evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
140.5 - Appeal Rights (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Nonparticipating physicians have the same rights to appeal the contractors redetermination in an unassigned claim for physicians services if the contractor denies or reduces payment on the basis of 1862 (a)(1) as they or participating physicians have in assigned claims. These rights of appeal also extend to determinations that a refund is required either because the physician knew or should have known that Medicare would not pay for the service, or because the beneficiary was not properly informed in wri ting in advance that Medicare would not pay or was unlikely to pay for the service or, if so informed, did not sign a statement agreeing to pay. In addition to the beneficiarys right to appeal the contractors decision to deny or reduce payment on the bas is of 1862 (a)(1), the beneficiary becomes a party to any request for appeal filed by the physician. Since the beneficiary and the physician may have adverse interests in a decision regarding refund, it is essential to notify the beneficiary in any case i n which the physician requests an appeal of the denial or reduction in payment or asserts that a refund is not required because one of the conditions in 140.4 is met. (See Chapter 29, Appeals for detailed appeals instructions.)   140.6 - Processing Initial Denials  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)
(Medicare Claims Processing Manual)
140.6 - Processing Initial Denials  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  In any unassigned claim for physicians services furnished on or after October 1, 1987, in which the contractor denies or reduces payment on the basis of 1862(a)(1) , the contractor will send separate notices to both the beneficiary and the physician. In some cases, the beneficiary (or physician) may submit a copy of an ABN which satisfies the requirements in 140.4. The contractor should not make an automatic finding that the service is not reasonable and necessary merely because the beneficiary has submit ted an ABN. The fact that there is an acceptable ABN must in no way prejudice the contractors determination as to whether there is or is not sufficient evidence to justify a denial under 1862(a)(1). In the case where there is an acceptable ABN, the contr actor will mail a standard denial MSN notice to the beneficiary. In the absence of an acceptable ABN, and depending on whether there is a full denial or a partial reduction in payment, the contractor will include, in addition to one of the medical necessity denial notices , one of the following notices in the MSN sent to the beneficiary.   140.6.1 - Initial Beneficiary Notices  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Notice 1 -  Full Denial   If the doctor should have known that Medicare would not pay for the denied services and did not tell you in writing before providing the services, you may be entitled to a refund of any amounts you paid. However, if the doctor requests an appeal of this cl aim within 30 days, a refund is not required until we complete our appeal. If you paid for this service and do not hear anything about a refund within the next 30 days, contact your doctors office.   Notice 2 -  Reduction in Payment
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Notice 2 -  Reduction in Payment   If the doctor should have known that Medicare would not pay for the more extensive service and did not tell you this in writing before providing the service, you may be entitled to a refund of any amount you paid which is more than the doctor is allowed by law to charge under Medicare for the less extensive service. However, if the doctor requests an appeal of this claim within 30 days, a refund is not required until we complete our appeal. If you paid for the more extensive service and do not hear anything about a refund within the next 30 days, contact your doctors office.   In addition, add the following paragraph:   You could have avoided paying $_______, the difference between the maximum amount the doctor or supplier is allowed to charge and the amount Medicare approved for the lesser service, if the claim had been assigned.   140.6.2 - Initial Physician Notices  (Rev. 4250; Issued: 03- 08-10; Effective: 04 -08-19; Implementation: 04 -08-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   Include in the notice to the physician the following:    The patients name and Medicare beneficiary identifier;    A description of the service by procedure code, date and place of service, and amount of the charge;    The same denial notice included on the beneficiarys MSN; and    Depending on whether the beneficiary submitted a copy of an acceptable ABN with his/her claim, include in the notice to the physician one of the following:   Notice 1 -  Advance Beneficiary Notice Received Prior to Initial Determination
(Medicare Claims Processing Manual)
 Depending on whether the beneficiary submitted a copy of an acceptable ABN with his/her claim, include in the notice to the physician one of the following:   Notice 1 -  Advance Beneficiary Notice Received Prior to Initial Determination   (The service identified above has been denied because/although payment has been made to the patient for a less extensive service,) the information furnished did not substantiate the need for the (more extensive) service. Since you informed the beneficiary in writing prior to furnishing the service that Medicare was likely to deny payment for the (more extensive) service and the beneficiary signed a statement agreeing to pay, the beneficiary is liable for (this/the more extensive) service.   Or  Notice 2 -  Advance Beneficiary Notice Not Submitted   (The service identified above has been denied because/Although payment has been made to the patient for a less extensive service,) the information furnished did not substantiate the need for the (more extensive) service).   If you have collected (any amount from the patient/any amount that exceeds your maximum allowable actual charge (MAAC) for the less extensive service), the law requires you to refund that amount to the patient within 30 days of receiving this notice. The l aw permits exceptions to this refund requirement in two cases:    If you did not know, and could not have reasonably been expected to know, that Medicare would not pay for this service; or    If you notified the beneficiary in writing before providing the service that you believed that Medicare was likely to deny the service, and the beneficiary signed a statement agreeing to pay for the service.   If you come within either exception, or if you believe the contractor was wrong in its determination that Medicare does not pay for this service, you should request an appeal of this determination by the contractor within 30 days of receiving this notice. Your request for appeal should include any additional information necessary to support your position.
(Medicare Claims Processing Manual)
If you request an appeal within this 30 day period, you may delay refunding the amount to the beneficiary until you receive the results of the appeal. If the appeal determination is favorable to you, you do not have to make any refund. If, however, the appeal is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable appeal decision.  The law also permits you to request an appeal of the determination at any time within six months of receiving this notice. An appeal requested after the 30 day period does not permit you to delay making the refund. Regardless of when an appeal is requested, the patient will be notifi ed that you have requested one, and will receive a copy of the determination.   The patient has received a separate notice of this denial decision. The notice advises that he or she may be entitled to a refund of any amounts paid, if you should have known that Medicare would not pay and did not tell him or her. It also instructs the p atient to contact your office if he or she does not hear anything about a refund within 30 days.  The requirements for refund are in 1842(1) of the Social Security Act. Section 1842(1) specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare progra m.  If you have any questions about this notice, please contact (Contractor contact, telephone number).   The contractor will ensure that the telephone number puts the physician in touch with a knowledgeable professional who can discuss the basis for the denial or reduction in payment.  NOTE:   These procedures do not apply to claims the contractor automatically denies under the A/B link procedures. In those cases, the QIO is responsible for notifying the beneficiary and physician of the refund requirements of 1842(1) and making the refund determination where appropriate.   140.7 - Processing Beneficiary Requests for Appeal  (Rev. 4250; Issued: 03- 08-10; Effective: 04 -08-19; Implementation: 04 -08-19)
(Medicare Claims Processing Manual)
140.7 - Processing Beneficiary Requests for Appeal  (Rev. 4250; Issued: 03- 08-10; Effective: 04 -08-19; Implementation: 04 -08-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   Where a beneficiary requests an appeal of the initial denial or reduction in payment, the contractor will process the appeal in the normal fashion except that, where the appeal results in a reversal to full or partial payment, the contractor will include the following special paragraph in the appeal notice sent to the beneficiary:   The doctor who furnished this service has been informed of this decision and advised that he/she may collect (his/her full charge for the service/up to the maximum amount he/she is allowed by law to charge under Medicare for the less extensive service for which payment has been made).   If the reversal is for the less extensive service, the contractor will incorporate in the notice the following:   You could have avoided paying $_______, the difference between the maximum amount the doctor is allowed to charge and the amount Medicare approved for the lesser service, if the claim had been assigned.   The contractor will send the physician who furnished the service a separate notice which clearly identifies the service for which full or partial payment is being made (i.e., includes the patients name, Medicare beneficiary identifier, a description of th e service billed by procedure code, date and place of service, and amount of the charge. Where only partial payment is being made, the contractor will clearly indicate the less extensive service for which payment has been made). The contractor will include  the following language:
(Medicare Claims Processing Manual)
You were previously advised that Medicare payment could not be made for this service. However, after reviewing this claim, we have determined that payment may be made (for a less extensive service). Therefore, if you have already refunded the amounts you c ollected from the beneficiary for this service, you may recollect (these amounts/any amounts which do not exceed your maximum allowable actual charge (MAAC) for the less extensive service for which payment has been made).   140.8 - Processing Physician Requests for Appeal  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Where a physician requests an appeal, the contractor will notify the beneficiary as discussed in 140.5. The appeal process consists of three stages, even though the physician may be contesting only one issue (e.g., the physician may assert that he/she did not know, and could not have reasonably have been expected to know, that Medicare would not pay for the services).   140.8.1 - Appeal of the Denial or Reduction in Payment  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  The first part of the appeal is a new, independent, and critical reexamination of the facts regarding the denial or reduction in payment. If the contractor finds that the initial denial or reduction in payment was appropriate, the contractor will go on to 140.8.2.  140.8.2 - Beneficiary Given ABN and Agreed to Pay  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A physician who has given the beneficiary an ABN and has obtained the beneficiarys signed statement agreeing to pay, is not required to make a refund. If the physician claims to have given an ABN to the beneficiary, the contractor will ask the physician t o furnish a copy of the signed ABN. The contractor will examine the ABN to determine whether it meets the guidelines in 140.4. In the absence of acceptable evidence of advance notice, the contractor will go on to 140.8.3.
(Medicare Claims Processing Manual)
140.8.3 - Physician Knowledge  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  In determining whether the physician knew, or could reasonably have been expected to know, that Medicare would not pay for the services, the contractor will apply the same rules that are applicable in determining physician liability under 1879 of the Act. (See 30.2.)   140.9 - Guide Paragraphs for Inclusion in Appeal Determination  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  The contractor, upon completion of its appeal, will send the physician an appeal notice and send a copy to the beneficiary. If the initial payment determination is reversed to full or partial payment, the contractor will include in the appeal notice the physician notice language required in 140.7. Otherwise, the contractor will include one of the following paragraphs concerning refund.  Paragraph 1. Refund Not Required -  Beneficiary Was Given Advance Beneficiary Notice and Agreed to Pay   Under 1842(l) of the Social Security Act, a physician who does not accept assignment and collects any amounts from a Medicare beneficiary for services for which Medicare does not pay on the basis of 1862(a)(1) of the Social Security Act, must refund these amounts to the beneficiary. However, a refund is not required if, prior to furnishing the services, the physician notified the beneficiary in writing that Medicare would not pay for the services and the beneficiary signed a statement agreeing to pay for them. After reviewing this claim, we have determined that you informed the beneficiary in advance that Medicare does not pay for the above services and the beneficiary agreed to pay for them. Therefore, you are not required to make a refund in this case. The beneficiary has been sent a copy of this notice.  Paragraph 2. Refund Not Required -  Physician Did Not Know That Medicare Would Not Pay For the Services
(Medicare Claims Processing Manual)
Under 1842(1) of the Social Security Act, a physician who does not accept assignment and collects any amounts from a Medicare beneficiary for services for which Medicare does not pay on the basis of 1862(a)(1) of the Social Security Act, must refund thes e amounts to the beneficiary. However, a refund is not necessary if the physician did not know, and could not reasonably have been expected to know, that Medicare does not pay for the services. After reviewing this claim, we find that you did not know, and could not reasonably have been expected to know, that Medicare would not pay for the above services. Therefore, you are not required to make a refund in this case. Upon your receipt of this notice, it is considered that you now have knowledge of the fact that Medicare does not pay for (description of services) for similar conditions. The beneficiary has been sent a copy of this notice.   Paragraph 3. Adverse Action on Denial -  Refund Required
(Medicare Claims Processing Manual)
Paragraph 3. Adverse Action on Denial -  Refund Required   Under 1842(1) of the Social Security Act, a physician who does not accept assignment and collects any amounts from a Medicare beneficiary for services for which Medicare does not pay on the basis of 1862(a)(1) of the Social Security Act, must refund thes e amounts to the beneficiary. A refund is not required if (1) the physician did not know, and could not reasonably have been expected to know, that Medicare would not pay for the services; or (2) the physician notified the beneficiary in writing before fur nishing the services that Medicare would not pay for the services and the beneficiary signed a statement agreeing to pay for them. After reviewing this claim, we have determined that neither of these conditions is met in this case. You must therefore refund any amount you collected for these services within 15 days from the date you receive this notice. A refund must be made within 15 days from receipt of this notice for you to be in compliance with the law. If we paid for a less extensive procedure, you ne ed refund only the amount which exceeds your maximum allowable actual charge (MAAC) for the less extensive procedure. The beneficiary has been sent a copy of this notice. Physicians who knowingly and willfully fail to make appropriate refunds may be subjec t to assessments of double the violative charges, civil money penalties (up to $2000 per violation), and/or exclusion from the Medicare program for a period of up to 5 years.   140.10 - Physician Fails to Make Refund  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)
(Medicare Claims Processing Manual)
140.10 - Physician Fails to Make Refund  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Under 1842(1)  of the Act, a physician who knowingly and willfully fails to make refund within the time limits in 140.3 may be subject to sanctions (i.e., civil money penalties and/or exclusion from the Medicare program). Generally, the failure of a physician to make a refund comes to the contractors attention as a result of a beneficiary complaint to the contractor, Social Security Administration (SSA), or CMS. If necessary, the contractor will contact the beneficiary to clarify the information in the co mplaint and to determine the amount the beneficiary paid the physician for the denied services. If the contractor determines that a physician failed to make a refund, it will contact the physician in person or by telephone to discuss the facts of the case. The contractor will attempt to determine why the amounts collected have not been refunded and will explain that the law requires that the physician make refund to the beneficiary and that if he/she fails to do so, the OIG may impose civil money penalties and assessments, and sanctions. The contractor will make a dated report of contact and include the information relayed to the physician and the physicians response. The contractor will recontact the beneficiary in 15 days to determine whether the refund has been made. When the amount in question is $300 or more or where there are at least three outstanding violations by the physician, the contractor will contact the Sanctions Coordinator in the appropriate field office of the OIG by telephone to discuss whether referral to OIG  is appropriate. If the case should be referred, the contractor will make the referral to the regional OIG Sanctions Coordinator in accordance with the procedures following. The contractor should not make a referral until the physicians appeal rights have  been exhausted, or until the time limit for an appeal has passed.   140.11 - OIG Referral Procedures  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  The contractor will include in the sanction recommendation to the OIG/FO (to the extent appropriate) the following:
(Medicare Claims Processing Manual)
The contractor will include in the sanction recommendation to the OIG/FO (to the extent appropriate) the following:    Identification of the Subject -  The subjects name, address and a brief description of the subjects special field of medicine.    Origin of the Case -  A brief description of how the violations were discovered.    Statement of Facts -  A statement of facts in chronological order describing each failure to comply with the refund requirements in 1842(1).    Documentation -  Copies of written correspondence and written summaries of any meetings or telephone contacts with the beneficiary and the physician regarding the physicians failure to make refund.    Other Significant Issues -  Any information that may be of value in the event of a hearing to bar a physician from receiving Medicare payment.   140.12 - Imposition of Sanctions  (Rev. 1, 10- 01-03)  Section 1842(1)(3)  of the Act provides that if a physician knowingly and willfully fails to make a required refund, the Secretary may impose the sanctions provided in 1842(j)(2) of the Act. These include assessments of double the violative charges, civil money penalties ( up to $2000 per violation), and/or exclusion from the Medicare program for a period of up to five years. However, sole community physicians and physicians who are the sole source of an essential specialty are not excluded from the program. The OIG makes determinations to levy a monetary penalty or program exclusion based upon a failure to make a refund.   150 - DMEPOS Refund Requirements (RR) Provision for Claims for Medical Equipment and Supplies under 1834(a)(18), 1834(j)(4), and 1879(h) - Instructions for Contractors and Suppliers  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03 -01-09)
(Medicare Claims Processing Manual)
Following are the procedures for implementing 1834(a)(18), 1834(j)(4) and 1879(h) of the Act. Under 132 of SSAA -1994 (Social Security Act Amendments of 1994, P.L. 103-432) which adds 1834(a)(18) to the Act, and under 133 of SSAA -1994 which adds 1834(j)(4) and 1879(h) to the Act, new liability protections for Medicare beneficiaries affect suppliers of medical equipment and supplies. All suppliers who sell or rent medical equipment and supplies to Medicare beneficiaries are subject to the refund provis ions of 1834(a)(18), 1834(j)(4) and 1879(h) of the Act. Beneficiaries liability for payment for certain items and services, that is, for otherwise covered medical equipment and supplies as defined in 150.10 , which are furnished on or after January 1, 1995, and for which Medicare payment is denied for one of several reasons specified below, may be limited as follows. For both assigned and unassigned claims, for which the supplier knew or should have known of  the likelihood that payment would be denied ( that is, the supplier is held to be liable) and for which the beneficiary did not know, the beneficiary has no financial responsibility and the refund provisions of the Act apply in virtually all cases. The single exception to this rule of applicability is  that, with respect to medical equipment and supplies for which the supplier accepted assignment and for which payment is denied because the item or service is not medically reasonable and necessary under 1862(a)(1) of the Act, the 1879 Limitation on Lia bility provisions which applied to such denials prior to January 1, 1995, still apply. The refund provisions do not apply to these denials.