evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
By contrast, when a beneficiary does return to that or another SNF by the end of the same day (a scenario that normally would serve to maintain the beneficiarys status as a resident of the originating SNF throughout the absence), the occurrence of one of the intervening events listed in the first three clauses above would nevertheless serve to end the beneficiarys resident status at that point.  For example, when a beneficiary leaves the SNF to receive outpatient emergency services at the hospital, th e emergency services would never be subject to CB even in a situation where the beneficiary returns to the SNF later that same day because the receipt of the emergency services themselves under the third clause above would have already served to suspend the beneficiarys SNF resident status with respect to those services under the regulations at 42 CFR 411.15(p)(3)(iii).  These requirements apply only to Medicare fee -for-service beneficiaries residing in a participating SNF or DPU.  Claims are submitted to the A/B MAC (A) on the ASC X12 837 institutional format or Form CMS -1450.  All services billed by the SNF (including those furnished under arrangements with an outside supplier) for a resident of a SNF in a covered Part A stay are included in the SNFs Part A bill.  If a resident is not in a covered Part A stay (Part A benefits exhausted, posthospital or level of care requirements not met), the SNF is required to bill for all physical therapy, occupational therapy, and/or speech- language pathology services provided to a SNF resident under Part B.  The CB provision requires that effective for services and items furnished on or after July 1, 1998, payment is made directly to the SNF.
(Medicare Claims Processing Manual)
Thus, SNFs are no longer able to unbundle services to an outside supplier that can then submit a separate bill directly to an A/B MAC (B) or DME MAC for residents in a Part A stay, or for SNF residents receiving physical therapy, occupational therapy, and/or speech -language pathology services paid under Part B.  Instead, the SNF must furnish the services either directly or under an arrangement with an outside supplier or provider of services in which the SNF (rather than the supplier or provider of servic es) bills Medicare.  Medicare does not pay amounts that are due a provider to any other person under assignment, or power of attorney, or any other direct payment arrangement.  As a result, the outside supplier must look to the SNF (rather than the A/B MAC  (A), or (B), or DME MAC or the beneficiary) for payment.  The SNF may collect any applicable deductible or coinsurance from the beneficiary.
(Medicare Claims Processing Manual)
NOTE :  The requirements for participation at 42 CFR 483.15(c)(1)(i)(A) -(F) specify the limited circumstances under which a resident can be involuntarily moved out of a Medicare- certified SNF or DPU.  These circumstances can include situations in which the resi dent's health has improved to the point where he or she no longer needs SNF care.  However, if a resident has exhausted Part A benefits but nevertheless continues to require SNF care, he or she cannot be moved out of the Medicare- certified SNF or DPU for reasons other than those specified in the regulations.  For example, the resident cannot be moved to avoid the CB requirements, or to establish a new benefit period.  The determination to move the beneficiary out of the SNF or DPU must not be made on the basis of the beneficiary having exhausted his or her benefits, but rather, on the beneficiary's lack of further need for SNF care.  Once a resident of a Medicare -certified DPU ceases to require SNF care, he or she may then be moved from the DPU to the Medicare non -certified area of the institution.  As discussed above, such a move would end the beneficiary's status as a SNF "resident" for CB purposes.  Enforcement of CB is done through editing in Medicare claims processing systems using lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the CB provision of SNF PPS.  In order to assure proper payment in all settings, Medi care systems must edit for services, provided to SNF beneficiaries, both included and excluded from CB.  Transmittals with instructions provide updates to previous lists of the exclusions, and some inclusions, to CB.  Such transmittals can be found on the CMS Web site at:  https://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Internet -Only -Manuals -IOMs.html  or http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html .  Step -by-step instructions for accessing the exclusion list itself appear in the Medicare Benefit Policy Manual, Chapter 8, 10.2.
(Medicare Claims Processing Manual)
The list of HCPCS codes enforcing CB may be updated each quarter.  For the notice on CB for the quarter beginning January, separate instructions are published for A/B MACs (A) and A/B MACs (B)/DME MACs.  Since this is usually the only quarter in which new permanent HCPCS codes are produced, this recurring update is referred to as an annual update.  Other updates for the remaining quarters of the year will occur as needed  prior to the next annual update.  In lieu of another update, editing based on the prior list of codes remains in effect.  Some non -January quarterly updates may apply to each of A/B MACs (A) and (HHH) and A/B MACs (B)/DME MACs, and the applicability of the instruction will be clear in each update.  All future updates will be submitted via a Recurring Update Notification form.    Effective July 1, 1998, CB became effective for those services and items that were not specifically excluded by law from the SNF prospective payment system (PPS) when they were furnished to residents of a SNF in a covered Part A stay and also includes physical therapy, occupational therapy, and/or speech-language pathology services in a noncovered stay.  SNFs became subject to CB once they transitioned to PPS.  Due to systems limitations, CB was not implemented at that time for residents not in a Part A covered stay (Part A benefits exhausted, post-hospital or level of care requirements not met).  Section 313 of the Benefits Improvement and Protection Act (BIPA) of 2000 subsequently repealed this aspect of CB altogether, except for physical therapy, occupational therapy, and/or s peech -language pathology services.  In addition, for either type of resident, the following requirements were also delayed: (1) that the physicians forward the technical portions of their services to the SNF; and (2) the requirement that the physician enter the facility provider number of the SNF on the claim.
(Medicare Claims Processing Manual)
 Effective July 1, 1998, under 42 CFR 411.15(p)(3)(iii) published on May 12, 1998, a number of other services are excluded from CB.  The hospital outpatient department will bill these services directly to the A/B MAC (A) when furnished on an outpatient basis by a hospital or a cri tical access hospital (see 20.1.2).  Physicians and other practitioners professional services will be billed directly to the A/B MAC (B) (see 20.1.1).  Hospice care (see 20.2.2) and the ambulance trip that initially conveys an individual to the SNF to be admitted as a resident, or that conveys an individual from the SNF when discharged and no longer considered a resident (see 20.3), are also excluded from CB.   Effective April 1, 2000, 103 of the Balanced Budget Refinement Act (BBRA) excluded additional services and drugs from CB that therefore had to be billed directly to the A/B MAC (B) or DME MAC by the provider or supplier for payment (see 20.3).  As opposed to whole categories of services being excluded, only certain specific services and drugs (identified by HCPCS code) were excluded in each category.  These exclusions included ambulance services furnished in conjunction with renal dialysis services, certa in specific chemotherapy drugs and their administration services, certain specific radioisotope services, and certain customized prosthetic devices.   Effective January 1, 2001, 313 of the BIPA, restricted CB to the majority of services provided to beneficiaries in a Medicare Part A covered stay and only to therapy services provided to beneficiaries in a noncovered stay (see 20.5).   Effective for claims with dates of service on or after April 1, 2001 , for those services and supplies that were not specifically excluded by law and are furnished to a SNF resident covered under the Part A benefit, physicians are required to forward the technical portions of any services to the SNF to be billed by the SNF to the A/B MAC (A) for payment (see 20.1.1).
(Medicare Claims Processing Manual)
10.2 - Types of Facilities Subject to the Consolidated Billing Requirement for SNFs  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11-  05-19) Consolidated billing applies to:    Participating SNFs;  Short term hospitals, long term hospitals, and rehabilitation hospitals certified as swing -bed hospitals, except critical access hospitals (CAHs) certified as swing bed hospitals (however, while a CAHs SNF -level swing bed services are not subject to consolidated billing, they remain subject to the bundling requirement for hospitals , as specified in the Medicare Claims Processing Manual, Chapter 3, 60).  Rural (non- CAH) swing bed hospitals that furnish SNF -level services are subject to both  the consolidated billing and  hospital bundling requirements (see 100.1); accordingly, as explained in the FY 2002 SNF PPS final rule (66 FR 39593, July 31, 2001), for the small number of services (such as dialysis) that are excluded from consolidated billing but remain subject to hospital bundling, the billing responsibility would remain with the rural swing bed hospital itself (in accordance with the hospital bundling requirement), but it would use a separate inpatient Part B claim to bill for those serv ices outside of the bundled SNF PPS rate (in recognition of their exclusion from the consolidated billing requirement).   But consolidated billing does not apply to:    A nursing home that is not Medicare -certified, such as:   o A nursing home that does not participate at all in either the Medicare or Medicaid programs;   o A non- certified part of a nursing home that also includes a participating distinct part SNF unit; and   o A nursing home that exclusively participates in the Medicaid program as an NF.    CAHs certified as swing -bed hospitals.  However, as noted above, CAH swing-bed services are subject to the hospital bundling requirement at section 1862(a)(14) of the Social Security Act and 42 CFR  411.15(m).
(Medicare Claims Processing Manual)
Medicare Coordinated Care Demonstration  Services for beneficiaries covered under the Medicare Coordinated Care Demonstration will not be subject to consolidated billing.  Common Working File (CWF) will appropriately edit for these codes so that the A/B MACs (B) will pay them separately.  10.3 - Types of Services Subject to the Consolidated Billing Requirement for SNFs  (Rev. 2573, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  As previously discussed, the consolidated billing requirement applies to all services furnished to a SNF resident in a covered Part A stay (other than the excluded service categories described below) and for physical therapy, occupational therapy, and/or speech -language pathology services provided to residents and paid under Part B. Examples of services that are subject to consolidated billing include:    Physical therapy, occupational therapy, and/or speech- language pathology services, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional (see 1888(e)(2)(A)(ii) of the Act).  Physical therapy, occupational therapy, and/or speech-language pathology services (other than audiology services, which are considered diagnostic tests rather than therapy services) furnished to a SNF resident during a noncovered stay must still be billed by the SNF itself.  This is known as Part B consolidated billing (see 20.5 of this chapter).   Psychological and other services furnished by a clinical social worker; and    Services furnished as an incident to the professional services of a physician or other excluded category of health care professional described in 20.1.1 below.   10.4 - Furnishing Services that are Subject to SNF Consolidated Billing Under an Arrangement With an Outside Entity  (Rev  .4001, Issued: 03- 16-18, Effective: 06- 19- 18, Implementation: 06-19-18)
(Medicare Claims Processing Manual)
As discussed in 10.1 and 10.3, the SNF consolidated billing provisions (at 1862(a)(18) , 1866(a)(1)(H)(ii), and 1888(e)(2)(A)  of the Act) place with the SNF itself the Medicare billing responsibility for most of its residents services.  Part A consolidated billing requires that a SNF must include on its Part A bill almost all of the services that a resident receives during the course of a Medicare -covered stay, other than those services that are specifically excluded from the SNFs global PPS per diem payment for the covered stay.  (These excluded services, such as the services of physicians and certain other practitioners, remain separately billable to the A/B MAC (B) directly by the outside entity that actually furnishes them.)  In addition, Part B consolidated billing makes the SNF itself responsible for submitting the Part B bills for any physical therapy, occupational therapy, and/or speech-language pathology services that a resident receives during a noncovered stay (see 20.5).  Further, for any Part A or Part B service that is subject to SNF consolidated billing, the SNF must either furnish the service directly with its own resources, or obtain the service from an outside entity (such as a supplier) under an arrangement, as described in 1861(w) of the Act and in 80.5.  Under such an arrangement, the SNF must reimburse the outside entity for those Medicare- covered services that are subject to consolidated billing; i.e., services that are reimbursable only to the SNF as part of its global PPS per diem or those Part B services that must be billed by the SNF.
(Medicare Claims Processing Manual)
Since the inception of the SNF PPS, several problematic situations have been identified where the SNF resident receives services that are subject to consolidated billing from an outside entity, such as a supplier.  (In this context, the term supplier can also include those practitioners who, in addition to performing their separately billable professional services, essentially act as a supplier by also furnishing other services that are subject to the consolidated billing requirement.)  As discussed in gr eater detail below, such situations most commonly arise in one of the following two scenarios:  1) A SNF does not accurately identify services as being subject to consolidated billing when ordering such services from a supplier or practitioner; or 2) A supplier fails to ascertain a beneficiarys status as a SNF resident when the beneficiary (or another individual acting on the beneficiarys behalf) seeks to obtain such services directly from the supplier without the SNFs knowledge.   The absence of a valid arrangement in the situations described above creates confusion and friction between SNFs and their suppliers.  Suppliers need to understand which services are subject to consolidated billing to avoid situations where they might impr operly attempt to bill the A/B MAC (B) (or other payers such as Medicaid and beneficiaries) directly for the services.  In addition, when ordering or furnishing services under arrangements, both parties need to reach a common understanding on the terms of payment; e.g., how to submit an invoice, how payment rates will be determined, and the turn- around time between billing and payment.  Without this understanding, it may become difficult to maintain the strong relationships between SNFs and their supplier s that are necessary to ensure proper coordination of care to the Medicare beneficiaries.  Whenever possible, SNFs should document arrangements with suppliers in writing, particularly with suppliers furnishing services on an ongoing basis, such as laboratories, x-ray suppliers, and pharmacies.  This also enables the SNF to obtain the suppliers assurance that the arranged -for services will meet accepted standards of quality (under the regulations at 42 CFR 483.70(g)(2), SNFs must ensure that services obtained under an arrangement with an outside source meet professional standards and principles that apply to professionals providing such services).
(Medicare Claims Processing Manual)
However, it is important to note that the absence of a valid arrangement does NOT invalidate the SNFs responsibility to reimburse suppliers for services included in the SNF bundle of services represented by the SNF PPS global per diem rate.  As the SNF has already been paid for the services, the SNF must be considered the responsible party when medically necessary supplier services are furnished to beneficiaries in Medicare Part A stays.  This obligation applies even in cases where the SNF did not specif ically order the service; e.g., during a scheduled physicians visit, the physician performs additional diagnostic tests that had not been ordered by the SNF; a family member arranges a physician visit without the knowledge of SNF staff and the physician bills the SNF for incident to services.   Finally, while establishing a valid arrangement prior to ordering services from a supplier minimizes the likelihood of a payment dispute between the parties, it is not unreasonable to expect occasional disagreements between the parties that may result in n on-payment of a supplier claim.  However, it is important to note that there are potentially adverse consequences to SNFs when patterns of such denials are identified.  Specifically, all participating SNFs agree to comply with program regulations when ente ring into a Medicare provider agreement which, as explained below, requires a SNF to have a valid arrangement in place whenever a resident receives services that are subject to consolidated billing from any entity other than the SNF itself.  Moreover, in r eceiving a bundled per diem payment under the SNF PPS that includes such services, the SNF is accepting Medicare payment, and financial responsibility, for the service.  Accordingly, these instructions reiterate and clarify the applicable consolidated billing requirements that pertain to SNFs and to the outside suppliers that serve SNF residents.  10.4.1 - Under Arrangements Relationships  (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)  Under an arrangement as defined in 1861(w)
(Medicare Claims Processing Manual)
Under an arrangement as defined in 1861(w) of the Act, Medicares payment to the SNF represents payment in full for the arranged-for service, and the supplier must look to the SNF (rather than to A/B MAC (B)) for its payment.  Further, in entering into such an arrangement, the SNF cannot function as a mere billing conduit, but must actually exercise professional responsibility over the arranged- for service (see the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, 10.3, and the Medicare Benefit Policy Manual, Chapter 8,  70.4, for additional information on services furnished under arrangements).  Medicare does not prescribe the actual terms of the SNFs relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement.  However, i n order for a valid arrangement to exist, the SNF must reach a mutual understanding with its supplier as to how the supplier is to be paid for its services.  Documenting the terms of the arrangement confers the added benefit of providing both parties wit h a ready means of resolution in the event that a dispute arises over a particular service.  This type of arrangement has proven to be effective in situations where suppliers regularly provide services to facility residents on an ongoing basis; e.g., laboratory and x-ray suppliers, DME supplies, etc.  Sample model agreements involving arrangements between SNFs and their suppliers are available for review on CMSs Best Practices Guidelines website, at https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/SNFPPS/BestPractices.html.  If a SNF elects to utilize an outside supplier to furnish medically appropriate services that are subject to consolidated billing, but then refuses to reimburse that supplier for the services, then there is no valid arrangement as contemplated under 1862( a)(18) of the Act.  Not only would this potentially result in Medicares noncoverage of the particular services at issue, but a SNF demonstrating a pattern of nonpayment would also risk being found in violation of the terms of its provider agreement.  Unde r 1866(a)(1)(H)(ii)
(Medicare Claims Processing Manual)
of the Act (and 42 CFR 489.20(s) ), the SNFs provider agreement includes a specific commitment to comply with the requirements of the consolidated billing provision.  Further, 1866(g) of the Act imposes a civil money penalty on any person who knowingly and willfully presents (or causes to be presented) a bill or request for payment inconsistent with an arrangement or in violation of the requirement for such an arrangement.   10.4.2 - SNF and Supplier Responsibilities  (Rev. 412, Issued: 12- 23-04, Effective: 05 -21-04, Implementation: 01- 24-05)  Problems involving the absence of a valid arrangement between an SNF and its suppliers typically tend to arise in one of the following two situations.   Problem Scenario 1:  An SNF elects to utilize an outside supplier to furnish a type of service that would be subject to Part A consolidated billing, but then fails to inform the supplier that the resident receiving the service is in a covered Part A stay.  This causes the supplier to conclude mistakenly that the service it furnishes to that resident is not subject to consolidated billing.  Based on the inaccurate impression that the residents SNF stay is noncovered, the supplier inappropriately submits a separate Part B claim for the service, and may also improperly bill other insurers and the resident.  Then, the supplier only learns of the actual status of the residents Medicare-covered SNF stay when that Part B claim is denied.  In this scenario, even though the supplier made reasonable efforts to ascertain from the SNF both the beneficiarys status as an SNF resident and the specific nature of the beneficiarys SNF stay, the information from the SNF (on which the supplier relied) proved to be inaccurate.