on the hospitals request to that on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the hos pital with the message, Thru dates must change for the claim change reason code D3.   If the claim change reason code is equal to D4 (PPS inpatient hospital), the FI compares diagnosis and procedure codes on the providers request to those on the claim to be adjusted on its history.  If these codes are the same and are in the same sequence,  it rejects the request back to the provider with the message, Diagnoses and/or procedures must change for claim change reason code D4.   If the claim change reason code is equal to D5 or D6, type of bill must be equal to xx8 on the providers request.  If type of bill is not equal to xx8, the FI rejects the request back to the provider with the message, Type of bill must be equal to xx8 for claim change reason codes D5 or D6.   If the claim change reason code is equal to D7, an MSP value code (12 -16, 41- 43, or 47) must be present, if a value code, 12- 16, 41- 43, or 47, is not
(Medicare Claims Processing Manual)
the claim change reason code is equal to D7, an MSP value code (12 -16, 41- 43, or 47) must be present, if a value code, 12- 16, 41- 43, or 47, is not present, the FI rejects the request back to the provider with the message, An MSP value code (12-16, 41- 43, or 47) must be present for claim change reason code D7.   If the claim change reason code is equal to D7, and one or more of value codes 12-16, 41- 43, and/or 47 is present but each value amount is equal to 0 (zero) or spaces, the FI rejects the request back to the provider with the message, invalid value amount for claim change reason code D7.   If the claim change reason code is equal to D8, and a value code 12 -16, 41- 43, or 47 is present, the FI rejects the claim back to the provider with the message, Invalid value code for claim change reason D8.   If the claim change reason code is equal to E0, the FI compares patient status on the providers request to that on the claim to be adjusted.  If patient status is the same, the FI rejects the request back to the provider with the message, Patient status must change for claim change reason E0.  The FI must suspend for investigation all adjustment requests with claim change reason codes D8, and D9.  Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may be reported to the OIG.
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130.1.2.3 - Additional Edits  (Rev. 1, 10- 01-03) The FI must perform the following additional edits and investigate adjustment requests the provider submits:   A full denial once the bill is paid, except to accomplish retraction of a duplicate payment;   Inpatient Hospital Only -  A change in DRG based on a change in age or sex;   A change in deductible;   An adjustment request that changes a previously submitted QIO adjustment request;   An adjustment of a bill due to a change in utilization or spell data on another bill;   A reopening to change a no- payment bill to a payment bill;   A reopening to pay a previously denied line item;   An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or   An adjustment request with a claim change reason code equal to E0, and the claim is for an inpatient PPS hospital.  The FI must investigate if the change is from patient status 02, transferred to another acute care facility.  130.1.3 - Late Charges  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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.