evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 If a network is awarded a contract, each member of the contracted network will submit its own Medicare claims and will be paid directly by Medicare for products and servi ces it furnishes under the Medicare DMEPOS Competitive Bidding Program.   20.5.2 - Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs)  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  The Medicare DMEPOS Competitive Bidding Program applies to SNFs and NFs located in a CBA to the extent their residents receive competitively bid items under Medicare Part B.  Unlike most suppliers, SNFs and NFs have the option to bid for, and be awarded, contracts to be specialty suppli ers that only furnish competitively bid items to their own residents.  SNFs and NFs may elect to submit a bid as a specialty supplier by indicating on the RFB that they will only furnish competitive bid items to their own residents.  Any SNF or NF awarded a contract would be paid the single payment amount for those items.  SNFs and NFs that elect to be specialty suppliers may not furnish competitively bid items and services to Medicare beneficiaries outside their facilities for purposes of Medicare payment .  If a SNF or NF is not awarded a contract, it must use a contract supplier for the CBA to furnish competitively bid items to its residents.  SNFs and NFs can also become regular contract suppliers that furnish competitively bid items to beneficiaries thr oughout a CBA.   If a SNF or NF is not a contract supplier (either a specialty contract supplier or a regular contract supplier), it must use a contract supplier for its CBA to furnish competitively bid items to its residents.   20.5.3 - Home Health Agencies  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)
(Medicare Claims Processing Manual)
20.5.3 - Home Health Agencies  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Home health agencies must submit a bid and be awarded a contract for the DMEPOS Competitive Bidding Program in order to furnish competitively bid items directly to Medicare beneficiaries who maintain a permanent residence in a CBA.  If a home health agency is not awarded a contract to furnish competitively bid items, then they must use a contract supplier for these items.    20.5.3.1 - Mail -Order Suppliers for Diabetic Supplie s (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  Medicare beneficiaries who maintain a permanent residence in a CBA in which CMS has implemented a competitive bidding program for mail order diabetic supplies may purchase their diabetic testing supplies from:   A mail order contract supplier for the CBA in which the beneficiary resides; or    Any enrolled Medicare supplier if the diabetic testing supplies are furnished at a storefront and are not subject to a competitive bidding prog ram established for non- mail order diabetic supplies.  Mail order contract suppliers will be reimbursed at the single payment amount for mail order diabetic supplies for the CBA in which the beneficiary maintains a permanent residence.  In situations where  a competitive bidding program has not been established for non- mail order diabetic supplies, noncontract suppliers that do not furnish items through mail order will be reimbursed at the fee schedule amount for the state in which the beneficiary maintains a permanent residence.  Medicare payment will not be made to noncontract suppliers that furnish mail order diabetic testing supplies to Medicare beneficiaries residing in a CBA.   Mail order diabetic suppliers must use the HCPCS modifier KL on each claim to  indicate that the item was furnished on a mail order basis.  The modifier must be used for both competitive bidding and non- competitive bidding mail order diabetic supplies.  Suppliers that furnish mail order diabetic items that fail to use the HCPCS modifier KL on the claim may be subject to penalties under of the False Claims Act.
(Medicare Claims Processing Manual)
20.5.4 - Items Furnished on a Mail Order Basis  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  A Medicare beneficiary who maintains a permanent r esidence in a CBA for which we have done competitive bidding for mail order items may purchase their mail order items from: (1) a mail order contract supplier for that CBA; or (2) a noncontract supplier, if the item is purchased at a storefront.  In situat ions where the beneficiary elects to obtain the item from a local storefront or from a local supplier via a mode of delivery other than mail order and the item is not subject to a competitive bidding program established for non -mail order items, the beneficiary may obtain the item from any Medicare enrolled supplier.   20.5.4.1 - Mail -Order Suppliers for Diabetic Supplies  (Rev. 1532, Issued: 06- 11-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Medicare beneficiaries who maintain a permanent residence in  a CBA in which CMS has implemented a competitive bidding program for mail order diabetic supplies may purchase their diabetic testing supplies from:   A mail order contract supplier for the CBA in which the beneficiary resides; or    Any enrolled Medicare s upplier if the diabetic testing supplies are furnished at a storefront and are not subject to a competitive bidding program established for non- mail order diabetic supplies.  Mail order contract suppliers will be reimbursed at the single payment amount for  mail order diabetic supplies for the CBA in which the beneficiary maintains a permanent residence.  In situations where a competitive bidding program has not been established for non- mail order diabetic supplies, noncontract suppliers that do not furnish items through mail order will be reimbursed at the fee schedule amount for the state in which the beneficiary maintains a permanent residence.  Medicare payment will not be made to noncontract suppliers that furnish mail order diabetic testing supplies to Medicare beneficiaries residing in a CBA.
(Medicare Claims Processing Manual)
Mail order diabetic suppliers must use the HCPCS modifier KL on each claim to indicate that the item was furnished on a mail order basis.  The modifier must be used for both competitive bidding and non- competitive  bidding mail order diabetic supplies.  Suppliers that furnish mail order diabetic items that fail to use the HCPCS modifier KL on the claim may be subject to penalties under of the False Claims Act.   20.6 - Noncontract Suppliers  (Rev. 1502; Issued:  05- 09-08; Effective/Implementation Date:  06 -09-08)  Noncontract suppliers that furnish competitively bid items in a CBA are not eligible for Medicare payment for the competitively bid items for that CBA unless one or more of the following exceptions appli es:   Suppliers of Grandfathered DME  - Beneficiaries who are receiving oxygen and oxygen equipment or rented DME at the time the competitive bidding program becomes effective may elect to continue to receive these items from a noncontract supplier if the supplier is willing to continue furnishing these items. See section 20.6.1 of this chapter for more information on grandfathering.    Repairs/Replacement  - Beneficiaries who maintain a permanent residence in a CBA may go to any Medicare- enrolled supplier (cont ract or noncontract supplier) for repairs or replacement parts for beneficiary owned items.  Labor to repair equipment is not subject to competitive bidding and, therefore, will be paid in accordance with Medicares general payment rules.  Payment for part s that are not competitively bid items and that are needed to repair a beneficiary -owned item will also be paid in accordance with these rules.  Payment for replacement parts that are part of the competitive bidding program for the areas in which the benef iciary resides would be paid at the single payment amount.  Unlike repairs, beneficiaries must obtain replacements of certain base equipment they own (e.g., wheelchairs or hospital beds) from a contract supplier, when the base equipment must be replaced in its entirety, rather than replacement parts for the repair of the base equipment.  A contract supplier is required to service all rented items included in its contract.
(Medicare Claims Processing Manual)
 Physicians and Other Practitioners  Who are Enrolled Medicare DMEPOS Suppliers -  Physi cians and treating practitioners have the option to furnish certain types of competitively bid items in a CBA to their own patients without submitting a bid and being a selected as a contract supplier, provided the following requirements are met:   o The item s are limited to crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and infusion pumps that are DME.   o The items must be billed using a billing number assigned to the physician, the treating practitioner or a group practice to which the physician or treating practitioner has reassigned the right to receive Medicare payment for competitive bid items.   Physicians and treating practitioners who do not to become contract suppliers may only provide the bid items identified above to thei r own patients and will not be allowed to act as contract suppliers to provide bid items to beneficiaries for purposes of Medicare payment.   The physician or treating practitioner will be paid the single payment amount when the furnished item is a competitive bid item and the beneficiary maintains a permanent residence in a CBA.    Physical Therapists and Occupational Therapists in Private Practice Who are Enrolled Medicare DMEPOS Suppliers -- Physical therapists and occupational therapists in private practice have the option to furnish certain types of competitively bid items to their own patients without submitting a bid and being a selected as a contract supplier, provided the following requirements are met:   o The only competitive bid items they may f urnish without becoming a contract supplier are OTS orthotics.  o The items must be furnished only to their own patients as part of the physical or occupational therapy service.   Physical and occupational therapists in private practice who do not to become contract suppliers may only provide competitive bid OTS orthotics to their own patients and will not be allowed to act as contract suppliers for purposes of Medicare payment.   The physical or occupational therapist will be paid at the single payment amount when the furnished item is a competitive bid item and the beneficiary maintains a permanent residence in a CBA.
(Medicare Claims Processing Manual)
The physical or occupational therapist will be paid at the single payment amount when the furnished item is a competitive bid item and the beneficiary maintains a permanent residence in a CBA.    Medicare Secondary Payer -  If a Medicare beneficiary is required under his or her primary insurance policy to use a supplier that is a noncontr act supplier, Medicare may make a secondary payment to a noncontract Medicare -enrolled supplier for competitive bid items. The supplier must have a valid NSC# and be eligible to receive secondary payments. The amount paid to the supplier will be calculated in accordance with established Medicare secondary payment rules.  If none of the exceptions above apply, then the noncontract supplier is responsible for notifying the beneficiary that it is not a contract supplier for the competitive bidding item in the CBA, and the beneficiary must go to a contract supplier for that item in order for Medicare to make payment for the item.  CMS has a supplier locator tool in order to assist beneficiaries and suppliers in finding contract suppliers.  The supplier locator tool can be found at www.medicare.gov.  Beneficiaries may also call 1 -800-Medicare to obtain information about contract suppliers.  20.6.1 - Special Rules for Certain Rented Durable Medical Equipment (DME), Oxygen and  Oxygen Equipment (Grandfathered Suppliers and Items)  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  Suppliers that were furnishing certain rented DME, or oxygen and oxygen equipment at the time a competitive bidding program begins in a CBA, may become grandfathered suppliers by continuing to furnish these items to the Medicare beneficiaries who have been receiving these items, even if the suppliers do not become contract suppliers for these items in the CBA. Grandfathered items must be any of the following:   (1)  Inexpensive or routinely purchased items furnished on a rental basis;  (2)  Items requiring frequent and substantial servicing;  (3)  Oxygen and oxygen equipment (not including oxygen contents, supplies or accessories  furnished for use in conjunction with beneficiary-owned equipment);  (4) Capped rental items furnished on a rental basis.  20.6.1.1 - Requirements for Grandfathered Suppliers  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)
(Medicare Claims Processing Manual)
(4) Capped rental items furnished on a rental basis.  20.6.1.1 - Requirements for Grandfathered Suppliers  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  20.6.1.1.1 - Eligibility (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  All suppliers must be in good standing and have an active NSC number which requires that the supplier meet any local and State licensure requirements, if any, for provision of the grandfathered item.   20.6.1.1.2 - Servicing Current Beneficiaries  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  A supplier that chooses to continue to furnish a grandfathered item(s) to any beneficiary in a CBA must continue to furnish that grandfathered item(s) to all beneficiaries who elect to continue receiving that item(s) from that supplier for the remainder of the payment period for the item(s), unless the item is no longer medically necessary.  In order to participate as a grandfathered supplier, the supplier must update its billing systems to incorporate any new billing codes, modifiers or other billing instr uctions for grandfathered suppliers in the Medicare DMEPOS Competitive Bidding Program.   20.6.1.1.3 - Notification to Beneficiaries by Suppliers that Choose to Become Grandfathered Suppliers  (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation : 07-07-08)  A noncontract supplier that elects to become a grandfathered supplier is responsible for providing notification to its Medicare customers residing in CBAs who are furnished items identified in section 20.6.1. This notification should meet the following guidelines:
(Medicare Claims Processing Manual)
A noncontract supplier that elects to become a grandfathered supplier is responsible for providing notification to its Medicare customers residing in CBAs who are furnished items identified in section 20.6.1. This notification should meet the following guidelines:   NOTE:  This notification should only be sent to beneficiaries who the supplier is currently serving and who maintain a permanent residence in a CBA.  The list of ZIP Codes for each CBA, the list of the HCPCS for competitively bid items, and the single payment amounts for these items are located in public use files on the CBIC Web site at: http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home.    It should state that the supplier is offering to continue to furnish rental DME, oxygen and oxygen equipment and/or related accessories and supplies that it is currently furnishing to the beneficiary (i.e., before the start of the competitive bidding program) and to provide these items to the beneficiary for the remainder of the rental period.   It should state that the beneficiary has the choice to continue to receive a grandfathered item(s) from the grandfathered supplier or to elect to begin receiving the i tem(s) from a contract supplier after the competitive bidding program begins.   It should provide the suppliers telephone number so the beneficiary or caregiver may call and notify the supplier of his/her election.   The supplier should provide notification to the beneficiary at least 30 days before the start date of the implementation of the Medicare DMEPOS Competitive Bidding Program.    The supplier should receive an election from a beneficiary and maintain a record as to whether the beneficiary chose to continue to receive the item from a grandfathered supplier, chose to go to a contract supplier to receive the item or did not respond.  The record should indicate, at a minimum, the date that the beneficiary is notified that the supplier elected to become a grandfathered supplier for the item(s), the date the beneficiary made an election (if applicable), and the methods of communication used in the case of each election activity (e.g. letter to the beneficiary).
(Medicare Claims Processing Manual)
 The supplier should inform the beneficiary of the end date of service and that arrangements will be made to pick -up the item within 10 days of picking up the item.   The supplier should remind the beneficiary of the date and time the equipment will be picked up within 2 business days of picking up the equipment.  Recommended Schedule for Suppliers to Notify Beneficiaries of the Necessity to Decide on Arrangements for Choosing to Use a Grandfathered Supplier or Contract Supplier   Notification - Supplier  Number of Days Before the Start Date of the Competitive Bidding Program  Initial Notification in writing  30 days  Notification before picking up equipment  Within 10 days before picking up the equipment.  Final Notification before picking up equipment  Within 2 business days of picking up the equipmen t  ** A sample notification letter will be posted on the CBIC Web site at www.dmecompetitivebid.com.  20.6.1.1.4 - Notification to Beneficiaries for Suppliers that Choose Not to Become Grandfathered Supplie rs (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation: 07-07-08)  A noncontract supplier that elects not to become a grandfathered supplier should provide notification to the beneficiary stating the supplier will not continue to furnish, after the start of the Medicare DMEPOS Competitive Bidding Program, the competitively bid item(s) that the beneficiary has been receiving from the supplier.  This notification should meet the following guidelines:  NOTE:  This notification should only be sent to beneficiaries who the supplier is currently serving and who maintain a permanent residence in a CBA.  The list of ZIP Codes for each CBA, the list of the HCPCS for competitively bid items, and the single payment amounts for these items are located in  public use files on the CBIC Web site at:  http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home.    It should state that the supplier will not continue to furnish rental DME and/or oxygen and oxygen equipment that it is currently furnishing to the beneficiary after the start of the competitive bidding program and that the beneficiary may need to select a contract supplier to continue to receive these items.
(Medicare Claims Processing Manual)
 It should inform the beneficiary of the start of the competitive bidding program and the date the supplier plans to pick up the item.   It should inform the beneficiary that he/she may obtain information about the competitive bidding program by calling 1-800- MEDICAR E or accessing www.medicare.gov on the Internet.  It should also refer him/her to the supplier locator tool on www.medicare.gov .   The supplier should provide this written notification to the beneficiary 30 days before the start date from the implementation of the Medicare DMEPOS Competitive Bidding Program.    The supplier should inform the beneficiary of the end date of service and that arrangements will be made to pick -up the item within 10 days of picking up the item.   The supplier should remind the beneficiary of the date and time the equipment will be picked up within 2 business days of picking up the equipment.  Recommended Schedule for Suppliers to Notify Beneficiaries to Lo cate a Contract Supplier   Notification - Supplier  Number of Days Before the Start Date of the Competitive Bidding Program Initial Notification in writing  30 days  Notification before picking up equipment  Within 10 days before picking up the equipment.  Final Notification before picking up equipment  Within 2 business days of picking up the equipment   ** A sample notification letter will be posted on the CBIC Web site at www.dmecompetitivebid.com.  20.6.2 - New Period of Continuous Use  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)  In the case of grandfathered items that are oxygen and oxygen equipment or capped rental DME, whenever a new period of continuous use begins following a break in use of greater than 60 days plus the days remaining in the last rental month, after the start of the competitive bidding program, the new or additional equipment covered under the new period of continuous use must be obtained from a competitive bidding contract supplier.  See 42 CFR 414.230 for determining a period of continuous use.  20.6.3 - Picking Up Equipment  (Rev. 1502; Issued:  05-09- 08; Effective/Implementation Date:  06 -09-08)
(Medicare Claims Processing Manual)
Under no circumstances may the supplier discontinue services by picking up a medically necessary item(s) prior to the end of a month for which the supplier is eligible to receive a rental payment, even if the last day ends after the start date of the Medicare DMEPOS Competitive Bidding Program.  A noncontract supplier may only pick up medically necessary oxygen equipment or capped rental DME prior to the start of the competitive bidding program or prior to the end of the month for which the supplier is eligible to receive payment if the beneficiary relocates his/her permanent residence outside the CBA and outside the normal service area of the supplier.  The pick up by the noncontract supplier and the delivery by the contract supplier of the equipment should occur on the same day and month as the item rental anniversa ry date.  The anniversary date is the day of the month on which the item was first delivered to the beneficiary.  For capped rental DME or oxygen and oxygen equipment, the noncontract supplier is responsible for submitting a claim for any rental period tha t begins prior to the start of the competitive bidding program.  In all cases, we expect the contract supplier to consult with the noncontract supplier to obtain the anniversary date.  The noncontract supplier should work with the contract supplier so that  there is no break in service or furnishing of medically necessary items.  We expect the contract supplier and the current supplier will work together to make arrangements suitable to the beneficiarys needs.   Examples:  Using July 1st as the beginning dat e of the Medicare DMEPOS Competitive Bidding Program   A.  If a beneficiarys last anniversary date before the beginning of the competitive bidding program is June 29, the noncontract supplier must submit a claim for the rental month beginning June 29 and e nding July 28th.  The noncontract supplier must not pick up the equipment prior to July 29th.   In this case, the current supplier would pick up its equipment, on July 29th, and the contract supplier would deliver its equipment on July 29th.