evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
 The blood or packed red cells have been replaced; or    The provider (or its blood supplier) receives from an individual, or a blood bank, a replacement offer.  This offer is applicable if the replacement blood would not endanger the health of a recipient and if the prospective donor's health would not be endan gered by making a blood donation.  In this case the provider is precluded from charging even if it or its blood supplier rejects the replacement offer.   Refer to Pub. 100-04, Medicare Claims Processing Manual, chapter 4, 231 regarding billing for blood and blood products under the Hospital Outpatient Prospective Payment System (OPPS).   10.1.5 - Services Requested by Beneficiary  (Rev. 1, 09-11-02)  This section is a further explanation of 10.1.1.  If services furnished at the request of a beneficiary (or his or her representative) are more expensive than, or in excess of, services covered under Medicare, a provider may charge the beneficiary an amount that does not exceed the difference between (1) the provider's customary charges for the services furnished; and (2) the provider's customary charges for the kinds and amounts of services that are covered under Medicare.  A provider may not charge for these services unless they have been requested by the beneficiary (or his or her representative) and may not require a beneficiary to request services as a condition of admission.  To avoid misunderstanding and disputes, a provider must inform any beneficiary who requests a service for which a charge will be made that there will be a specified charge for that service.
(Medicare General Information, Eligibility, and Entitlement)
10.1.6 - Provider Charges to Beneficiary Where Provider Customarily Furnishes More Expensive Services Not Requested by Beneficiary  (Rev. 1, 09-11-02)  A provider that customarily furnishes an individual items or services that are more expensive than the items or services determined to be necessary in the efficient delivery of needed health services, may charge an individual entitled to benefits under Medicare for such more expensive items or services even though not requested by the individual.  The charge, however, may not exceed the amount by which the cost of (or, if less, the customary charges for) more expensive items or services furnished by such provider in the second cost reporting period immediately preceding the cost reporting period in which such charges are imposed, exceeds the applicable limit imposed under the provisions of 42 CFR 413.30.  This charge may be made only if:    The A/B MAC (A) or (HHH) determines that the charges have been calculated properly in accordance with the provisions of this regulation section;   The services are not emergency services as defined in 20.1 or 20.2  of this chapter;    The admitting physician has no direct or indirect financial interest in such provider;   CMS has provided notice to the public through notice in a newspaper of general circulation servicing the provider's locality and such other notice as the Secretary may require, of any charges the provider is authorized to impose on individuals entitled to benefits under Medicare on account of costs in excess of the costs determined to be necessary in the efficient delivery of needed health services under Medicare; and    The provider has identified such charges to such individual or person acting on his/her behalf as charges to meet the costs in excess of the costs determined to be necessary in the efficient delivery of needed health services under Medicare.  10.1.7 - Hospitals Participating in State Reimbursement Control Systems or Demonstration Projects  (Rev. 1, 09-11-02)  This section is a further explanation of 10.1.1.  A hospital receiving payment for a covered hospital stay under:   Either a State reimbursement control system approved under 1886 (c) of the Act; or
(Medicare General Information, Eligibility, and Entitlement)
A hospital receiving payment for a covered hospital stay under:   Either a State reimbursement control system approved under 1886 (c) of the Act; or    A demonstration project authorized under section 402(a) of Pub. L. 90 - 248 (42 U.S.C. 1395b - 1) or section 222(a) of Pub. L. 92 - 603 (42 U.S.C.1395b - 1 (NOTE)); and    Would otherwise be subject to the prospective payment system set forth in part 412 of this chapter, may also charge a beneficiary for custodial care and medically unnecessary services described in CFR CUR 412.42(c), after the conditions of 412.42(c)(1) through(c)(4) are met.  10.1.8 - Medicare Secondary Payer Involvement of Failure to File Proper Claims (Rev. 1, 09-11-02)  This section is a further explanation of 10.1.1.  A provider that has not filed a proper claim and has received a reduced payment because of this from a payer primary to Medicare agrees:   To bill Medicare for an amount no greater than would have been payable as secondary payment if the primary insurer's payment had been based on a proper claim; and    To charge the beneficiary only (a) the amount it would have been entitled to charge if it had filed a proper claim and received payment based on such a claim; and (b) an amount equal to any third-party payment reduction attributable to failure to file a proper claim, but only if the provider can show that:  o It failed to file a proper claim solely because the beneficiary, for any reason other than mental or physical incapacity, failed to give the provider the necessary information; or  o The beneficiary, who was responsible for filing a proper claim, failed to do so for any reason other than mental or physical incapacity.
(Medicare General Information, Eligibility, and Entitlement)
10.1.9 - Advance Directive Requirements  (Rev. 1, 09-11-02)  Effective December 1, 1991, participating hospitals must comply with the advance directive provisions of 4206 of OBRA 1990.  Therefore, an agreement per 1866 of the Act with a hospital includes that the hospital 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.   10.1.10 - Posting of Signs in Hospital Emergency Departments   Section 6018(a)(2) of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89), effective July 1, 1990, requires hospitals with emergency departments to post signs which specify the rights (under section 1867 of the Social Security Act) of women in labor and individuals with emergency medical conditions to examination and treatment.  To comply with these requirements, hospitals must post signs that meet the following criteria:    At a minimum, the signs must specify the rights of unstable individuals with emergency conditions and women in labor who come to the emergency department for health care services;    It must indicate whether the facility participates in the Medicaid program;   The wording of the sign must be clear and in simple terms understandable by the population serviced;   Print the signs in English and other major languages that are common to the population of the area serviced;   The letters within the signs must be clearly readable at a distance of at least 20 feet or the expected vantage point of the emergency department patrons; and    Post signs 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 (e.g., entrance, admitting area, waiting room, treatment area).
(Medicare General Information, Eligibility, and Entitlement)
 Post signs 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 (e.g., entrance, admitting area, waiting room, treatment area).   The sample below may be adapted, contains sufficient information to satisfy these requirements, and may be adapted to satisfy the visibility requirement.  IT'S THE LAW!   IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR   YOU HAVE THE RIGHT TO RECEIVE, WITHIN THE CAPABILITIES OF THIS HOSPITAL'S STAFF AND FACILITIES:   An appropriate medical SCREENING EXAMINATION   Necessary STABILIZING TREATMENT (including treatment for an unborn child)  And if necessary   An appropriate TRANSFER to another facility  Even if  YOU CANNOT PAY OR DO NOT HAVE MEDICAL INSURANCE   OR  YOU ARE NOT ENTITLED TO MEDICARE OR MEDICAID   This hospital (does/does not) participate in the Medicaid program  10.2 - Admission of Medicare Patients for Care and Treatment  (Rev. 120, Issued: 11-02-18, Effective: 12- 04-18, Implementation: 12- 04-18  The participation of a provider of services, which voluntarily files an agreement to participate in the health insurance program, contemplates that such provider will admit Medicare beneficiaries for care and treatment, and upon admission, will provide the m with such services as are ordinarily furnished by the provider to its patients generally.  A provider may have restrictions on the types of services it makes available and/or the types of health conditions it accepts, or may establish other criteria relating to the admission of persons for care and treatment.  However, the law does not contempla te that such restrictions or criteria will apply only to Medicare beneficiaries as a class.  It does contemplate, however, that if such restrictions or criteria apply to Medicare beneficiaries, they will be applied in the same manner in which they are applied to all other persons seeking care and treatment by the provider.  Thus, a provider admission or patient policy or practice which is not consistent with the objective contemplated in the law may be used by CMS as a basis for termination of the agreement for cause (see the regulations at 42 CFR 489.53(a)(2), and also see Pub. 100-04, Medicare Claims Processing Manual, chapter 1, 30.1.3).
(Medicare General Information, Eligibility, and Entitlement)
10.3 - Under Arrangements  (Rev. 28; Issued:  08-12- 05; Effective/Implementation:  09 -12-05)  A provider may have others furnish certain covered items and services to their patients through arrangements under which receipt of payment by the provider for the services discharges the liability of the beneficiary or any other person to pay for the service. In permitting providers to furnish services under arrangements, it was not intended that the provider merely serve as a billing mechanism for the other party.  Accordingly, for services provided under arrangements to be covered, the provider must exercise professional responsibility over the arranged- for services.   The provider's professional supervision over arranged- for services requires application of many of the same quality controls as are applied to services furnished by salaried employees.  The provider must accept the patient for treatment in accordance with its admission policies, and maintain a complete and timely clinical record on the patient, which includes diagnoses, medical history, physician's orders, and progress NOTEs relating to all services received, and must maintain liaison with the attending physician regarding the progress of the patient and the need for revised orders.  In the case of home health services and outpatient physical therapy or speech- language pathology services, the provider must ensure that the required plan of treatment is periodically reviewed by the physician and secure from the physician the required certifications and recertifications.  Additionally, the provider (other than a SNF) must ensure that the medical necessity of such services is reviewed on a sample basis by the uti lization review (UR) committee if one is in place, the facility's health professional staff, or an outside UR group.  (Effective October 1, 1990, a SNF is no longer required to have a plan for UR.)  The provider, including a SNF that conducts optional UR s ervices, is responsible for medical necessity decisions made under arrangement by an outside group.   10.4 - Term of Agreements  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)
(Medicare General Information, Eligibility, and Entitlement)
10.4 - Term of Agreements  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  An agreement with a hospital, HHA, hospice, and (for the purposes of furnishing outpatient physical therapy, occupational therapy, or speech -language pathology services) a clinic, a rehabilitation agency, or public health agency is not time limited and has  no fixed expiration date.  The agreement remains in effect until such time as there is a voluntary termination, or involuntary termination, or a change of ownership.  10.4.1 - Agreement with a SNF  (Rev. 1, 09- 11-02)  All agreements with SNFs are required to be for a specified term of up to l2 full calendar months with fixed expiration dates.  In appropriate situations, the agreement may also contain a cancellation clause.  Therefore, when it is determined that a SNF is  eligible and that its agreement for participation in the Medicare program will be accepted for filing, the term of the agreement will be determined in the following manner:   A. No Deficiencies -  If a SNF is certified as being in full compliance with all standards contained in the requirements for participation for SNFs, the term of the agreement is, as appropriate to the period of certification for it has been approved, for a ter m of up to 12 full calendar months.  B. Deficiencies -  If a SNF is certified as not being in full compliance, the term of the agreement is, as appropriate to the period of certification or conditional period of certification for which it has been approved:   1. For a term which expires no later than the close of the 60th day following the last day of the time period specified in the written plan providing for the correction of deficiencies in meeting the requirements for participation, provided that such term doe s not exceed 12 full calendar months or   2. Provide a conditional term of up to 12 full calendar months, subject to a cancellation clause that the agreement may be canceled on a predetermined date (no later than the close of the 60th day following the last day of the time period specified in the written plan providing for the correction of deficiencies in meeting the requirements for participation), provided that date will occur within the 12- month term.
(Medicare General Information, Eligibility, and Entitlement)
If the health and safety of Medicare patients are not jeopardized, the term of an agreement may be extended for 2 full calendar months when necessary to prevent irreparable harm to the facility, to prevent hardship to Medicare beneficiaries furnished care,  or if it is impracticable within the term of the agreement to determine whether the SNF is complying with the provisions of the Act and regulations issued thereunder.   10.4.2 - Agreement with Rurhal Health Clinic (RHC)/Federally Qualified Health Clinic (FQHC)  (Rev. 1, 09- 11-02)  Agreements between RHCs/FQHCs and CMS are generally for a term of 1 year.  They may be annually renewed by mutual agreement of the RHC/FQHC and CMS, i.e., a new agreement need not be signed each year.  Special circumstances may result in a term of less tha n 1 year for an initial agreement, e.g., a clinic or center may wish the agreement year to run concurrently with the RHC/FQHC's fiscal year or have some other technical considerations.   10.5 - Responsibilities of Participating Provider  (Rev. 1, 09- 11-02)  Upon acceptance for participation, a provider becomes responsible for remaining in compliance with the terms of the agreement and the provisions of title XVIII and regulations issued thereunder.  Where the agreement is made retroactive, the provider must comply with its responsibilities as of the retroactive date.  Payment to the provider for covered items and services it furnishes on or after the effective date of the agreement will require that the provider have a recordkeeping capability sufficient for determining the cost of services furnished Medicare beneficiaries.   The termination of participation (see 10.6  of this chapter) does not immediately abrogate all of the provider's responsibilities and in specific matters a responsibility may extend beyond the effective date of termination.  For example, the provider continues to be responsible (as applicable) for those provisions of the law and regulations which provide for program coverage to remain in effect for specified periods of time beyond the effective termination date, for those beneficiaries who were accepted for care and treatment by the provider before such date.  The provider also continues to be responsible for filing a final cost report and/or the repayment of any overpayment, as these actions relate to final program cost settlement after termination.
(Medicare General Information, Eligibility, and Entitlement)
10.6 - Termination of Provider Participation  (Rev. 1, 09-11-02)  A provider may voluntarily terminate its participation in the program or have it terminated by the Secretary for cause.    10.6.1 - Voluntary Termination  (Rev. 1, 09-11-02)  A provider may terminate its agreement (and in the case of a SNF, it may terminate its agreement prior to the close of the specified term of its agreement) by filing with the Secretary a written notice of its intention to terminate the agreement.  The Secr etary may accept the termination date stated in the notice (the date must be the first day of a month and, in the case of a SNF, must occur within the specified term of such facility's agreement) or set a different date.  However, the termination date set by the Secretary may not be more than 6 months from the date the provider's notice is filed.  10.6.2 - Involuntary Termination, Including SNF Agreement Cancellations  (Rev. 1, 09-11-02)  The Secretary may terminate an agreement (and in the case of a SNF, he/she may terminate its agreement prior to the close of the specified term of the agreement) with a provider if it is determined that the provider:   Is not complying substantially with the provisions of the agreement or with the applicable provisions of title XVIII of the Act and regulations;   No longer meets the appropriate requirements for participation;   Has failed to supply information which is necessary to determine whether payments are due or were due and the amounts of such payments; or    Refuses to permit examinations of fiscal and other records, including medical records.   The cancellation of a SNF agreement at the close of the predetermined date stated in the cancellation clause contained in such agreement (see 10.6.2 of this chapter) is viewed as an involuntary termination of the agreement by the Secretary for cause.  Such actions involve a finding that the SNF has not satisfactorily completed its written plan providing for the correction of deficiencies with respect to one or more of the standards in the applicable requirements for participation, or that the facility has not made substantial effort and progress in correcting such deficiencies.
(Medicare General Information, Eligibility, and Entitlement)
A provider which is dissatisfied with the Secretary's determination terminating its agreement is entitled to request a hearing thereon in accordance with the appeals procedures contained in 42 CFR Part 498.  There is no reconsideration step before the opportunity for a hearing.  NOTE:   The involuntary termination of a hospital's approval authorizing it to provide extended care services, i.e., to be a swing bed facility, does not automatically result in the involuntary termination of the hospital's agreement relating to the provision of hospital services.   10.6.3 - Expiration and Renewal - Nonrenewal of SNF Term Agreements  (Rev. 1, 09-11-02)  All agreements with skilled nursing facilities are required to be for a specified term of up to 12 full calendar months with fixed expiration dates.  The agreement expires at the close of the last day of its specified term and is not automatically renewable from term to term.  When the term of an agreement is extended (see 10.6.3 of this chapter), the close of the last day of its specified term is the close of the day of the extension of the agreement.  Thus, when the term of an agreement is extended, the provider's participation in the program continues, and the agreement does not expire until the close of the last day to which it has been extended.  Since an agreement with a SNF is not automatically renewable from term to term, each term agreement with a SNF requires that the SNF qualify for participation and that its agreement be accepted for filing.  A participating SNF may, however, continue its participation under the agreement form previously accepted for filing, provided the SNF continues to qualify for participation and the agreement form is again accepted for filing and renewed for a term which begins on the date immediately following the close of the last day of the prior term of the agreement.  When the requirements for participation continue to be met, there is no limit to the number of times that the SNF's agreement form may again be accepted and renewed for a specified term.
(Medicare General Information, Eligibility, and Entitlement)
When the time -limited agreement (including an agreement which has had its term extended) is renewed on the day immediately following the close of the last day of its term, the expiration of the agreement is not considered a termination of participation in the program.  However, once an agreement with a SNF is (1) not renewed, or (2) voluntarily terminated by the SNF, or (3) involuntarily terminated (including cancellations) by the Secretary, the previously accepted agreement cannot again be accepted and renewed.  In such cases, the SNF is required to execute and file a new agreement if it is again found eligible to participate in the Medicare program.  The effective date of the new agreement must be determined in accordance with regulatory provisions (42 CFR 489.13).   The Secretary's determination not to accept and renew a SNF agreement is a determination relating to the qualifications of the SNF in the period immediately following the close of the SNF's existing agreement and the SNF is entitled to request a reconsider ation of the determination in accordance with the appeals procedure contained in 42 CFR part 405, subpart 0.  Such determinations involve a finding that:    Based on a State agency resurvey and recertification, the SNF will not be approved for a period of certification because it is out of compliance with one or more requirements for participation;   Based on a State agency resurvey and recertification, the SNF continues to be out of compliance with the same standard(s) in the requirements for participation as were found out of compliance during the term of the agreement and the facility will not be ap proved for a new period of certification; or    The SNF has violated the terms of its agreement or the provisions of title XVIII or regulations promulgated thereunder.   In cases of nonrenewal by the Secretary, the A/B MAC (A)'s role is the same as for involuntary terminations.  10.6.4 - Determining Payment for Services Furnished After Termination of Provider Agreement  (Rev. 42, Issued: 11- 09-06, Effective: N/A, Implementation: 12 -11-06)  Effective with the date a provider agreement (or swing bed approval) terminates no payment is made to the provider under such agreement for the following:   A. Hospital