evekhm/cms_iom_500 huggingface dataset:
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FL 14. Priority (Type) of Admission or Visit   a. One numeric position.  b. Required only if the type of bill is 11X, 12X, 18X, 21X, 22X, or 41X.   FL 15. Point of Origin for Admission or Visit.  a. One numeric position  b. Must be present   FL 17. Patient Discharge Status.  a. Two numeric positions   b. Present on all Part A inpatient, SNF, hospice, home health agency, and outpatient hospital services.  Types of bill:  11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 33X, 34X, 41X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, 83X, or 85X.   FL 03b. Medical/Health Record Number   a. If provided by the hospital, must be recorded by the A/B MAC (A) for the QIO.   b. Must be left justified in CWF record for QIO.   FLs 18 thru 28. Condition Codes.  a. Each code is two numeric digits.  b. If code 07 is entered, type of bill must not be hospice 81X or 82X.  c. If codes 36, 37, 38, or 39 are entered, the type of bill must be 11X and the provider must be a non-PPS hospital or exempt unit.  d. If code 40 is entered, the From and Through dates in FL 6 must be equal, and there must be a 0 or 1 in FL 7 (Covered Days).  e. Only one code 70, 71, 72, 73, 74, 75, or 76 can be on an ESRD claim.  FLs 31, 32, 33, and 34. Occurrence Codes and Dates  a. All dates must be valid.
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b. Each code must be accompanied by a date.  c. All codes are two alphanumeric positions.  d. If code 20 or 26 is entered, the type of bill must be 11X or 41X.  If code 21 or 22 is entered, the type of bill must be 18X or 21X.  e. If code 27 is entered, the type of bill must be 81X or 82X.  f. If code 28 is entered, the first digit in FL 4 must be a 7 and the second digit a 5.  g. If code 42 is entered, the first digit in FL 4 must be 8 and the second digit 1 or 2 and the third digit 1 or 4.  h. If 01 - 04 is entered, Medicare cannot be the primary payer, i.e., Medicare- related entries cannot appear on the A lines of FLs 58-62.  i. If code 20 is entered:   Must not be earlier than Admission date (FL 17)  or later than Through date (FL 6).   Must be less than 13 days after the admission date (FL 17) if From date is equal to admission date (less than 14 days if billing dates cover the period December 24 through January 2).  j. If code 21 is entered:    Cannot be later than Statement Covers Period Through date; or    Cannot be more than 3 days prior to the Statement Covers Period From date.   k. If code 22 is entered, the date must be within the billing period shown in FL 6.   l. If code 31 is entered, the type of bill must be 11X, 21X, or 41X.   m. If code 32 is entered, the type of bill must be 13X, 14X, 23X, 32X, 33X, 34X, 71X, 72X, 73X, 74X, 75X, 81X, or 82X.   FL 35 and 36. Occurrence Span Codes and Dates   a. Dates must be valid.   b. Code entry is two alphanumeric positions.  c. Code must be accompanied by dates.   d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.
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b. Code entry is two alphanumeric positions.  c. Code must be accompanied by dates.   d. If code 70 is entered, the type of bill must be 11X, 18X, 21X, or 41X.   e. If code 71 is entered, the first digit of FL 4 must be 1, 2, or 4 and the second digit must be 1.   f. If code 72 is entered, the type of bill must be 11X, 12X, 13X, 14X, 18X, 21X, 22X, 23X, 32X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 77X, 81X, 82X, or 85X.  g. If code 74 is entered, the type of bill must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 74X, 75X, 81X, or 82X.   h. If code 75 is entered, the first digit of FL 4 must be 1 or 4 and the second digit must be 1.   i. If code 76 is entered, occurrence code 31 must be present (inpatient only).  j. If code 76 is entered, occurrence code 32 must be present (outpatient only).  k. If code 76, 77, or M1 is present, the bill type must be 11X, 13X, 14X, 18X, 21X, 34X, 41X, 71X, 72X, 73X, 74X, 75X, 81X, 82X, or 85X.   l. Neither the From nor the Through portion can exceed eight positions allowing for separations (nonnumeric characters) in the third and sixth positions of each field.   m. If code M2 is present, the bill type must be 81X or 82X.   n. Code 79 is for payer use only.  Providers do not report this code.   FLs 39, 40, and 41. Value Codes and Amounts.   a. Each code must be accompanied by an amount.   b. All codes are two alphanumeric digits.  c. Amounts may be up to ten numeric positions. (00000000.00)   d. If code 06 is entered, there must be an entry for code 37.
(Medicare Claims Processing Manual)
b. All codes are two alphanumeric digits.  c. Amounts may be up to ten numeric positions. (00000000.00)   d. If code 06 is entered, there must be an entry for code 37.   e. If codes 08 and/or 10 are entered, there must be an entry in FL 10.   f. If codes 09 and/or 11 are entered, there must be an entry in FL 9.   g. If codes 12, 13, 14, 15, 41, 43, or 47 are entered as zeros, occurrence codes 01, 02, 03, 04, or 24 must be present.   h. Entries for codes 37, 38, and 39 cannot exceed three numeric positions.  i. If the blood usage data is present, code 37 must be numeric and greater than zero.   FL 42. Revenue Codes.   a. Four numeric positions.  b. Must be listed in ascending numeric sequence except for the final entry, which must be 0001 for hardcopy claims only.  c. There must be a revenue code adjacent to each entry in FL 47.   d. For bill types 32X and 33X the following revenue codes require a 5- position HCPCS code:   0274, 029X, 042X, 043X, 044X, 055X, 056X, 057X, 0601, 0602, 0603, and 0604.  e. For bill type 34X, the following revenue codes require a 5 -position HCPCS   code:   0271- 0274, 42X, 43X, 44X, and 0601- 0604.   f. For bill type 21X, 32X, 33X, or 11X (IRF facilities) the following revenue codes require a 5 -position HIPPS code:   0022 (SNF only), 0023 (HH only), 0024 (IRFs only).  FL 45. Service Date   a. Six numeric positions, MMDDYY.   b. A single line item date of service (LIDOS) is required on every revenue code present on types of bill 12X, 13X, 14X, 22X, 23X, 24X, 32X, 33X, 34X, 71X, 73X, 74X, 75X, 76X, 81X, 82X, and 83X.
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Exception:  LIDOS are not required for CAHs, Indian Health Service hospitals, and hospitals located in American Samoa, Guam, and Saipan.   c. When a particular service is rendered more than once during the billing period, the revenue code and HCPCS code must be entered separately for each service date.   FL 46. Units of Service   a. Up to seven numeric positions.   b. Must be present for all services with the exception of the HIPPS line item service.  (Exception:  Units are required on the HIPPS line for SNF claims)   c. Accommodation units must equal covered days with the exception of the R No-Pay.  FL 47. Total Charges   a. Up to 10 numeric positions (00000000.00).  b. There must be an entry adjacent to each entry in FL 42.   c. The 0001 amount must be the sum of all the entries for hardcopy only.  FLs 50A, B, and C. Payer Identification   a. "Medicare must be entered on one of these lines depending upon whether it is the primary, secondary or tertiary payer.   b. If value codes 12, 13, 14, 15, 16, 41, 42, 43, or 47 are present, data pertaining to Medicare cannot be entered in Line A of FLs 50 -62.  FL 56. National Provider Identifier  Billing Provider   a. Effective May 23, 2007, providers are required to submit their NPI.  b. Left justified.   FLs 58A, B, and C. Insureds Name   a. Must be present.  Cannot be all spaces.   FLs 60A, B, and C. Certificate/Social Security Number/HI Claim/Identification Number   a. Must be present.
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a. Must be present.  Cannot be all spaces.   FLs 60A, B, and C. Certificate/Social Security Number/HI Claim/Identification Number   a. Must be present.   b. Must contain nine numeric characters and at least one alpha character as a suffix.  The first alpha suffix is entered in position 10, the second in position 11, etc. The first three numbers must fall within the range of 001 through 680 or 700 through 728.  c. The alpha suffix must be A through F, H, J, K, M, T, or W.  Alpha suffixes A and T must not have a numeric subscript.  Alpha suffixes B, C, D, E, F, M, and W may or may not have a numeric subscript.  d. If the alpha suffix is H, it must be followed by A, B or C in position eleven.  The numeric subscript (position twelve) must conform with the above for the A, B, or C suffix to be used.   e. RRB claim numbers must contain either six or nine numeric characters, and must have one, two, or three -character alpha prefix.   f. For prefixes H, MH, WH, WCH, PH and JA only a 6- digit numeric field is permissible.  For all other prefixes, a six or nine numeric field is permissible.   g. Nine numeric character claim numbers must have the same ranges as the SSA 9 -position claim numbers.  FL 67. Principal Diagnosis Code and Present on Admission Indicator.   a. If ICD -9-CM, must be four or five positions left justified, with no decimal points.  If ICD -10-CM, must be three to seven positions, left justified, with no decimal points.  b. Must be valid ICD diagnosis code for date of service.   c. POA is a one position field.  FLs 67 A -  Q.  Other Diagnosis Codes and Present on Admission Indicator.   a. If present, for ICD -9-CM must be four or five positions, left justified, with no decimal points.  For ICD -10-CM must be three to seven positions, left justified, with no decimal points.  b. POA is a one position field.  FL 74. Principal Procedure Code and Date
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b. POA is a one position field.  FL 74. Principal Procedure Code and Date   a. If present, must be valid procedure code for service date.  For ICD -9-CM must be 3 - 5 characters; first character may be numeric or alpha, characters 2 - 5 must be numeric.  For ICD -10-PCS must be 3 -  7 characters; first character must be alpha, second character must be numeric, characters 3  7 may be alpha or numeric.  b. If code is present, date must be present and valid.  c. Date must fall before the Through date in FL 6.  (In some cases it may be before the admission date, i.e., where complications and admission ensue from outpatient surgery.)   FL 74 a -e. Other Procedure Codes and Dates.   a. If present, apply edits for FL 74   FL 76. Attending Provider Name and Identifiers.   a. The UPIN must be present on inpatient Part A bills with a Through date of January 1, 1992, or later.  For outpatient and other Part B services, the UPIN must be present if the From date is January 1, 1992, or later.  This requirement applies to all provider types and all Part B bill types.  Effective May 23, 2007, providers are required to submit NPI.  b. An institutional provider may not submit their own NPI, except for Institutional billing of COVID -19, influenza, and pneumococcal vaccinations and their administration as the only billed service on a claim, roster billing of COVID -19, influenza, and pne umococcal vaccinations and their administrations, self -referred screening mammography as the only billed service on a claim, HCPCS K1034 as the only billed service on a claim, or where the provider only has a type -1 NPI as a physician/practitioner owned sole -proprietor (i.e., RHC).   c. An institutional provider may not submit an organizational type -2 NPI in the attending NPI field except as noted above in b.   FL 77. Operating Physician Name and Identifiers   a. Effective May 23, 2007, providers are required to submit NPI.  NPI must be present if:    Bill type is 11X and a procedure code is shown in FL 74;
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FL 77. Operating Physician Name and Identifiers   a. Effective May 23, 2007, providers are required to submit NPI.  NPI must be present if:    Bill type is 11X and a procedure code is shown in FL 74;    Bill type is 83X or 13X and a HCPCS code is reported that is subject to the ASC payment limitation or is on the list of codes the QIO furnishes that require approval; or    Bill type is 85X and HCPCS code is in the range of 10000 through 69979.  b. If required:    NPI, last name and first initial must be present; and    Left justified.   80.3.3 - Timeliness Standards for Processing Other -Than -Clean Claims  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
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The Social Security Act, at 1869(a)(2), mandates that Medicare process all other -than-clean claims and notify the individual filing such claims of the determination within 45 days of receiving such claims.  Claims that do not meet the definition of clean claims are other -than-clean claims.  Other -than-clean claims require investigation or development external to the contractors Medicare operation on a prepayment basis.  The contractor shall process all other -than-clean claims and notify the provider and provider of the determination within 45 calendar days of receipt.  (See Pub100- 4, Chapter 1, 80.2.1 for the definition of receipt date and for timeliness standards for clean claims.)  However, when the contractor develops to the provider/supplier or beneficiary for additional information, the contractor shall cease counting the 45 calendar days on the day that the contractor sends the development letter.  Upon receiving the materials requested in the development letter from the provider/supplier and/or beneficiary, the contractor shall resume counting the 45 calendar days.  EXAMPLE:   The contractor receives a claim on June 1st, but does not send a development letter to the provider/supplier/ and/or beneficiary until June 5th.  In this situation, 5 of the 45 allotted calendar days will have already passed before the contractor requested  the additional information.  Upon receiving the information back from the provider/supplier and/or beneficiary, the contractor has 40 calendar days left to process the claim and notify the individual that filed the claim of the payment determination for that claim.   Contractors shall follow existing procedures relative to both the length of time the provider/supplier and/or beneficiary is afforded to return information requested in the development letters and situations where the provider/supplier and or beneficiary does not respond.  Contractors shall report the number of other -than-clean claims processed in 45 days or less on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) report.  Use identifier code 0005 in column 1 to report this information.  Report t he number of other -than-clean claims processed in 46 days or longer on Form Y of the CROWD system, under column 1 on a line using code 0006 as the identifier.   The following types of claims do not apply to this instruction:
(Medicare Claims Processing Manual)
The following types of claims do not apply to this instruction:    Claims where the Social Security Administration blocks a beneficiarys Medicare beneficiary identifier,    Claims the contractors are required to hold due to CMS instructions,    Translator rejects,    Claims where CWF is unable to process due to technical issues with the CWF beneficiary record or beneficiary identification issues,    Claims submitted by a hospice, and    Claims in development due to processing requirements (e.g. medical review), in Publication 100- 8, the Medicare Program Integrity Manual.   80.4 - Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment)  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.
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A.  General  To remain on PIP, providers, (with the exception of HHAs that do not receive PIP with the advent of PPS mandated by law on October 1, 2000), must submit 85 percent of their bills timely and accurately.  Timely and accurately means that 85 percent of its bi lls (excluding those listed below) are submitted within 30 days of discharge and pass front -end edits for consistency and completeness.  A bill is not considered received unless it can pass FI edits.  FIs must accumulate statistics on inpatient and SNF billing performance for each PIP provider to monitor whether it meets this requirement. These instructions do not effect bi -weekly payments for pass -throughs (Medicare Provider Reimbursement Manual, (PRM) 2405.2) and for adjustments to indirect cost for medi cal education (PRM 2405.3). The evaluation for timeliness of billing should be consistent with the frequency for monitoring the payment amounts under the PIP program.  Thus, for non- PPS hospitals and SNFs the evaluation process is scheduled at 3- month intervals and PPS providers are evaluated every 4 months.  The evaluation includes data from the entire 3-  or 4-month period.  In determining whether a provider submitted its bills within 30 days of discharge or through date on interim bills, count the date from Form CMS -1450 FL6 (through date) to the date received by the FI.  If the provider does not meet the criteria, discontinue PIP immediately.  The periodic performance report that is provided in accordance with subsection B will constitute advance notice before discontinuing PIP. Exclude the following:   MSP cases (value codes 12 -16);  Any special situation identified by the provider or FI that is documented as beyond provider control.  Exclusions must be approved by the RO; and   Bills that have not passed FI front -end edits for acceptance.  (Such bills are counted only when acceptable to the shared system edit processes.)  The FIs must accumulate statistics monthly and summarize them for the entire evaluation period. B.  Procedure for Measuring and Reporting to Hospitals and SNFs  The FIs accumulate a record for each bill that passes front -end edits. Bills must be counted in the month received regardless of the discharge month.  No later than 10 work-days after the end of the month, FIs furnish a report to each hospital/SNF. For the  month indicating
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-end edits. Bills must be counted in the month received regardless of the discharge month.  No later than 10 work-days after the end of the month, FIs furnish a report to each hospital/SNF. For the  month indicating the following:   The total number of bills received;   The number not excluded as described in section A;   The number not excluded received in 30 days or less;   The percentage not excluded received in 30 days or less. Also, for providers that fail to meet the standard, furnish individual case identification of claims that were not billed within 30 days of discharge.  List only claims that are not excluded and are identified in subsection A.  The report must be furnished in electronic media, unless the FI determines a paper listing would be cheaper to process.  If electronic media is used, use the following record format.  Determine the physical characteristics of the file.  Fld Description  Psn. Picture  Just From  Thru  1 Provider Number  6 X(6)  L 001 006 2 Blank  3 X(3)   007 009 3 Blank  1 X  010  4 Medicare beneficiary identifier  12 X(12)  L 011 022 5 Blank  1 X  023  6 Beneficiary Surname  6 X(6)  L 024 029 7 Blank  1 X  030  8 Patient Control Number  17 X(17)  L 031 047 9 Blank  1 X  048  10 From Date  6 9(6)  049 054 11 Blank  1 X  055  12 Discharge or Thru Date  6 9(6)  056 061 13 Blank  1 X  062  14 Date Bill Received  6 9(6)  063 068 15 Blank  1 X  069  16 Days Elapsed  4 9(4) R 070 073 If sub -provider identification is used, positions 7, 8, and 9 may be utilized.  C.  Reinstatement of PIP  Do not reinstate PIP for a provider until it meets all criteria in PRM 2405.1.B  and 2407 and has met the requirements in subsection A for timeliness and accuracy for six consecutive months.  D.  New Request for PIP  Evaluate new requests for PIP as in subsections A and B.  At least three months experience is required for new requests, (except for new providers with less experience).  E.  Hospitals on 100 Percent PRO Prepayment Review  The 30- day requirements for submitting bills to FIs are not applicable.  The RO
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At least three months experience is required for new requests, (except for new providers with less experience).  E.  Hospitals on 100 Percent PRO Prepayment Review  The 30- day requirements for submitting bills to FIs are not applicable.  The RO makes determinations of timely and accurate bill submission by hospitals for which the PRO reviews 100 percent of the discharges before payment.  However, other standards remai n applicable for retaining PIP in such cases.  See PRM 2405.1.B and 2407 for the requirements.
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80.5 - Do Not Forward Initiative (DNF)  (Rev. 1, 10- 01-03)
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80.5.1 - Carrier DNF Requirements  (Rev. 1, 10- 01-03) B3-4021, B -02-023 This initiative entails the use of Return Service Requested envelopes to preclude the forwarding of Medicare checks to locations other than those recorded on the Medicare provider files.  The use of these envelopes permit the U.S. Postal Service to retur n Medicare checks to local carriers and durable medical equipment regional carriers (DMERCs) free of charge, as the postal service has done for the DMERCs since February 1997. A.  Returned Check Process for Carriers and DMERCs  The CMS requires carriers and DMERCs to use Return Service Requested envelopes for all checks they mail to providers and suppliers.  In addition, carriers and DMERCs must use return service requested envelopes for hardcopy remittance advices, with respect to providers that have elected to receive hardcopy remittance advices. They do not use return service requested envelopes for beneficiary correspondence, such as Explanations of Benefits (EOB) or Medicare Summary Notices (MSNs), or for overpayment de mand letters.  Carriers and DMERCs must be in compliance with postal regulations when developing their DNF envelopes.  Carriers and DMERCs must sort outgoing mail to identify provider or supplier checks, and must only place these checks in Return Service Requested enve lopes.  The postal service will forward remittance advice without checks and checks to beneficiaries.  When the check is returned, if applicable, the postal service will provide the carrier or DMERC with a new address or reason for nondelivery.  If the postal service supplies a carrier or DMERC with a new address for the provider or supplier with the returned check or remittance, do not automatically change the address of the provider or supplier or re-mail the check/remittance.  (See the change of address process described below.)  Once the post office returns an envelope, record the check number and any correspondence in the envelope, using normal procedures for incoming mail.  For example, microfiche, and photocopy the mail.  Contractors must also log and account for the checks, noting pertinent information, such as the provider or suppliers name and number, date of the check, the check number, the amount