evekhm/cms_iom_500 huggingface dataset:
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costs solely to begin to accommodate late receipt of claims if not already equipped to do so. The cutoff time for paper claims may not exceed the cutoff time for electronic claims. However, the cutoff time for electronic claims may exceed the cutoff time for paper claims and, indeed, carriers and FIs are encouraged to use this tool where their syst em and overnight batch run schedules permit.  Likewise, at a carrier or FIs option, it may consider electronic claims received on a weekend or holiday as received on the actual calendar date of receipt, even though paper claims received in a P.O. box on a  weekend or holiday would not be considered received until the next business day.  Where a carrier or FI prepares bills for payment for purchased DME because the $50 tolerance is exceeded (see 40.4.1) it establishes any date consistent with its system processing requirements as the receipt date for the second and succeeding bills.  It uses the date as close to its payment as possible.  80.2.1.1 - Payment Ceiling Standards  (Rev. 454, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05) Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987.  Clean claims must be paid or denied within the applicable number of days from their receipt date as follows:  Time Period for Claims Received  Applicable Number of Calendar Days  01-01-93 through 09 -30-93 24 for EMC and  27 for paper claims  10-01-93 and later  30 All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.  Interest must be paid on claims that are not paid within the ceiling period. The count starts on the day after the receipt date and it ends on the date payment is made.  For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.  The RAPs submitted by home health agencies under the HH PPS (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not Medicare claims as defined under the Social Security Act.  Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected
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after October 1, 2000) are not Medicare claims as defined under the Social Security Act.  Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected to payment ceiling standards and interest payment.  See Chapter 24,  30.2 for definitions of electronic and paper claims for use in application of the Medicare payment floor.  See Chapter 1,  80.2.1.2 for differentiation between electronic claims that comply with the requirements of the standard implementation guides adopted for national use under HIPAA and those submitted electronically using pre -HIPAA formats supported by Medicare.  This HIPAA format differentiation applies to the payment floor, but not to the ceiling.  80.2.1.2 - Payment Floor Standards (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)
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The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The payment floor date is the earliest day after receipt of the clean claim that payment may be made.   The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.   There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:   An electronic claim is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch- tone telephone is not considered as an electronic claim.   A paper claim is submitted and received on paper, including fax print -outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology.  Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.  Based on the waiting periods, the payment floor dates are as follows:   Claim Receipt Date  Payment Floor Date  10-01-93 through 6/30/04  14th day for EMC 27th day for paper claims  07-01-04 and later  14th day for HIPAA -compliant EMC  27th day for paper and non- HIPAA EMC  01/01/2006 and later  29th day for paper   Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: no- payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.
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Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: no- payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.   NOTE:  The basis for treating a non- HIPAA -compliant electronic claim as a paper claim for the purpose of determining the applicable payment floor is as follows: Effective October 16, 2003, HIPAA requires that claims submitted to Medicare electronically comply wit h standard claim implementation guides adopted for national use under HIPAA. A claim submitted via direct data entry (DDE), if DDE is supported by the contractor is considered to be a HIPAA -compliant electronic claim. A contingency plan has been approved t o enable claims to continue to be submitted temporarily after October 15, 2003 in a pre -HIPAA electronic format supported by Medicare. Effective July 1, 2004, the Medicare contingency plan is being modified to encourage migration to HIPAA formats. Effectiv e July 1, 2004, for purposes of the payment floor, only those claims submitted in a HIPAA -compliant format will be paid as early as the 14th day after the date of receipt. Claims submitted on paper after July 1, 2004 will not be eligible for payment earlier than the 27th day after the date of receipt. All claims subject to the 27 -day payment floor, including non- HIPAA electronically submitted claims, are to be reported in the paper claims category for workload reporting purposes. Effective January 1, 2006, paper claims will not be eligible for payment earlier than the 29th day after the date of receipt.   This differentiation in treatment of HIPAA -compliant and non- HIPAA -compliant electronic claims does not apply to Contractor Performance Evaluation (CPE) reviews of carriers and FIs conducted by CMS. For CPE purposes, carriers and FIs must continue to proce ss the CPE specified percentage of clean paper and clean electronic (HIPAA or non -HIPAA) claims within the statutorily specified timeframes. Effective for claims received January 1, 2006 and later, clean paper claims will no longer be included in CPE scori ng for claims processing timeliness.   80.2.2 - Interest Payment on Clean Non -PIP Claims Not Paid Timely  (Rev. 1771, Issued: 07- 17-09, Effective: 08 -17-09, Implementation: 08- 17-09)
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80.2.2 - Interest Payment on Clean Non -PIP Claims Not Paid Timely  (Rev. 1771, Issued: 07- 17-09, Effective: 08 -17-09, Implementation: 08- 17-09)  Interest must be paid on clean claims if payment is not made within the applicable number of calendar days (i.e., 30 days) after the date of receipt as described above.  The applicable number of days is also known as the payment ceiling.  For example, a cl ean claim received on March 1, 2009, must have been paid before the end of business on March 31, 2009.  Interest is not paid on:    Claims requiring external investigation or development by the providers FI or carrier;   Claims on which no payment is due;  Full denials;  Claims for which the provider is receiving PIP; or  HH PPS RAPs   Interest is paid at the rate used for 3902(a) of title 3l, U.S. Code (relating to interest penalties for failure to make prompt payments).  The interest rate is determined by the applicable rate on the day of payment.  This rate is determined by the Treasury Department on a 6 -month basis, effective every January and July 1.  Providers may access the Treasury Department Web page http://fms.treas.gov/prompt/rates.html for the correct rate. Medicare contractors shall include notification to providers of any change to the Treasury Department interest rate in their routine educational materials and/or website for providers.  Interest is calculated using the following formula:  Payment amount x rate x days divided by 365 (366 in a leap year) = interest payment  The interest period begins on the day after payment is due and ends on the day of payment.  NOTE:  The example below is for one 6-month period in which the interest rate was 5.625 percent.  Milestones  Clean Paper Claim  (in calendar days) Clean Electronic Claim  (in calendar days) Date Received  March 1, 2009 March 1, 2009 Payment Due March 31, 2009 March 31, 2009 Payment Made  April 3, 2009 April 3, 2009 Interest Begins April 1, 2009 April 1, 2009 Days for Which Interest is Due 3 3 Amount of Payment $100 $100 Interest Rate  5.625% 5.625%   See section 80.2.1.1 for the definition of EMC and paper claims.   The following formula is used:
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See section 80.2.1.1 for the definition of EMC and paper claims.   The following formula is used:  For the clean paper claim -  $100 X .05625 X 3 divided by 365 = $.0462 or $.05 when rounded to the nearest penny.   For the clean electronic claim -  $100 X .05625 X 3 divided by 365 = $.0462 or $.05 when rounded to the nearest penny.   When interest payments are applicable, the Medicare contractor reports the amount of interest on each claim on the remittance record to the provider.   PIP/Non -PIP:  Under the periodic interim payment  ("PIP) mechanism, a provider receives flat biweekly payments to approximate the average costs of covered inpatient services during a 2- week period.  Non- PIP claims are claims made by a provider not under the periodic interim payment mechanism. PIP on inpatient bills does not preclude interest payments on outpatient bills. Interest is paid on a per bill basis at the time of payment.   80.2.2.1 - Determining and Paying Interest  (Rev. 273, Issued 08- 13-04, Effective: 07 -01-04, Implementation: 07- 06-04)  The contractor must pay interest on clean, non -PIP (FIs) claims for which it does not make payment within the payment ceiling specified in  80.2.1.1, provided payment is due on such claim. The interest rate and formula for calculation are shown above. The interest rate is determ ined by the rate applicable on the carrier or FIs payment date.   The contractor applies interest to the net payment amount after all applicable deductions are determined (e.g., deductible, copayment, and/or MSP).  Interest is rounded to the nearest penny.   A.  Reporting Interest Payment on Remittance Record   See 100 -22 for remittance advice completion instructions.  B.  Payment Made to Beneficiary   If interest is paid on a claim for which payment is made directly to the beneficiary, the contractor adds the following messages on the beneficiary notice:   Your payment includes interest since we were unable to process your claim timely.   C.  Claims Paid Upon Appeal
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Your payment includes interest since we were unable to process your claim timely.   C.  Claims Paid Upon Appeal   Interest payments are not payable on clean claims initially processed to denial and on which payment is made subsequent to the initial decision as a result of an appeal request.  This applies to appeals where more than the applicable number of days elapsed before an initial denial, but the claim was later paid upon appeal.  Where an appeal of a previously paid claim results in increased payment FIs follow the following section.   D.  Interest on Postpayment Denials and Other Adjustments   If a paid claim is later denied in full, the carrier or FI recovers any interest paid as well as the incorrect payment. It does not pay interest on the related no payment bill.  If the claim is partially denied, interest is payable on the reduced amount.  The FI recalculates the interest due based upon the new reimbursement amount.  It uses the rate of interest and elapsed days applicable to the original claim.  This can be accomplished by applying a ratio of the new reimbursement amount (from its debit action) to the reimbursement amount on the initial claim (from its credit action).  It multiplies the result by the interest amount paid on the initial claim. The result is the interest amount payable on its debit action.   The following formula is used to ca lculate interest:  Interest =  Debit action reimbursement amount   Credit action reimbursement amount x original interest paid   Use of the formula is preferable to expanding an FI system to handle multiple scheduled payment dates and calculation procedures.   80.2.2.2 - Preparation of IRS Form 1099-INT  (Rev. 1, 10- 01-03)
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Use of the formula is preferable to expanding an FI system to handle multiple scheduled payment dates and calculation procedures.   80.2.2.2 - Preparation of IRS Form 1099-INT  (Rev. 1, 10- 01-03)  The IRS requires that interest paid in the course of a trade or business be reported if it totals at least $600 for any person. Interest payments a carrier or FI makes fall within the trade or business definition.  Therefore, FIs and carriers must prepare and file with the IRS, Form 1099- INT when interest payments for a calendar year to a beneficiary or provider total at least $600.  The carrier or FI uses the beneficiarys individual Social Security Number (SSN) to report interest paid to the beneficia ry.  Individual SSNs are identified by the suffix A or M, J, T, or TA.  Other suffixes mean benefits are based upon a spouses, parents or childs (F1 thru 8) SSN.  If the spouses, parents or childs SSN is involved, the FI determines the individuals S SN to report interest.  If the individuals SSN is not present, the carrier or FI calls its Social Security Office contact for the information.  80.3 - Other Claims (other than clean)  (Rev. 1, 10- 01-03) A3-3600.1 Item 4, HO -401.E, B2- 5240.11.B   Claims that do not meet the definition of clean claims are other claims.  Other claims require investigation or development external to the carrier or FIs Medicare operation on a prepayment basis.  Other claims are those that are not approved by C WF for payment that the FI identifies as requiring outside development.  Examples are claims on which the providers FI/carrier:    Requests additional information from the provider or another external source.  This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;    Requests information or assistance from another contractor.  This includes requests for charge data from the carrier, or any other request for information from the carrier;    Develops Medicare Secondary Payer (MSP) information;    Requests information necessary for a coverage determination;    Performs sequential processing when an earlier claim is in development; and
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 Develops Medicare Secondary Payer (MSP) information;    Requests information necessary for a coverage determination;    Performs sequential processing when an earlier claim is in development; and   Performs outside development as a result of a CWF edit.   80.3.1 - Incomplete or Invalid Claims Processing Terminology  (Rev. 1588; Issued:  09- 05-08; Effective/Implementation Date:  08 -18-08)  The following definitions apply to 80.3.2.  For carriers the requirements apply to Part B assigned and unassigned claims (Form CMS -1500) or electronic data interchange equivalent.   Unprocessable Claim -  Any claim with incomplete or missing, required information, or any claim that contains complete and necessary information; however, the information provided is invalid.  Such information may either be required for all claims or required conditionally.  Incomplete Information - Missing, required or conditional information on a claim (e.g., no Unique Physician Identification Number (UPIN) / Provider Identification Number (PIN) or National Provider Identifier (NPI) when effective).   Invalid Information - Complete required or conditional information on a claim that is illogical, or incorrect (e.g., incorrect UPIN/PIN or NPI when effective), or no longer in effect (e.g., an expired number).   Required -  Any data element that is needed in order to process a claim (e.g., Provider Name, Date of Service).   Not Required -  Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., Patients Marital Status).
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Not Required -  Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., Patients Marital Status).   Conditional -  Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, then the primary insurers group name and number must be entered on a claim or if the insured is different from the patient, then the insur eds name must be entered on a claim).   Return as Unprocessable or Return to Provider (RTP) - Returning a claim as unprocessable to the provider (RTP) does not mean that the carrier or FI should physically return every claim it received with incomplete or invalid information.  The term return to provider is used to refer to the many processes ut ilized today for notifying the provider or supplier of service that their claim cannot be processed, and that it must be corrected or resubmitted.  Some (not all) of the various techniques for returning c laims as unprocessable include:    Incomplete or invalid information is detected at the front- end of the carrier or FI claims processing system.  The claim is returned to the provider (RTPd) either electronically or in a hardcopy/checklist type form explaining the error(s) and how to corre ct the errors prior to resubmission.  Claim data are not retained in the system for these RTP'd claims.  No RA is issued.   Incomplete or invalid information is detected at the front- end of the claims processing system and is suspended and developed.  If requested corrections and/or medical documentation are submitted within a 45- day period, the claim is processed. Otherwise, t he suspended portion is returned and the supplier or provider of service is notified by means of the RA.   Incomplete or invalid information is detected within the claims processing system and is rejected through the remittance process.  Suppliers or providers of service are notified of any error(s) through the remittance notice and how to correct prior to resu bmission.  A record of the claim is retained in the system (NOTE :  This applies to carriers only.  FIs do not use the remittance advice process for return to provider (RTP)).
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A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal rights.  80.3.2 - Handling Incomplete or Invalid Claims  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  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.   Claims processing specifications describe whether a data element is required, not required, or conditional (a data element which is required when certain conditions exist).  The status of these data elements will affect whether or not an incomplete or invalid claim (hardcopy or electronic) will be "returned as unprocessable" by the A/B MAC (B) or returned to provider (RTP) by the A/B MAC (A).  The contractor shall not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.  (See 80.3.1 for Definitions.)   If a data element is required and it is not accurately entered in the appropriate field, the contractor returns the claim to the provider of service.    If a data element is required, or is conditional (a data element that is required when certain conditions exist) and the conditions of use apply) and is missing or not accurately entered in its appropriate field, the contractor shall return as unprocessabl e or RTP the claim to either the supplier or provider of service.
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NOTE:   Effective for claims with dates of service (DOS) on or after the implementation date of the ordering and referring phase 2 edits, Part B clinical lab and imaging technical or global component claims, Durable Medical Equipment, Prosthetics, claims and Hom e Health Agency (HHA) claims shall be denied, in accordance with CMS -6010- F final rule published on April 24, 2012, if the ordering or referring providers information is invalid or if the provider is not of a specialty that is eligible to order and r efer.   If a claim must be returned as unprocessable or RTP for incomplete or invalid information, the contractor shall, at minimum, notify the provider of service of the following information:   o Beneficiarys Name;   o Medicare beneficiary identifier ;  o Dates of Service (MMDDCCYY) (Eight -digit date format effective as of October 1, 1998);   o Patient Account or Control Number (only if submitted);   o Medical Record Number (FIs only, if submitted); and  o Explanation of Errors (e.g., Remittance Advice Reason and Remark Codes)   NOTE:   Some of the information listed above may in fact be the information missing from the claim.  If this occurs, the contractor includes what is available.   Depending upon the means of return of a claim, the supplier or provider of service has various options for correcting claims returned as unprocessable or RTP for incomplete or invalid information.  They may submit corrections either in writing, on- line, or  via telephone when the claim was suspended for development, or submit as a corrected claim or as an entirely new claim if data from the original claim was not retained in the system, as with a front -end return, or if a remittance advice was used to retu rn the claim. The chosen mode of submission, however, must be currently supported and appropriate with the action taken on the claim.   NOTE:   The supplier or provider of service must not be denied any services (e.g., modes of submission or customer service), other than a review, to which they would ordinarily have access.    If a claim or a portion of a claim is returned as unprocessable or RTP for incomplete or invalid information, the contractor does not generate an MSN to the beneficiary.