evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
50.11 - Claims Submitted for Medicare Beneficiaries Previously Enrolled in a Medicare Advantage Plan  (Rev. 2231, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)  Under DMEPOS Competitive Bidding, if a beneficiary resides in a CBA and elects to leave their MA plan or loses his/her coverage under this plan, the beneficiary may continue to receive items requiring frequent and substantial servicing, capped rental, oxygen and oxygen equipment, or inexpensive or routinely purchased rented items from t he same DME supplier under the MA plan without going to a contract supplier under the Medicare DMEPOS Competitive Bidding Program.  However, the supplier from whom the beneficiary previously received the item under the plan must be a Medicare enrolled supplier; meet the Medicare FFS coverage criteria and documentation requirements; and must elect to become a grandfathered supplier.  All competitive bid grandfathering rules apply in these situations.  50.12 - Claims for Repairs and Replacements (Rev. 2231, I ssued: 05 -27-11, Effective: 08- 28-11, Implementation: 08- 28-11)  Under the DMEPOS Competitive Bidding Program, any DMEPOS supplier, provided they have a valid Medicare billing number, can furnish and bill for services (labor and parts) associated with the repair of DME or enteral nutrition equipment owned by beneficiaries who reside in a CBA.  In these situations, Medicare payment for labor will be made based on the standard payment rules.  Medicare payment for claims for replacement parts associated with r epairing competitively bid DME or enteral nutrition equipment, that are submitted with the RB modifier, will be based on the single payment amount for the part if the part and equipment being repaired are included in the same competitive bidding product ca tegory in the CBA.  Otherwise, Medicare payment for replacement parts associated with repairing equipment owned by the beneficiary will be made based on the standard payment rules.
(Medicare Claims Processing Manual)
The replacement of an entire item, as opposed to the replacement of a part  for repair purposes, which is subject to the DMEPOS Competitive Bidding Program, must be furnished by a contract supplier.  Medicare payment for the replacement item would be based on the single payment amount for the item in the beneficiarys CBA.  Refer  to Pub. 100- 04, the Medicare Claims Processing Manual, Chapter 20, 10.2 for instructions on submitting claims for repairs and replacements.   50.13 - Billing for Oxygen Contents to Suppliers After the 36th Month Rental Cap (Rev. 2231, Issued: 05- 27-11, Eff ective: 08 -28-11, Implementation: 08- 28-11)  The Medicare law requires that the supplier that furnishes liquid or gaseous oxygen equipment (stationary or portable) for the 36th continuous month must continue to furnish the oxygen contents necessary for the effective use of the liquid or gaseous equipment during any period after the payment cap and of medical need for the remainder of the reasonable useful lifetime established for the equipment.  This requirement continues to apply under the Medicare DMEPOS Competitive Bidding Program, regardless of the role of the supplier (i.e., contract supplier, grandfathered supplier, or non- contract supplier) and the location of the beneficiary (i.e. residing within or outside a CBA).   Should a beneficiary travel or tem porarily relocate to a CBA, the oxygen supplier that received the payment for the 36th continuous month must make arrangements for furnishing oxygen contents with a contract supplier in the CBA in the event that the supplier that received the 36th month pa yment elects to make arrangements for a temporary oxygen contents billing supplier.   The Medicare payment amount is always based on the location in which the beneficiary maintains a permanent residence.  If the beneficiary resides in a CBA, payment for the oxygen contents will be based on the single payment amount for that CBA.  If the beneficiary resides outside of a CBA and travels to a CBA, payment for the oxygen contents will be based on the fee-schedule amount for the area where the beneficiary maintai ns a permanent residence.
(Medicare Claims Processing Manual)
50.14 - Purchased Accessories & Supplies for Use With Grandfathered Equipment  (Rev. 2231, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)  Non-contract grandfathered suppliers must use the KY modifier on claims for CBA -residing beneficiaries with dates of service on or after January 1, 2011, for purchased, covered accessories or supplies furnished for use with rented grandfathered equipment.  The following HCPCS codes are the codes for which use of the KY modifie r is authorized:    Continuous Positive Airway Pressure Devices, Respiratory Assistive Devices, and Related Supplies and Accessories -  A4604, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, and E0562   Hospita l Beds and Related Accessories -  E0271, E0272, E0280, and E0310    Walkers and Related Accessories -  E0154, E0156, E0157 and E0158   Grandfathered suppliers that submit claims for the payment of the aforementioned purchased accessories and supplies for use wi th grandfathered equipment should submit the applicable single payment amount for the accessory or supply as their submitted charge on the claim.  Non-contract grandfathered suppliers should be aware that purchase claims submitted for these codes without t he KY modifier will be denied.  In addition, claims submitted with the KY modifier for HCPCS codes other than those listed above will be denied.   After the rental payment cap for the grandfathered equipment is reached, the beneficiary must obtain replacement supplies and accessories from a contract supplier.  The supplier of the grandfathered equipment is no longer permitted to furnish the supplies and accessories once the rental payment cap is reached.   50.15 - Hospitals Providing Walkers and Related Acces sories to Their Patients on the Date of Discharge  (Rev. 2231, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)
(Medicare Claims Processing Manual)
Hospitals may furnish walkers and related accessories to their own patients for use in the home during an admission or on the da te of discharge and receive payment at the applicable single payment amount, regardless of whether the hospital is a contract supplier or not. Separate payment is not made for walkers furnished by a hospital for use in the hospital, as payment for these it ems is included in the Part A payment for inpatient hospital services.  To be paid for walkers as a non- contract supplier, the hospital must use the modifier J4 in combination with the following HCPCS codes: A4636; A4637; E0130; E0135; E0140; E0141; E0143;  E0144; E0147; E0148; E0149; E0154; E0155; E0156; E0157; E0158; and E0159. Under this exception, hospitals are advised to submit the claim for the hospital stay before or on the same day that they submit the claim for the walker to ensure timely and accura te claims processing.   Hospitals that are located outside a CBA that furnish walkers and/or related accessories to travelling beneficiaries who live in a CBA must affix the J4 modifier to claims submitted for these items.   The J4 modifier should not be used by contract suppliers.  50.16 - Exception for Wheelchair Accessories Furnished with Non -Competitively Bid Wheelchair Base Equipment  (Rev.  3324, Issued: 08- 14-15, Effective: 07- 01-13, Implementation: 01- 04-16)  Effective for c laims with dates of service on or after July 1, 2013, competitively bid wheelchair accessories are paid in accordance with standard Medicare DMEPOS payment rules, not competitive bidding rules, when furnished with non- competitively bid wheelchair base equipment.Transmittals Issued for this Chapter
(Medicare Claims Processing Manual)
Rev #  Issue Date  Subject  Impl Date  CR#  R11427CP  05/20/2022  Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  01/03/2023  12734  R11414CP  05/12/2022  Claims Processing Manual Update - Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) - Rescinded and replaced by Transmittal 11427  06/13/2022  12734  R3953CP  01/19/2018  Revisions to the Claims Processing for Grandfathered Oxygen Claims that Span Competitive Bidding Rounds  07/02/2018  10420  R3593CP  08/17/2016  Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP): Additional Instructions for the Implementation of Round 2 Recompete of the DMEPOS CBP and National Mail Order (NMO) Recompete  10/03/2016  9579  R3565CP  07/20/2016  Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP): Additional Instructions for the Implementation of Round 2 Recompete of the DMEPOS CBP and National Mail Order (NMO) Recompete - Rescinded and replaced by Transmittal 3593  10/03/2016  9579  R3500CP  04/28/2016  Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS ) Competitive Bidding Program (CBP): Additional Instructions for the Implementation of Round 2 Recompete of the DMEPOS CBP and National Mail Order (NMO) Recompete - Rescinded and replaced by Transmittal 3565  10/03/2016  9579  R3324CP  08/14/2015  Clarification of the Policy for Competitively -Bid Wheelchair Accessories Furnished with Non-Competitively Bid Wheelchair Base Equipment  01/04/2016  9272  R2979CP  06/27/2014  Update to Pub. 100 -04, Chapter 36 to Provide Language -Only Changes for Updating ASC X12  07/28/2014  8771  R2231CP  05/27/2011  Phase 3 of Manual Revisions to Reflect Payment
(Medicare Claims Processing Manual)
Update to Pub. 100 -04, Chapter 36 to Provide Language -Only Changes for Updating ASC X12  07/28/2014  8771  R2231CP  05/27/2011  Phase 3 of Manual Revisions to Reflect Payment Changes for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) 08/28/2011  7401  Rev #  Issue Date  Subject  Impl Date  CR#  Items as a Result of the DMEPOS Competitive Bidding Program and the Deficit Reduction Act of 2005  R1544CP  06/26/2008  Manual Revisions to R eflect Special Billing Instructions for DMEPOS Items as a Result of the DMEPOS Competitive Bidding Program  07/07/2008  6007  R1532CP  06/11/2008  Phase 2 of Manual Revisions to Reflect Payment Changes for DMEPOS Items as a Result of the DMEPOS Competitive Bidding Program and the Deficit Reduction Act of 2005  07/07/2008  6119  R1502CP  05/09/2008  Initial Release of Chapter -Competitive Bidding  06/09/2008  5978  Back to top of chapter
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
Medicare Claims Processing Manual  Chapter 37 - Department of Veterans Affairs (VA) Claims Adjudication Services Project   Table of Contents  (Rev. 11427, 05- 20-22)  Transmittals for Chapter 37   1 - Background on the VA Claims Adjudication Services Project  1.1 - Requirements for Processing VA  Institutional and Professional  Claims                  1.1.2  Requirements for Processing VA Durable Medical Equipment            Prosthetics Orthotics and Supplies (DMEPOS) Claims  1.2 - Department of VA Claims Adjudication: Coinsurance and Deductible  1.3 - Generating Unsolicited Responses to the VA  1.4 - Use of Legacy Provider Numbers After National Provider Ident ifiers (NPIs ) Are Fully Implemented  1 - Background on the VA Claims Adjudication Services Project  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04- 07-08)  Current law permits the VA to collect appro priate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:    At VA facilities; and   For veterans eligible to receive both VA health and Medicare benefits and also having Medicare supplemental insurance.   To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency agreement with the VA whereby CMS will help the VA work with the designated CMS MAC to adjudicate cl aims for these services to produce remittance advices equivalent to those ordinarily produced for Medicare claims.  Medicare does not pay these claims, but the remittance advices show how much Medicare would have paid had the claims been payable by Medicar e along with the applicable deductibles and coinsurance.  In adjudicating a claim and generating these remittance advice notices, the CMS MAC must verify that the services provided are covered benefits, certify admission where appropriate, conduct prepayme nt utilization screening, and authorize payment.  CMS has a single A/B MAC (A) and (B) to process these claims.  The remittance advices, sent by the VA to the supplemental insurers, will help the insurers determine payment amounts they owe to the VA.   The VA funds all of the work on this project, including systems changes.
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
The VA funds all of the work on this project, including systems changes.   1.1 - Requirements for Processing VA Institutional and Professional Claims (Rev.  4023, Issued: 04- 20-18, Effective: 07 - 20-18, Implementation: 07- 20- 18)  Veterans typically see more than one physician at a VA facility on a given day.  The A/B MAC (B) -defined provider number will contain a V in the first position and specialty codes.  Including specialty codes permits the VA to have multiple provider numbers to accommodate various pr ofessional services furnished at a given facility on the same day for the same beneficiary -veteran.  CWF will edit to ensure that only claims having all three of the following conditions will be processed according to the special VA claims adjudication procedures of this project:   1. A demo number of 31 is present;   2. A V is present in the first position of the A/B MAC (B) defined provider number field (HUBC Field 83 Provider Number, Positions 440- 449); and   3. The VA A/B MAC (B) number is present   If only two of these conditions are present, then CWF will reject the claim.  If only the demo code of 31 is present, CWF will also reject the claim.   The VA will use the ASC X12 837 professional claim format for A/B MAC (B) equivalent claims.   To process VA claims from various localities, the VA A/B MAC (A) and (B) has established a database for the Medicare physician fee schedule to include pricing information for all of the States.   The VA will use the following bill types for A/B MAC (A) equivalent claims: 11x, (Hospi tal Inpatient, Part A), 12x (Hospital Inpatient, Part B), 13x (Hospital Outpatient), 14x (Hospital Other, Part B), 18x (Hospital Swing Beds), 21x (SNF inpatient), and 23x (SNF outpatient).  These claims are submitted using the ASC X12 837 institutional cla im format.   The SNF VA provider numbering scheme is as follows:   a 2 digit numeric state code, followed by a 5, followed by a 1 digit one up number, followed by with a V, ending with a single position alpha numeric .
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
a 2 digit numeric state code, followed by a 5, followed by a 1 digit one up number, followed by with a V, ending with a single position alpha numeric .  1.1.2  Requirements for Processing VA Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Claims  (Rev. 11427; Issued: 05- 20-22; Effective: 01 -01-23; Implementation: 01- 03-23)
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medi cal Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records  management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  For claims with dates of service prior  to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs  are mentioned.   The process of receiving VA DMEPOS claims for a no- pay Electronic Medicare Remittance Advice (e- MRA) is effective on April 1, 2018.  The processing of these claims, as with the Part A and Part B claims, allows for a CMS no -pay e -MRA to be generated for all DMEPOS claims submitted to CMS by the VA.  VA DMEPOS claims are processed by a single DME MAC.  For VA DMEPOS claims the e- MRA displays the amount that Medicare would have paid for the claim using the same fee schedule payments as DMEPOS Medicare claims wouldve paid and are based on the beneficiarys state of residence. The same deductible and coinsurance rules applicable to Medicare are applied to the VA claims and are provided on the e -MRA.
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
The VA submits DMEPOS claims via the ANSI X12  837P electronic format. The VA claims will be processed through the Medicare DME MAC Common Electronic Data Interchange (CEDI) front end system, DMEPOS claims processing system (VMS) and the common working file (CWF).   In addition to following the ANSI X 12 837P standards for claims submissions the following criteria applies:   The VA's submitter of record is the approved biller and submits all VA electronic claims to CEDI.   The VA supplies CMS, the VA DME MAC and CEDI with the VA facility NPI list. Validation of the NPI is done at the CMS front end contractor.   VA claims are processed as mandatory assigned claims, no beneficiary submitted claims will be processed.   VA DMEPOS submitted claims must be for beneficiaries that reside in the US and its territories.   The VA must submit claims for Medicare approved HCPCS provided on the DMEPOS jurisdiction list which can be found at https://www.cms.gov/Center/Provider -Type/Durable -Medical -Equipment -DME -Center.html.   The VA DMEPOS claims are subject to the Medicare timely  filing rules. Claims will be accepted for processing with dates of service one year prior to the date of receipt.   The VA will submit paper CMNs for DMEPOS items that require a CMN per Medicare rules. The CMNs will be faxed (until the time VA has the ability to submit CMNs electronically) to the DME MAC. Claims requiring a CMN may be held for up to 2 weeks to allow for receipt of the CMN. Claims will be denied if a CMN is not received within 2 weeks.
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
The CWF edits to ensure the same three conditions stated above for A/B claims are applicable and must be present for adjudication on the DMEPOS claims.  In addition, MSP claims are accepted from the VA and the CWF will apply MSP editing to VA DMEPOS claims.   Finalized claims will be included in the VA e -MRA an d produced in the CMS flat file format.  CEDI will translate the VA e -MRA flat file to the ANSI X12 835 format and make the file(s) available for the VAs submitter of record to retrieve.    Adjustments to claims submitted by the VA can be made only for redeterminations or cancels.  This applies to all DMEPOS claims submitted by the VA for VA facilities and for independent suppliers.  1.2 - Department of VA Claims Adjudication: Coinsurance and Deductible  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04 -07-08)  Part of this process involves the calculation of the deductible applicable to the Medicare -equivalent VA claims.  The CWF calculates the deductible based on true Medicare claims, i.e., for Medicare services rendered by Medicare p roviders to Medicare beneficiaries, and sends this information back to the shared system maintainers for this project.  The MCS and FISS further adjust the deductible information received from CWF with the deductible amounts that apply to the Medicare -equivalent VA claims.  This arrangement results in a calculation of the deductible for the VA's equivalent of Part A and B claims.   In addition, effective January 1, 2005, CWF began to calculate the Part B -equivalent deductible for Medicare claims taking into consideration the VA equivalents of both Medicare outpatient and professional claims as well as true Medicare claims.   To confirm that CMS has made no payment on the VA claim, the remittance advice will include message MA118 Coinsurance and or deductible  amounts apply to a claim for services or supplies furnished to a Medicare Eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued".
(Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:)
Existing claim adjustment reason codes 1 (deductible) and/or 2 (coinsurance) will be used to report those amounts on these remittance advice transactions.  As necessary, CWF expands the VA claim auxiliary file within CWF so that the history of VA Part A -equivalent no- pay claims, adjudicated for the MRA Project, contai n sufficient information about the VA claims and Medicare -equivalent Part A deductible and coinsurance amounts applied so that an unsolicited response can be generated.  The auxiliary file contains sufficient information so that there can be one such unsol icited response for each VA claim affected.   The VA auxiliary file within CWF also provides a claims history for VA Part B equivalent claims.  The auxiliary contains the information about VA claims necessary to show Medicare- equivalent Part B deductibles s atisfied by the VA claims.  National Claims History is not updated with the VA deductible information, and these changes have no effect on Medicare claims.  CWF sends the Part B deductible information to the A/B MACs (A) and (B) for this project.  This aff ects claims with dates of service of January 1, 2004, and after and will use deductible amounts for calendar years 2004 and after.  1.3 - Generating Unsolicited Responses to the VA  (Rev. 1454, Issued: 02- 22-08, Effective: 04 -01-08, Implementation: 04- 07-08)