evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
The following is a table summarizing the certification/recertification signature requirements and timeframes for various provider types.  Please review sections above for more detailed information on Certifications/Recertifications and their required conte nt:   Provider Type  Who Signs Certification  Certification Timeframe  Recertification  Hospital Inpatient  Attending physician or by another physician with knowledge of the case with authorization from attending physician or by a member of hospital's medical staff with knowledge of the case.  No later than the 12th day of hospitalization  Interval between recertifications not to exceed 30 days  SNF Attending physician or physician on staff at SNF with knowledge of case, or physician extender  as discussed in 40.1 of this chapter  Obtain at time of admission or shortly thereafter  First recertification no later than the 14th day of inpatient extended care services. Subsequent at intervals not exceeding 30 days.  HHA  Attending physician  Obtain at time POC is established or shortly thereafter  Physician must recertify at least once every 60 days  Hospice  For initial 90 -day period, must obtain written certification statements from medical director of hospice or physician member of the hospice interdisciplinary group and the attending physician.  If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained. Must be obtained for each period of hospice care; written certification by hospice medical director or physician member of interdisciplinary group.   Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI
(Medicare General Information, Eligibility, and Entitlement)
12/21/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update  01/02/2024  13496  R10757GI  05/11/2021  Physician Certification and Recertification of Services Manual Update to Incorporate Allowed Practitioners into Home Health Policy  08/11/2021  12222  R126GI  10/04/2019  Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  11/05/2019  11454  R120GI  11/02/2018  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)  12/04/2018  11004  R114GI  03/16/2018  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512  R101GI  09/16/2016  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748  R98GI  05/13/2016  Clarification of Inpatient Psychiatric Facilities (IPF) Requirements for Certification, Recertification and Delayed/Lapsed Certification and Recertification  08/15/2016  9522  R94GI  10/16/2015  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (2015)  11/16/2015  9336  R92GI  04/22/2015  Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services  05/11/2015  9119  R91GI  04/10/2015  Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services   Rescinded and replaced by Transmittal 92  05/11/2015  9119  R84GI  04/04/2014  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669  R76GI  01/13/2012  Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and
(Medicare General Information, Eligibility, and Entitlement)
100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669  R76GI  01/13/2012  Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  02/13/2012  7701  R68GI  04/22/2011  Physician Certification and Recertification of Services Manual Changes  05/12/2011  7377  R50GI  12/21/2007  Revision to Certification for Hospital Services Covered by the Supplementary Hospital Insurance Program as it Pertains to Ambulance Services  01/07/2008  5833  R47GI  08/17/2007  Revision to Certification for Hospital Services Covered by the Supplementary Medical Insurance Program as it Pertains to Ambulance Services  09/17/2007  5684  R39GI  06/09/2006  Update -Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Rate Year 2007  07/03/2006  5129  R28GI  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100 -01 09/12/2005  3912  R01MGI  09/11/2002  Initial Publication of Manual  NA NA
(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 5 - Definitions   Table of Contents  (Rev. 12425; Issued: 12-21-23)  Transmittals for Chapter 5
(Medicare General Information, Eligibility, and Entitlement)
10 - Provider and Related Definitions  10.1 - Provider Agreements  10.1.1 - Basic Commitment in Provider Agreement 10.1.2 - Part A Deductible and Coinsurance  10.1.3 - Part B Deductible and Coinsurance  10.1.4 - Blood 10.1.5 - Services Requested by Beneficiary  10.1.6 - Provider Charges to Beneficiary Where Provider Customarily Furnishes More Expensive Services Not Requested by Beneficiary  10.1.7 - Hospitals Participating in State Reimbursement Control Systems or Demonstration Projects  10.1.8 - Medicare Secondary Payer Involvement of Failure to File Proper Claims  10.1.9 - Advance Directive Requirements  10.1.10 - Posting of Signs in Hospital Emergency Departments  10.2 - Admission of Medicare Patients for Care and Treatment  10.3 - Under Arrangements  10.4 - Term of Agreements  10.4.1 - Agreement with a SNF  10.4.2 - Agreement with RHC/FQHC  10.5 - Responsibilities of Participating Provider  10.6 - Termination of Provider Participation  10.6.1 - Voluntary Termination 10.6.2 - Involuntary Termination, Including SNF Agreement Cancellations  10.6.3 - Expiration and Renewal - Nonrenwal of SNF Term Agreements   10.6.4 - Determining Payment for Services Furnished After Termination of Provider Agreement  10.6.5 - Change of Provider Ownership  20 - Hospital Defined  20.1 -  Definition of Emergency Inpatient and Outpatient Services  20.2 -  Definition of an Emergency Services Hospital  20.3 -  Psychiatric Hospital 20.4 -  Certification of Parts of Institutions as Hospital 20.5 -  Part of a Psychiatric Institution as a Psychiatric Hospital 20.6 -  General Hospital Facility of Psychiatric Hospital 20.7 -  Part of a General Hospital as a Psychiatric Hospital  30 - Skilled Nursing Facility Defined  30.1 -  Distinct Part of an Institution as a SNF  30.2 -  Transfer Agreements  30.3 -  Hospital Providers of Extended Care Services  40 - Religious Nonmedical Health Care Institution  Defined  50 - Home Health Agency Defined  50.1 -  Subdivisions of Agencies as Home Health Agencies  50.2 -  Arrangements by Home Health Agencies  50.3 -  Arrangements with Parent Agency and Other Entities  50.4 -  Notice of Noncoverage of Services  50.5 -  Rehabilitation Centers  60 - Hospice Defined  60.1 -  Subdivision of Organizations as Hospices  60.2 -  Arrangements by
(Medicare General Information, Eligibility, and Entitlement)
Agencies  50.3 -  Arrangements with Parent Agency and Other Entities  50.4 -  Notice of Noncoverage of Services  50.5 -  Rehabilitation Centers  60 - Hospice Defined  60.1 -  Subdivision of Organizations as Hospices  60.2 -  Arrangements by Hospices  70 - Physician Defined  70.1 -  Doctors of Medicine and Osteopathy 70.2 -  Dentists  70.3 -  Doctors of Podiatric Medicine  70.4 -  Physicians in Federal Hospitals  70.5 -  Optometrists  70.6 -  Chiropractors  70.7 -  Interns and Residents  80 - Health Maintenance Organizations (HMOs) Defined  90 - Other Definitions  90.1 -  Supplier Defined  90.2 -  Laboratory Defined 90.3 -  Practitioners Defined  90.4 -  Group Practice Defined
(Medicare General Information, Eligibility, and Entitlement)
10 - Part A Provider and Related Definitions  (Rev. 12425, Issued: 12-21-23, Effective: 01-01-24, Implementation: 01-02-24)    Section 1866(e) of the Social Security Act defines the term "provider of services" (or provider) as:    (1) A clinic, rehabilitation agency, or public health agency if, in the case of a clinic or rehabilitation agency, such clinic or agency meets the requirements of  section  1861(p)(4)(A) (or meets the requirements of such section through the operation of section 1861(g) ), or if, in the case of a public health agency, such agency meets the requirements of section 1861(p)(4)(B)  (or meets the requirements of such section through the operation of section 1861(g) ), but only with respect to the furnishing of outpatient physical therapy services (as therein defined) or (through the operation of section 1861(g) ) with respect to the furnishing of outpatient occupational therapy services; and     (2) A community mental health center (as defined in section  1861(ff)(3)(B)) , but only with respect to the furnishing of partial hospitalization services (as described in section 1861(ff)(1))  or intensive outpatient services (as described in section 1861(ff)(4) ).  Definitions of providers, physicians, practitioners, and suppliers, and a description of the requirements that each must meet in order for their services to be considered covered are described in the following sections.   10.1 - Provider Agreements  (Rev. 12425, Issued: 12-21-23, Effective: 01-01-24, Implementation: 01-02-24)    The following provider types must have provider agreements under Medicare:     Hospitals,   Skilled nursing facilities (SNFs),   Home health agencies (HHAs),   Clinics, rehabilitation agencies, and public health agencies,   Comprehensive outpatient rehabilitation facilities (CORFs),   Hospices,   Critical access hospitals (CAHs), and    Community mental health centers (CMHCs).    Clinics, rehabilitation agencies, and public health agencies may enter into provider agreements only for furnishing outpatient therapy services as defined in section 10 above. CMHCs may enter into provider agreements only to furnish partial hospitalization or intensive outpatient  services.
(Medicare General Information, Eligibility, and Entitlement)
The term "provider agreement" is defined in 42 CFR 489.3 as an agreement between CMS and one of these providers specified in this section to provide services and to comply with the requirements of section 1866 of the Act.    A provider which has executed an agreement becomes qualified to participate after the agreement is accepted.  When the agreement is made retroactive, the provider must comply with the terms of the agreement and the provisions of title XVIII and regulations  issued thereunder as of the retroactive date.  For payment to be made to the provider for covered items and services it furnishes on or after the effective date of the agreement, the provider must have a record keeping capability sufficient to determine t he costs of services furnished to Medicare beneficiaries.    Provider agreements require the providers to comply with regulations.  Therefore, new provider agreements are not made when regulations change.    Providers as defined in this section may also function as suppliers and bill the program for other services provided as suppliers if they meet the applicable requirements for supplying the specific service.      10.1.1 - Basic Commitment in Provider Agreement  (Rev. 58, Issued: 03-06- 09, Effective: 06 -08-09, Implementation: 06-08-09)  Section 1866 of the Act and 42 CFR 489 require the provider to agree to the following:  1. To limit its charges to beneficiaries and to other individuals on their behalf to:   The deductible and coinsurance amounts (see 10.1.2 for details;  The blood deductible (see 10.1.4 for details); and   Services requested by the beneficiary. (See 10.1.5 )  2. To return any amounts incorrectly collected from a beneficiary or any other person on the beneficiary's behalf;   3. To notify the A/B MAC (A) or (HHH) promptly if it hires an individual who at any time during the preceding year was employed in a managerial, accounting, auditing, or similar capacity by a MAC;   4. In the case of a hospital or a Critical Access Hospital (CAH), either to furnish directly or to make arrangements (as defined in 10.3  of this chapter) for all Medicare -covered services to inpatients of a hospital or a CAH except the following:
(Medicare General Information, Eligibility, and Entitlement)
 Physicians' services that meet the criteria of 42 CFR 405.550(b) for payment on a reasonable charge basis;    Physician assistant services, as defined in section 1861(s)(2)(K)(I) of the Act, that are furnished after December 31, 1990;   Certified nurse -midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, 1990;   Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, 1990; and    Services of an anesthetist, as defined in 42 CFR 410.69.  5. In the case of a hospital or CAH that furnishes inpatient hospital services or inpatient CAH services for which payment may be made under Medicare, to maintain an agreement with a PRO for that organization to review the admissions, quality, appropriateness, and diagnostic information related to those inpatient services.  The requirement of this paragraph applies only if, for the area in which the hospital or CAH is located, there is a PRO that has a contract with CMS under Part B of title XI of the Act;   6. To maintain a system that, during the admission process, identifies any primary payers other than Medicare so that incorrect billing and Medicare overpayments can be prevented;  7. To bill other primary payers before billing;  8. If the provider receives payment for the same services from Medicare and another payer that is primary to Medicare, to reimburse Medicare any overpaid amount within 60 days;  9. If the provider receives, from a payer that is primary to Medicare, a payment that is reduced because the provider failed to file a proper claim; to reimburse Medicare any overpaid amount up to the amount that would have been paid had the provider filed a proper claim timely.   10. In the State of Oregon, because of a court decision, and in the absence of a reversal on appeal or a statutory clarification overturning the decision, hospitals may bill liability insurers first.  However, if the liability insurer does not pay "promptly," the hospital must withdraw its claim or lien and bill Medicare for covered services;
(Medicare General Information, Eligibility, and Entitlement)
11. In the case of home health agencies, to offer to furnish catheters, catheter supplies, ostomy bags, and supplies related to ostomy care to any individual who requires them as part of their furnishing of home health services;   12. In the case of hospital emergency department services that provide for medical screening to determine if an emergency medical condition exists, CMS guidelines provided in CFR 42 489.24(d) for transfer of patients to other facilities should be followed;   13. In the case of hospital emergency department services report to CMS or the State Survey Agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospita l in violation of the requirements of CFR 42 489.24(d);   14. In the case of inpatient hospital services for admissions on and after January 1, 1987, to participate in the Tricare program;  15. In the case of inpatient hospital services for admissions on and after July 1, 1987, to admit veterans whose admission is authorized by the VA and to meet related VA admission and payment requirements;   16. In the case of a hospital, to give each beneficiary a notice about his or her discharge rights at or about the time of the individual's admission;   17. In the case of a hospital with an emergency department:    To post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergenc y departments (that is, entrance, admitting area, waiting room, treatment area), a sign (in a form specified by the Secretary) specifying rights of individuals under Section 1867 of the Act with respect to examination and treatment for emergency medical co nditions and women in labor; and    To post conspicuously information indicating whether or not the hospital or critical access hospital participates in the Medicaid program under a State plan approved under title XIX;   18. In the case of a hospital with an emergency department (including both the transferring and receiving hospitals), to maintain:    Medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer;
(Medicare General Information, Eligibility, and Entitlement)
 Medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer;    A list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition; and    A central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.   19. Effective December 1, 1991, in the case of a hospital to comply with the advance directive provisions of 4206 of OBRA 1990.  Hospitals must, in accordance with written policies and procedures, for all adult individuals:    Inform them, in writing, of State laws regarding advance directives;    Inform them, in writing, of its policies regarding the implementation of advance directives (including a clear and concise explanation of a conscientious objection, to the extent that State law permits for a hospital or any agent of a hospital that, as a matter of conscience, cannot implement an advance directive);    Document in the individual's medical record whether the individual has executed an advance directive;    Not condition the provision of care or otherwise discriminate against an individual based on whether that individual has executed an advance directive (since the law does not require the individual to do so); and    Educate staff and the community on issues concerning advance directives.
(Medicare General Information, Eligibility, and Entitlement)
 Educate staff and the community on issues concerning advance directives.  20. Effective October 1, 2007, CMS revised the regulations governing provider agreements that require hospitals to disclose physician ownership information to patients when a referring physician (or his or her immediate family member) has an ownership interest in the hospital.  Pursuant to 42 CFR 489.20(u), hospitals must: (1) furni sh written notice to each patient at the beginning of the patients hospital stay or outpatient visit that the hospital is a physician- owned hospital, in order to assist the patient in making an informed decision regarding his or her care.  The notice must  disclose the fact that the hospital meets the Federal definition of a physician -owned hospital and that the list of physician owners or immediate family members of physicians is available upon request and must be provided to the patient at the time of the  request; and (2) require each physician who is a member of the hospitals medical staff to agree, as a condition of continued medical staff membership or admitting privileges, to disclose in writing to all patients the physician refers to the hospital any ownership or investment interest in the hospital held by the physician or held by an immediate family member of the physician.  Disclosure must be made at the time of the referral.   Effective October 1, 2008, hospitals that do not have any physician owners who refer patients to the hospital are exempt from the disclosure requirements (See 42 CFR 489.20(v)).  In addition, CMS may deny a provider agreement to a hospital that does not have procedures in place to notify patients of physician ownership in the hospital (See 42 CFR 489.12).  10.1.2 - Part A Deductible and Coinsurance  (Rev. 1, 09-11-02)  This section is a further explanation of 10.1.1 above.   The provider may charge the beneficiary or his or her representative:   The amount of the inpatient hospital deductible or, if less, the actual charges for the services;    The amount of inpatient hospital coinsurance applicable for each day the individual is furnished inpatient hospital services after the 60th day, during a benefit period;   The posthospital extended care coinsurance amount; and    In the case of durable medical equipment (DME) furnished as a home health service, 20 percent of the fee schedule amount.
(Medicare General Information, Eligibility, and Entitlement)
 The posthospital extended care coinsurance amount; and    In the case of durable medical equipment (DME) furnished as a home health service, 20 percent of the fee schedule amount.  10.1.3 - Part B Deductible and Coinsurance  (Rev. 1, 09-11-02)  This section is a further explanation of 10.1.1 above.   The provider may charge the beneficiary or other person on his or her behalf: the $100 deductible and 20 percent of the customary (insofar as reasonable) charges in excess of that deductible.  For hospital outpatient services, the allowable deductible charges depend on whether the hospital can determine the beneficiary's deductible status.  If the hospital is unable to determine the deductible status, it may charge the beneficiary its full custo mary charges up to $100.  If the beneficiary provides official information as to deductible status, the hospital may charge only the unmet portion of the deductible.  The hospital is required to indicate on the claim the amounts collected.  In the case of DME furnished as a home health service under Medicare Part B, the coinsurance is 20 percent of the fee schedule amount for the services, with the following exception:  If the DME is used, purchased by, or on behalf of the beneficiary at a pr ice at least 25 percent less than the reasonable charge for comparable new equipment, no coinsurance is required.  10.1.4 - Blood  (Rev. 18, Issued: 03-04- 05, Effective: 07 -01-05, Implementation: 07-05-05)   This section is a further explanation of 10.1.1.  A provider may charge the beneficiary (or other person on his or her behalf) only for the first three pints of blood or units of packed red cells furnished during the calendar year.  The charges may not exceed the provider's customary charges.  The provider may not charge for any whole blood or packed red cells in any of the following circumstances:   The provider obtained the blood or red cells at no charge other than a processing or service charge;    The blood or packed red cells have been replaced; or