evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
NOTE : In order to bill with the default code the beneficiary must at least meet the requirements for SNF coverage.   EXAMPLE 1 : The SNF is notified on June 15th that its payment ban was lifted effective June 1.  The beneficiary was admitted on June 1.  The SNF did not perform any of the Medicare -Required Assessments.  However, the SNF did perform the initial OBRA assessment.  The initial OBRA assessment shall be used to bill the 5- day Medicare -Required Assessment for up to 14 days.  Day 15 is day 1 for purposes of starting the Medicare -required assessment schedule and a 5 -day Medicare required assessment shall be performed.   EXAMPLE 2:  The SNF is notified on August 15 that its payment ban was lifted on June 1.  The beneficiary was admitted on June 1.  The SNF did not perform any of the Medicare -Required Assessments.  However, the SNF did perform the initial OBRA Assessment.  The initial OBRA assessment shall be used to bill the 5 -day Medicare required assessment and the 14 -day Medicare required assessment.  The 30 -day assessment shall be billed through day 44 at the default rate.  Day 45 is day 1 for purposes of starting the Me dicare - required assessment schedule and a 5 -day Medicare required assessment shall be performed.   See 120.1 for the revised Medicare -required assessment schedule under the SNF PDPM effective October 1, 2019.  50.5 - Physician Certification  (Rev. 1, 10- 01-03)  PM AB -01-131  The SNFs under a payment ban are still participating providers, and remain subject to Medicare coverage requirements.  Providers are still responsible for evaluating whether beneficiaries meet the Medicare Part A medical necessity and level of care requirements for Medicare Part A coverage, and for obtaining the required physician certifications even though Medicare payment cannot be made for the admission.  The SNFs are required to obtain physician certifications upon notification that a sanction was lifted.  The date of notification will be considered day 1 when verifying the timeliness of the physician certification.
(Medicare Claims Processing Manual)
When A/B MACs (A) process a reconsideration for a claim that was billed as a Part A stay, but rejected due to an incorrect application of the sanction provision, the physician certification is required regardless of the dates of service.  Since the provider clearly believed the stay was eligible for Part A payment, all Medicare coverage requirement s must have been met.   50.6 - A/B MACs (A) Responsibilities  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  The A/B MACs (A) will receive notices from the CMS Regional Office when sanctions have been imposed or lifted and in some cases when sanctions are proposed.  The CMS primary objective is always to bring the facility into compliance.  In many cases, enforcement activity does not go beyond the notice of intent.  A/B MACs (A) shall initiate action only when notified that sanctions have been imposed.   Upon notification that a sanction is imposed, A/B MACs (A) shall identify claims affected with admission dates on and after the effective date of the sanction.  Overpayments for claims erroneously paid should be recovered and CWF properly updated to reflec t the payment ban action.  Claims for new admissions should be denied from the date of admission through the last date of the sanction period.   In addition, A/B MACs (A) shall determine whether claims with admission dates after the effective date of the sanctions qualify for readmission status, as defined in the previous sections, and are not subject to a payment ban.  A/B MACs (A) shall bypass local payment ban edits for claims that are not subject to a payment ban when dates associated with occurrence span code 80, Prior Same -SNF stay for payment ban purposes, indicates the beneficiary resided in the SNF prior to the imposition of the ban.  (See 50.2 above for further payment ban bypassing criteria for hospitalizations and LOAs).   50.7 - Retroactive Removal of Sanctions  (Rev. 4409, Issued: 10- 04- 19, Effective: 11 -05-19, Implementation: 11- 05-19)   PM AB -01-131
(Medicare Claims Processing Manual)
50.7 - Retroactive Removal of Sanctions  (Rev. 4409, Issued: 10- 04- 19, Effective: 11 -05-19, Implementation: 11- 05-19)   PM AB -01-131   Occasionally, resolution between the State Agency and the SNF is reached after the payment ban has been imposed, and the ban is removed retroactive to its effective date.   If bills were denied before notice was received that the ban had been reversed, they  should be reprocessed and paid.  When reprocessing bills, MDS assessments are needed to support the case -mix classification group billed.    Beneficiaries and providers may request A/B MACs (A) to reopen and process bills denied as a result of a misunderstanding of the sanction requirements.  These reopenings shall be done on a request basis only, and will be limited to service dates on and aft er January 1, 1999.   60 - Billing Procedures for a Composite SNF or a Change in Provider Number  (Rev. 767, Issued: 12- 02-05, Effective: N/A, Implementation: N/A)  SNF -520, A3- 3600.5   A hospital with a sub- provider that meets the criteria for a composite distinct part SNF defined in 42 CFR 483.5 is required to use the single SNF number assigned for all claims, beginning with the date the provider number is effective.   Where there is a change of ownership (CHOW), and the new owner refuses assignment of the existing provider agreement, the old owner submits all claims for periods prior to the CHOW using the old provider number.  The new owner submits claims for services rendered after the date of the CHOW using the new provider number.   Also with respect to CHOWs, the SNF submits a bill with the old provider number for the period before the change and another with the new provider number for the period after the change.  The date of discharge on the first bill and the date of admission on the second bill are the same, which is the effective date of the new provider number.  All subsequent billings are submitted under the new provider number.   70 - Billing for Services After Termination of Provider Agreement, or After Payment is Denied for New Admissions (Rev. 767, Issued: 12- 02-05, Effective: N/A, Implementation: N/A)
(Medicare Claims Processing Manual)
70 - Billing for Services After Termination of Provider Agreement, or After Payment is Denied for New Admissions (Rev. 767, Issued: 12- 02-05, Effective: N/A, Implementation: N/A)  70.1 - General Rules  (Rev. 767, Issued: 12- 02-05, Effective: N/A, Implementation: N/A)  A SNF whose provider agreement terminates or that is denied payment for new admissions as an alternative to termination for noncompliance with one or more requirements for participation, may only be paid for covered Part A inpatient services under the following conditions:   Termination (Voluntary or Involuntary)    Payment can continue to be made for up to 30 days for covered Part A inpatient services furnished on and after  the effective date of termination for beneficiaries who were admitted prior  to the termination date.   EXAMPLE:  Termination date:  9/30/86  o Beneficiary admitted:  before 9/30/86  o Payment can be made:  from 9/30/86, up to and including 10/29/86  Denial of Payments for New Admissions (DPNA)    Payment can continue to be made for covered Part A inpatient services furnished on or after  the effective date of denial of payments for beneficiaries who were admitted before the effective date of denial of payments.   EXAMPLE:  Denial of payment date:  9/30/86  o Beneficiary admitted before:  9/30/86 o Payment can be made:  Indefinitely   For detailed instructions on SNF payment bans, or denial of payment for new admission see IOM 100 -04, Chapter 6, section 50.  NOTE:   An inpatient, who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.   70.2 - Billing for Covered Services  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)
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70.2 - Billing for Covered Services  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -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.   Upon cessation of a SNFs participation in the program, or when a SNF is not receiving payments for new admissions, the RO is supplied with the names and Medicare beneficiary identifiers of Medicare beneficiaries entitled to have payment made on their behalf for services in accordance with 80.1 .  SNFs no longer participating in the program, or those under a denial of payment for new admissions, continue to bill for covered services per 80.l.  They continue to submit no-payment death, discharge and reduction from SNF level of care bills for Medic are beneficiaries admitted prior to the termination of their agreement, or prior to the denial of payments for new admissions. 70.3 - Part B Billing (Rev. 767, Issued: 12-02- 05, Effective: N/A, Implementation: N/A)  Following termination of its agreement, a SNF is considered to be a nonparticipating provider.  An inpatient of such a SNF who has Part B coverage, but for whom Part A benefits have been exhausted or are otherwise not available, is entitled to payment only for those services that are covered in a nonparticipating institution.  Do not bill Part A services furnished on or after  the effective date of termination.   80 - Billing Related to Physicians Services  (Rev. 2245, Issued: 06- 16-11, Effective: 08-01-11, Implementation: 08-01-11)
(Medicare Claims Processing Manual)
80 - Billing Related to Physicians Services  (Rev. 2245, Issued: 06- 16-11, Effective: 08-01-11, Implementation: 08-01-11)  Normally physicians are responsible for billing for their own services.  The services of facility -based physicians (e.g., those on a salary or percentage arrangement, lessors of departments, etc., whether or not they bill patients directly) include two distinct elements - the professional component and the provider component.  The professional component of facility- based physicians services includes services directly related to the medical care of the individual patient.  SNFs cannot bill for the professional components of physician services, these must be billed under a physic ian provider number to the A/B MAC (B).  The technical component (e.g. the component representing the performance of the diagnostic procedure itself) of physician services delivered to SNF inpatients are bundled into the Part A PPS payment and not paid separately.   A - Podiatry Services   Covered professional services rendered by facility -based podiatrists to individual patients are covered only as physicians services under Part B.  Note that certain foot care services are excluded under both Part A and Part B.  Payments to podiatrists for noncovered services are not allowable Medicare costs regardless of whether the podiatrists professional services are covered under Part B.   80.1 - Reassignment Limitations  (Rev. 1, 10-01-03) SNF -507  Assigned benefits for physicians services may not be paid to anyone other than the physician who furnished the services, except:   To the employer of the physician who provided the service, if such physician is required as a condition of his employment to turn over his fee for the service to his employer.  (See 80.2 below.)   To a facility in which the service is provided if there is a contractual arrangement between the facility and the physician furnishing the service under which only the facility can bill for the service.  (See 80.3 below.)   To an organization, which furnishes health care through an organized health care delivery system (e.g., a freestanding physician clinic, or prepaid group practice prepayment plan) if there is a contractual arrangement between the organization and the physician furnishing the service under which only the organization can bill for the service.
(Medicare Claims Processing Manual)
80.2 - Payment to Employer of Physician  (Rev. 1, 10-01-03) SNF -508, SNF-510  Subject to the conditions and limitations described below, payment of Part B benefits due a physician under assignment for services furnished in a facility may be made to the facility if the facility and physician have an agreement under which only the fac ility may bill and receive fees or amounts charged for the services.  40.1 Form CMS -855R must be completed to describe the arrangement with the facility.  This form and instructions for completing it can be downloaded from the CMS Forms Web page .  See the Medicare Program Integrity Manual for processing instructions after completion.  The contractual arrangement between the facility and a physician may apply to all services the physician furnishes in the facility, or merely to a particular category of services that is clearly distinguishable from other categories.  The distinction betwe en the categories must be consistent with proper determination of Part B reimbursement and may not be based on whether the patient has Medicare.  While the law permits physicians to reassign to a facility the Part B benefits for the patient care services they perform in the facility, this exception in favor of the facility is intended to apply to an arrangement in which the facility obtains a signif icant degree of control or interest in the disposition of the benefits.  Under the law, Medicare benefits cannot be paid to a facility under terms that make the facility a mere conduit for payment to another person or entity.  EXAMPLE   Under an agreement between a facility and a partnership of teaching physicians, the facility bills and receives payment in its name for the physician services but is required to turn over to the partnership all fees received, less a small deduction to defr ay billing expenses.  The partnership distributes the monies received among its physician members in accordance with the partnership agreement.  Since the SNF functions under the agreement as a mere conduit for payment to the partnership, the agreement is not an acceptable contractual arrangement for purposes of the exception to the prohibition on reassignment.   80.3 - Information Necessary to Permit Payment to a Facility  (Rev. 1, 10- 01-03) SNF -510.1
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80.3 - Information Necessary to Permit Payment to a Facility  (Rev. 1, 10- 01-03) SNF -510.1  A facility may ordinarily qualify to receive Part B payment for the services of physicians in the facility by submitting a Form CMS -855R to its A/B MAC (A), certifying that it will bill for their services only as called for by its written contractual arrangements.   For purposes of Medicare benefits payable for the services, this agreement may be terminated by either party upon written notice to the other, but such termination is not binding upon Medicare until two weeks after the A/B MACs (A) receives a revised Form CMS -855R notice of this termination.  80.4 - Services Furnished Within the SNF  (Rev. 1, 10- 01-03) SNF -510.2  The term facility is limited for purposes of furnishing services to individuals as inpatients, e.g., hospitals, university medical centers that own and operate hospitals, SNFs, nursing homes, homes for the aged, or other institutions of a similar nature.  Physician services furnished outside the physical premises of the facility are considered furnished in the SNF if furnished in connection with services received by patients in the SNF.  For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment.  80.5 - Billing Under Arrangements  (Rev. 1, 10- 01-03) SNF -510.2  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 is 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 exer cise professional responsibility over the arranged- for services.  See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions, 10.3, for additional discussion on services furnished under arrangement.
(Medicare Claims Processing Manual)
The law is silent regarding specific terms of a SNFs payment to the outside provider or supplier and currently does not authorize the Medicare program to impose any requirements in this regard.  Thus, the issue of the outside provider or suppliers payment by the SNF is a private, contractual matter that must be resolved through direct negotiations between the parties.  However, services provided under consolidated billing arrangements must be provided by Medicare certified providers that are licensed to provide the service involved.  In addition, payment may not be made if the provider or supplier is subject to OIG sanctions that would prohibit Medicare payment for the service if the provider or supplier were billing independently.  In some cases, SNFs may purchase services for their patients from a hospital under arrangements.  Such services may include a physician component.  When the physician has entered into a valid contractual arrangement with the hospital in which his/her services are furnished for it to bill for the services, no additional written authorization is needed for SNFs to bill for his/her services.  For example, where SNFs arrange to obtain an EKG interpretation from Hospital B, and Hospital B has a valid contractual arrangement with its cardiologist authorizing it to bill for his/her services, SNFs do not need written authorization from the cardiologist to bill Medicare for the cost of the services.   See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 70.4, for additional information on services under arrangements.   80.6 - Indirect Contractual Arrangement  (Rev. 1, 10- 01-03) SNF -510.3  The necessary contractual arrangement between physicians and the facility in which they perform their services may exist indirectly by reason of the terms of their relationship with an employer and the employers contractual arrangement with the facility.  EXAMPLE
(Medicare Claims Processing Manual)
The necessary contractual arrangement between physicians and the facility in which they perform their services may exist indirectly by reason of the terms of their relationship with an employer and the employers contractual arrangement with the facility.  EXAMPLE   A professional corporation enters into a contractual arrangement with an SNF to provide physician services for it.  Under this arrangement, the SNF alone bills and receives payment for the physician services and pays the corporation a percentage of the cha rges.  The corporation, in turn, employs several physicians to provide the services, and under the terms of their employment, is entitled to any fees payable for the services (other than the portion of the fees retained by the SNF).  The combination of the  two arrangements -  between the SNF and the corporation and the corporation and the physicians -  constitutes an indirect contractual arrangement between the SNF and the physicians.  For the SNF to bill and receive payment for the physician services furnished in the SNF, the SNF must also enter into a direct contractual arrangement with the physicians for this purpose.   80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on the Basis of Reassignment  (Rev. 1, 10-01-03) SNF -512
(Medicare Claims Processing Manual)
A SNF wishing to receive Part B payment as a reassignee of one or more physicians must furnish the A/B MAC (B) sufficient information to establish clearly that it qualifies or does not qualify to receive payment for their services.  Where there is any doubt that a SNF qualifies as a reassignee, A/B MACs (B) will obtain additional evidence.  In some cases, a SNF may qualify to receive payment for the services of a physician both as the employer of the physician and as the facility in which the services are performed.  As soon as it is determined that a SNF can qualify on either basis, no further development is undertaken with respect to that physician or to other physicians having the same status, and reassigned claims submitted by the SNF for services furnished by those physicians are honored.  However, where other physicians have, or appear to have different status, further development is required.  It is possible in some instances that a determination is made that Part B payment can be made only to the physician himself.  Where the SNF qualifies as a reassignee, it assumes the same liability for any overpayments that it may receive as a reassignee as the physician would have had if the payment had been made to him/her.  90 - Medicare Advantage (MA) Beneficiaries  (Rev. 1252, Issued:  05-25- 07; Effective:  10 -01-06; Implementation:  08 -27-07)  For billing to MA plans, SNFs follow the requirements of the agreement they have with the plans.  In cases where the patient may have enrolled or disenrolled from the plans during the billing period, the SNF will split the bill and send the plans portion to it and the remaining portion to the A/B MAC (A).  90.1 - Beneficiaries Disenrolled from MA Plans  (Rev. 1618, Issued: 10- 24-08, Effective: 04-01- 09; Implementation: 04 -06-09)
(Medicare Claims Processing Manual)
If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an inpatient of an SNF and converts to original Medicare (i.e., fee for service) the requirement for a three day hospital stay will be waived if  the beneficiary meets the level of care criteria found in 42 CFR 409, Subpart D, up through the effective date of dis-enrollment.  The beneficiary will then be eligible for the number of days that remain out of the 100 day SNF benefit for that particular SNF stay minus those days that would have been covered by the program under original Medicare while the beneficiary was enrolled in the risk MA plan.  However, in cases where the beneficiary disenrolls from a risk MA plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day rule, all requirements for original Medicare (i.e., fee for service), including the 3-day hospital stay must be met.  Rules regarding cost sharing apply to these cases.  That is, providers may only charge beneficiaries for SNF coinsurance amounts.  If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet all original Medicare requirements for a SNF stay, including that of a three day inpatient hospital stay.  SNFs submit all applicable fee -for-service inpatient SNF claims with condition code 58 to indicate a patient was disenrolled from an MA plan and the 3-day prior stay requirement was not met.  Claims with condition code 58 will not require the 3-day prior inpatient hospital stay.  The A/B MAC (A) must use CWF files to validate the beneficiary was enrolled in an MA organization upon admission to the SNF and that the MA enrollment period ended prior to the from date on the claim.  The A/B MAC (A) does not need to verify that the MA plan was the one that terminated.