evekhm/cms_iom_500 huggingface dataset:
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d. If the NO box is checked in item 20 and an acquisition price is entered under the word $CHARGES. RARC: MA110  e. If the YES box is checked in item 20 and the acquisition price is entered under $CHARGES", but the performing physician or other suppliers name, address, ZIP Code, and NPI is not entered into item 32a of the Form CMS -1500 when billing for diagnostic  services subject to the anti -markup payment limitation.  RARC: N294   Entries f  k are effective for claims received on or after April 1, 2004:   f. On the Form CMS -1500, if the YES box is checked in Item 20, and more than one test is billed on the claim;  g. On the Form CMS -1500, if both the technical component and professional component are billed on the same claim and the dates of service and places of service do not match;   h. On the Form CMS -1500, if the YES box is checked in Item 20, both the technical component and professional component are submitted and the date of service and place of service codes do not match.   i. On the ASC X12 837 professional claim format, if there is an indication on the claim that a test is subject to the anti- markup payment limitation, more than one test is billed on the claim, and line level information for each total acquisition amount is not submitted for each test.   j. On the Form CMS -1500 if the YES box is checked in Item 20 and on the ASC X12 837 professional claim format if there is an indication on the claim that a test is subject to the anti- markup payment limitation, and the service is billed using a global code rather than having each component billed as a separate line item.   k. If there is an indication on the claim that the test is subject to anti- markup and the NPI of the performing entity (in Item 32a of the CMS -1500 or its ASC X12 837 equivalent) belongs to the billing provider OR the performing entity is not a valid, Medi care enrolled entity.   4.   If a provider of service or supplier is required to submit a diagnosis in item 21 and either the diagnosis code is missing, incorrect or truncated; or a narrative diagnosis was not provided on an attachment.  RARC: M76
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4.   If a provider of service or supplier is required to submit a diagnosis in item 21 and either the diagnosis code is missing, incorrect or truncated; or a narrative diagnosis was not provided on an attachment.  RARC: M76   5.   For claims received on or after April 1, 2013, if a provider of service or supplier is required to submit a diagnosis in Item 21 of the Form CMS - 1500 and an ICD -9-CM E code (external causes of injury and poisoning) is reported in the first field of  Item 21. And, effective for dates of service on or after the effective date for ICD -10-CM codes, if an ICD -10-CM diagnosis code within the code range of V00 through Y99 is reported in the first field of Item 21. RARC: MA63  For paper claims, ICD -10-CM codes can be reported only on the revised CMS -1500 claim form version 02/12, but not before the effective date of ICD -10-CM.  The revised form (02/12) has the capacity to accept either ICD -9-CM or ICD -10-CM codes depending upon the effective date of the ICD code set.  The old form version (08/05) had only the capacity to accept ICD -9-CM codes.   Refer to chapter 26 for more information about the old and revised forms).  6.   If a rendering physician, physician assistant, nurse practitioner, clinical nurse specialist, supplier/or other practitioner who is a sole practitioner or is a member of a group practice does not enter his/her NPI into item 24J of Form CMS -1500 except  for influenza virus and pneumococcal vaccine claims submitted on roster bills that do not require a rendering provider NPI.  RARC: N290  7.   If a primary insurer to Medicare is indicated in item 11, but items 4, 6, and 7 are incomplete.  Item 4: RARC: MA92.  Item 6: RARC: MA89.  Item 7: RARC: MA88.
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8.   If there is insurance primary to Medicare that is indicated in item 11 by either an insured/group policy number or the Federal Employee Compensation Act number, but a Payer or Plan identification number (use HPID when effective) is not entered in field 11C (RARC: MA92), or the primary payers program or plan name when a Payer or Plan ID (use HPID when effective) does not exist (RARC: N245).  9.   If a HCPCS code modifier must be associated with a HCPCS procedure code or if the HCPCS code modifier is invalid or obsolete.  RARC: M20   10.   If a date of service extends more than 1 day and a valid to date is not present in item 24A.  RARC: M59   11.   If an unlisted procedure code or a not otherwise classified (NOC) code is indicated in item 24D, but an accompanying narrative is not present in item 19 or on an attachment.  RARC: M51   12. If the name, address, and ZIP Code of the facility where the service was furnished in a hospital, clinic, laboratory, or facility other than the patients home or physicians office is not entered in item 32 (Remark code MA114 is used.)  Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered. RARC: MA114
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Effective for claims with dates of service on or after October 1, 2007, the name, address, and 9 -digit ZIP Code of the service location for services paid under the Medicare Physician Fee Schedule and anesthesia services, other than those furnished in place of service home  12, and any other places of service A/B MACs treat as home, must be entered according to Pub. 100- 04, Chapter 1, sections 10.1.1 and 10.1.1.1.  RARC: MA114  Effective for claims with dates of service on or after October 1, 2007, f or claims received that require a 9 -digit ZIP Code with a 4 digit extension, a 4- digit extension that matches one of the ZIP9 file or a 4 -digit extension that can be verified according to Pub. 100- 04, Chapter 1, sections 10.1.1 and 10.1.1.1 must be entered on the claim.  RARC: MA114   Effective January 1, 2011, for claims processed on or after January 1, 2011, on the Form CMS -1500, the name, address, and 5 or 9- digit ZIP code, as appropriate, of the location where the service was performed for services paid under the Medicare Physician Fee Schedule and anesthesia services, shall be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 for services provided in all places of service.  RARC: MA114  Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional electronic claim format for services payable under the MPFS and anesthesia services when rendered in POS home (or any POS th ey consider home) if submitted without the service facility location.  RARC: MA114  13. Effective for claims received on or after April 1, 2004, if more than one name, address, and ZIP Code is entered on the Form CMS -1500 in item 32.   14. If any of the modifiers PA, PB, or PC are incorrectly associated with a service which is other than a wrong surgery on a patient, surgery on the wrong body part, surgery on the wrong patient or a service related to one of these surgical errors.
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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: 4  RARC: N/A  MSN: N/A  80.3.2.1.3 - A/B MAC (B) Specific Requirements for Certain Specialties/Services  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  Unless otherwise specified, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under the policies in this section.   These CARC/RARC combinations compliant with CAQH CORE Business Scenario Tw o.  Group Code: CO  CARC: 16  RARC: shown below.  MSN: N/A   A/B MACs (B) must return the following claim as unprocessable to the provider of service/supplier:   A.   For chiropractor claims:   1.   If the x- ray date is not entered in item 19 for claims with dates of service prior to January 1, 2000.  Entry of an x- ray date is not required for claims with dates of service on or after January 1, 2000.  2.   If the initial date actual treatment occurred is not entered in item 14.  RARC: MA122  B.   For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and the groups name, address, and ZIP Code is not entered in item 33 or if the NPI is not entered in item 33a of the Form CMS -1500, if their personal NPI is not entered in item 24J of the Form CMS -1500.  RARC: MA112   C.   For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location where the order was accepted were not entered in item 32.  RARC: MA114   D.   For physicians who maintain dialysis patients and receive a monthly capitation payment:
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1.   If the physician is a member of a professional corporation, similar group, or clinic, and the NPI is not entered into item 24J of the Form CMS -1500.  RARC: N290   2.   If the name, address, and ZIP Code of the facility other than the patients home or physicians office involved with the patients maintenance of care and training is not entered in item 32.  RARC: MA114.  Effective for claims received on or after Apr il 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered.   E.   For routine foot care claims, if the date the patient was last seen (RARC: N324) and the attending physicians NPI is not present in item 19 (RARC: N253).    F.   For immunosuppressive drug claims, if a referring/ordering physician, physicians assistant, nurse practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a. (RARC: N264), or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).  G.   For all laboratory services, if the services of a referring/ordering physician, physicians assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. (RARC: N264) or if the NPI is not e ntered in item 17b. of the Form CMS -1500 (RARC: N286).    H.   For laboratory services performed by a participating hospital -leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patients home or physicians office (including services to a patient in an institution) , if the name, address, and ZIP Code of the location where services were performed is not entered in item 32.  RARC: MA114  Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services ot her than those furnished in place of service home  12 must be entered.   I.   For independent laboratory claims:
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I.   For independent laboratory claims:   1.   Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., Homebound).  RARC: MA116  2.   If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patients home or physicians office.  RARC: MA114.  Effective for claims received on or after April  1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered.   3.   When a diagnostic service is billed as an anti -markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a.  If Items 32 and 32a are not entered. RARC: MA114   J.   For mammography diagnostic and screening claims, if a qualified screening center does not accurately enter their 6 -digit, FDA -approved certification number in item 32 when billing the technical or global component.  RARC: MA128   K.   For parenteral and enteral nutrition claims, if the services of an ordering/referring physician, physician assistant, nurse practitioner, clinical nurse specialist are used and their name is not present in item 17 (RARC: N264) or if the NPI is not ent ered in item 17b. of the Form CMS -1500(RARC: N286).    L.   For portable x- ray services claims, if the ordering physician, physician assistant, nurse practitioner, clinical nurse specialists name, and/or NPI is not entered in items 17  (RARC: N264) or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).
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M.   For radiology and pathology claims for hospital inpatients, if the referring/ordering physician, physician assistant, nurse practitioner, or clinical nurse specialists name, if appropriate, is not entered in item 17 (RARC: N264) or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).    N.   Effective for claims with dates of service on or after October 1, 2012, all claims for physical therapy, occupational therapy, or speech -language pathology services, including those furnished incident to a physician or nonphysician practitioner (NPP) services, must have the name and NPI of the certifying physician or NPP of the therapy plan of care.  For the purposes of processing professional claims, the certifying physician/NPP is considered a referring provider.  For paper billing, the certifying physician/NPP name and NPI is entered in Items 17 and 17b.  Providers and suppliers filing electronic claims are required to comply with applicable HIPAA ASC X12 837 claim completion requirements for reporting a referring provider.  (See Pub. 100- 04, chapter  5, 20 and Pub. 100- 02, chapter 15, 220 and 230 for therapy service policies.)   NOTE:   For items 80.3.2.1.3 (g), (k), (l), (m),  and (n) above, e ffective for claims with dates of services (DOS) on or after the implementation date of the Phase 2 ordering and referring denial edits, the Part B clinical lab and imaging technical or global component claim, or Durable Medical Equipment, Prosthetics, and Orthotics Suppliers (DMEPOS) claim is denied due to the ordering/referring provider not allowed to order/refer.   For item N only: 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.   Group Code: CO  CARC: 183  RARC: N574  MSN: N/A  The claim is denied when the first four letters of the last name provided on the ordering/referring providers claim does not match what is listed in the providers record. RARC: N264
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If the claim is submitted that lists an ordering/referring provider and the required matching NPI is not reported, then the claim shall be rejected.  This is the only instance when a rejection is allowed.  RARC: N256.  O.   For all laboratory work performed outside a physicians office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS -1500 if the services were performed at a location other than the place of service home  12.  RARC: MA114
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P.   For all physician office laboratory claims, if a 10- digit CLIA laboratory identification number is not present in item 23.  This requirement applies to claims for services performed on or after January 1, 1998.  RARC: MA120  Q.   For investigational devices billed in an FDA -approved clinical trial if an Investigational Device Exemption (IDE) number is not present in item 23, for dates of service through March 31, 2008.  RARC: MA50.  With the use of new modifier Q0, effective f or dates of service on and after April 1, 2008, contractors will no longer be able to distinguish an IDE claim from other investigational clinical services.  Therefore this edit will no longer apply.  R.   For physicians performing care plan oversight services if the 6 -digit Medicare provider number of the home health agency (HHA) or hospice is not present in item 23.   S.   For Competitive Acquisition Program drug and biological claims, in accordance with the instructions found in the Medicare Claims Processing Manual, chapter 17, section 100.2.1  section 100.9.  T.   For claims for artificial hearts covered by Medicare under an approved clinical trial, if procedure code 0051T is entered in Item 24D, and an 8- digit clinical trial number that matches an approved clinical trial listed at:  http://www.cms.hhs.gov/MedicareApprovedFacilitie/06_artificialhearts.asp#TopOfPage is not entered in Item 19; and the HCPCS modifier Q0 is not entered on the same line as the procedure code in Item 24D, and the diagnosis code V70.7 (if ICD -9-CM is applicab le) or Z00.6 (if ICD -10-CM is applicable) is not entered in Item 21 and linked to the same procedure code.   For item T only: 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.
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For item T only: 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: 4  RARC: N/A  MSN: N/A  U.   For clinical trial claims processed after September 28, 2009, with dates of service on or after January 1, 2008, claims submitted with either the modifier QV or the modifier Q1, if the diagnosis code V70.7 (if ICD -9-CM is applicable) or Z00.6 (if ICD -10-CM is applicable) is not submitted with the claim.   V.   For ambulance claims, claims submitted without the ZIP Code of the loaded ambulance trips point -of-pickup in Item 23 of the CMS -1500 Form.  80.3.2.2 - Consistency Edits for Institutional Claims  (Rev. 12107; Issued:06- 29-23; Effective: 04 -01-23; Implementation: 01 -02-24)  In order to be processed correctly and promptly, a bill must be completed accurately. Medicare contractors processing institutional claims edit all Medicare required fields as shown below. If a bill fails these edits, contractors return it to the provider for correction.  If bill data is edited online, the edits are included in the software.  Depending upon special services billed, contractors may require additional edits.   The following instructions follow the format of Form CMS -1450.  For instructions about the location of these data elements on the ASC X12 837 institutional claim transaction format see the related implementation guide.   FL 4. Type of Bill   a. Must not be spaces.   b. Must be a valid code for billing.  Valid codes are:   First Digit -  Type of Facility:   1 - Hospital   NOTE : Hospital- based multi -unit complexes may also have use for the following first digits when billing non- hospital services:   2 - Skilled Nursing  3 - Home Health   4 - Religious Non- Medical (Hospital)   7 - Clinic or Renal Dialysis Facility (requires special information in second digit below)   8 - Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)   Second Digit -  Classification (if first digit is 1 -5):  1 - Inpatient (Part A)
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8 - Special Facility or Hospital ASC Surgery (requires special information in second digit, see below)   Second Digit -  Classification (if first digit is 1 -5):  1 - Inpatient (Part A)   2 - Hospital -Based or Inpatient (Part B) (includes HHA visits under a Part B plan of treatment)   3 - Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)   4 - Other (Part B) (includes HHA medical and other health services not under a plan of treatment, hospital and SNF for diagnostic clinical laboratory services for nonpatients)   8 - Swing bed (used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement)   Second Digit -  Classification (first digit is 7):   1 - Rural Health Clinic (RHC)   2 - Hospital -Based or Independent Renal Dialysis Facility   4 - Other Rehabilitation Facility (ORF)   5 - Comprehensive Outpatient Rehabilitation Facility (CORF)   6 - Community Mental Health Center (CMHC)   7 - Free -Standing Provider -Based Federally Qualified Health Center (FQHC)   Second Digit -  Classification (first digit is 8):   1 - Hospice (Nonhospital -based)   2 - Hospice (Hospital -based)   5 - Critical Access Hospital (CAH)   Third Digit -  Frequency:   A - Admission/Election Notice   B - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution -Termination/Revocation Notice   C - Hospice Change of Provider   D - Hospice/Medicare Coordinated Care Demonstration/Religious Non-Medical Health Care Institution -Void/Cancel   E - Hospice Change of Ownership   F - Beneficiary Initiated Adjustment Claim (For A/B MAC (A) use only)   G - CWF Initiated Adjustment Claim (For A/B MAC (A) use only)   H - CMS initiated Adjustment Claim (For A/B MAC (A) use only)   I - A/B MAC (A) Adjustment Claim (Other than QIO or Provider) (For A/B MAC (A) use only)   J - Initiated Adjustment Claim- Other (For A/B MAC (A) use only)   K - OIG Initiated Adjustment Claim (For A/B MAC (A) use only)   M - MSP Initiated Adjustment Claim (For A/B MAC (A) use only)
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K - OIG Initiated Adjustment Claim (For A/B MAC (A) use only)   M - MSP Initiated Adjustment Claim (For A/B MAC (A) use only)   P - QIO Adjustment Claim (For A/B MAC (A) use only)   Q  Claim Submitted for Reconsideration Outside of Timely Limits (For A/B MAC (A) use only)   0 - Nonpayment/zero claims   1 - Admit Through Discharge Claim   2 - Interim -  First Claim  3 - Interim  Continuing Claims (Not valid for PPS bills.  Exception:  SNF PPS bills)   4 - Interim  Last Claim (Not valid for PPS bills. Exception:  SNF PPS bills)   5 - Late charge   7 - Correction   8 - Void/Cancel   9 - Final Claim for a Home Health PPS Episode   FL 6. Statement Covers Period (From -  Through)   a. Cannot exceed eight positions in either From or Through portion allowing for separations (nonnumeric characters) in the third and sixth positions.   b. The From date must be a valid date that is not later than the Through date.   c. The Through date must be a valid date that is not later than the current date.   d. With the exception of Home Health PPS claims, the statement covers period may not span 2 accounting years.   FL 09. Patients Address   a. The address of the patient must include:   City State (P.O. Code)  ZIP  b. Valid ZIP Code must be present if the type of bill is 11X, 13X, 18X, or 83X or   85X.  c. Cannot exceed 62 positions.   FL 10. Birthdate   a. Must be valid if present.  b. Cannot exceed 10 positions allowing for separations (nonnumeric characters) in the third and sixth positions.  FL 11. Sex   a. One alpha position.  b. Valid characters are M or F.   c. Must be present.   FL 12. Admission Date   a. Must be valid if present.  b. Cannot exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions.   c. Present only if the type of bill is 11X, 12X, 18X, 21X, 22X,  32X, 33X, 41X, 81X or 82X.    FL 14. Priority (Type) of Admission or Visit