evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
NOTE:   This instruction to send a remittance advice to the supplier in the case of denial of an unassigned claim is a specific requirement of 1834(a)(18)(C)  of the Act, incorporated by reference into 1834(j)(4)  and 1879(h)  of the Act, applicable to denials of claims for medical equipment and supplies furnished on or after January 1, 1995.  If the beneficiary signed an ABN which satisfies the requirements in subsection II.6 and the supplier included a GA modifier on the claim to that effect, do not make an automatic finding that the claim should be denied on the basis of 1862(a)(1) , 1834(a)(17)(B) , 1834(j)(1) , or 1834(a)(15)  of the Act, merely because the supplier submitted a GA modifier.  The fact that an ABN was given to the beneficiary will in no way prejudice the contractors determination as to whether there is or is not sufficient evidence to justify a denial.  In the c ase where there is an ABN, mail a standard denial MSN notice to the beneficiary.  If the beneficiary did not sign an ABN and the supplier included a GZ modifier on the claim to that effect, include, in addition to one of the denial notices in Chapter 21, Medicare Summary Notices, the following initial beneficiary notice in the MSN sent to the beneficiary.   A. Initial Beneficiary Notice   (MSN 8.54)   If the supplier knew that Medicare wouldnt pay and you paid, you might get a refund unless you signed a notice in advance.  Refunds may be delayed if the provider appeals.  Call your supplier if you dont hear anything within 30 days.  (MSN 8.54) -  In Spanish   Si pag por un servicio que su proveedor saba Medicare no iba a pagar, usted tiene derecho a un reembolso, a menos de que haya firmado un aviso por adelantado.  Los reembolsos se pueden demorar si el proveedor apela la decisin.  Llame a su proveedor si no escucha nada en 30 das .
(Medicare Claims Processing Manual)
B. Initial Supplier Notice   Include in the notice to the supplier the following;    The patients name Medicare beneficiary identifier;    A description of the item or service by procedure code, date and place of service, and amount of the charge;    The same denial notice included on the beneficiarys MSN, (see Chapter 21, Medicare Summary Notices); and    If the supplier submitted a GA modifier (signed ABN obtained), include in the notice to the supplier the following Notice 1.  However, if the supplier submitted a  -GZ modifier (a signed ABN was not obtained), include in the notice to the supplier the fol lowing Notice 2.  Notice 1.  Signed Advance Beneficiary Notice Obtained  (Remittance Advice Remark Code N124)   Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item.  The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished t hat we would not pay for it, and the patient agreed to pay.   Remittance Advice Remark Codes cannot be reported without a Claim Adjustment Reason Code and a Group Code.  For Notice 1 where ABN has been obtained, use CARC 96 -  Non -covered charge(s), and Group Code  PR (Patient Responsibility).  Or  Notice 2.  Signed Advance Beneficiary Notice Not Obtained  (Remittance Advice Remark Code N125)
(Medicare Claims Processing Manual)
Notice 2.  Signed Advance Beneficiary Notice Not Obtained  (Remittance Advice Remark Code N125)   Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item.  If you have collected any amount from the patient, you must refund that a mount to the patient within 30 days of receiving this notice.  The law permits exceptions to this refund requirement in two cases: if you did not know, and could not have reasonably been expected to know, that Medicare would not pay for this service/item; or if you notified the beneficiary in writing before providing it that Medicare likely would deny the service/item, and the beneficiary signed a statement agreeing to pay.  Remittance Advice Remark Codes cannot be reported without a Claim Adjustment Reason Code and a Group Code.  For Notice 2 where ABN has NOT been obtained, use CARC 96 -  Non -covered charge(s), and Group Code  CO (Contractual obligation).   If an exception applies to you, or you believe the contractor was wrong in denying payment, you should request an appeal of this determination by the contractor within 30 days of receiving this notice.  Your request for appeal should include any additional  information necessary to support your position.  If you request an appeal within 30- days, you may delay refunding to the beneficiary until you receive the results of the appeal.  If the appeal determination is favorable to you, you do not have to make any refund.  If the appeal is unfavorable, you must make the refund within 15 days of receiving the unfavorable appeal decision.   You may request an appeal of the determination at any time within 120 days of receiving this notice.  An appeal requested after the 30 -day period does not permit you to delay making the refund.  Regardless of when an appeal is requested, the patient will b e notified that you have requested one, and will receive a copy of the determination.
(Medicare Claims Processing Manual)
The patient has received a separate notice of this denial decision.  The notice advises that he or she may be entitled to a refund of any amounts paid, if you should have known that Medicare would not pay and did not tell him or her.  It also instructs the  patient to contact your office if he or she does not hear anything about a refund within 30 days.  The requirements for refund are in 1834(a)(18)  of the Act (and in 1834(j)(4)  and 1879(h)  by cross -reference to 1834(a)(18) ).  Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program.  If you have any questions about this notice, please contact (contractor contact, t elephone number).   Ensure that the telephone number puts the supplier in touch with a knowledgeable professional who can discuss the basis for the denial or reduction in payment.  NOTE:   These procedures do not apply where the contractor automatically denies Part B services related to hospital inpatient services denied by the Quality Improvement Organization (QIO).  In those cases, the QIO is responsible for notifying the beneficiary and supplier of the refund requirements of 1834(a)(18) , 1834(j)(4) , and 1879(h)  of the Act and making the refund determination where appropriate.   150.9 - Processing Beneficiary Requests for Appeal  (Rev. 4250; Issued: 03- 08-10; Effective: 04 -08-19; Implementation: 04 -08-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   Where a beneficiary requests an appeal of the initial denial, process the appeal in the normal fashion except that, where the appeal results in a reversal, include the following special paragraph in the appeal notice sent to the beneficiary:
(Medicare Claims Processing Manual)
Where a beneficiary requests an appeal of the initial denial, process the appeal in the normal fashion except that, where the appeal results in a reversal, include the following special paragraph in the appeal notice sent to the beneficiary:   The supplier which furnished this item or service has been informed of this decision and advised that it may collect its full charge for the item or service.   Send the supplier which furnished the item or service a separate notice which clearly identifies the item or service for which payment is being made (i.e., include the patients name, Medicare beneficiary identifier, a description of the item or service billed by procedure code, date and place of service, and amount of the charge. Include the following language:   You were previously advised that Medicare payment could not be made for this item or service. However, after reviewing this claim, we have determined that payment may be made. Therefore, if you have already refunded the amounts you collected from the benef iciary for this item or service, you may recollect these amounts.  150.10 - Processing Supplier Requests for Appeal  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Where a supplier requests an appeal, notify the beneficiary as discussed in 150.7 . The appeal process consists of three stages, even though the supplier may be contesting only one issue (e.g., the supplier may assert that it did not know, and could not have reasonably have been expected to know, that Medicare would not pay for the ite ms or services).   150.10.1 - Appeal of the Denial of Payment  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)  The first stage of the appeal is a new, independent, and critical reexamination of the facts regarding the denial of payment. If the contractor finds that the initial denial of payment was appropriate, go on to 150.10.2.  150.10.2 - Beneficiary Given Advance Beneficiary Notice and Agreed to Pay (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)
(Medicare Claims Processing Manual)
A supplier which has given the beneficiary an ABN and has obtained the beneficiarys signed statement agreeing to pay, is not required to make a refund.  If the supplier claims to have given an ABN to the beneficiary, the contractor will ask the supplier to furnish a copy of the ABN. Examine the ABN to determine whether it meets the standards in 40.3 and 50.  In the absence of acceptable evidence of advance beneficiary notice, go on to 150.10.3.  150.10.3 - Supplier Knowledge  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)  A supplier which did not know and could not reasonably have been expected to know that Medicare would not pay for the medical equipment or supplies is not required to make a refund. If the supplier claims not to have had any such knowledge, the contractor will determine whether the supplier knew, or could reasonably have been expected to know, that Medicare would not pay by applying the knowledge standards provided in 150.5.  150.11 - Guide Paragraphs for Inclusion in Appeal Determination  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)  Upon completion of the appeal, the contractor will send the supplier an appeal notice. Send a copy to the beneficiary. If the initial payment determination is reversed to payment, include in the appeal notice the supplier notice language required in 150.9. Otherwise, include one of the following paragraphs concerning refund.   Paragraph 1. Refund Not Required -  Beneficiary Was Given Advance Beneficiary Notice and Agreed to Pay
(Medicare Claims Processing Manual)
Paragraph 1. Refund Not Required -  Beneficiary Was Given Advance Beneficiary Notice and Agreed to Pay   Under 1834(a)(18) and under 1834(j)(4) of the Social Security Act, a supplier which does not accept assignment and collects any amounts from a Medicare beneficiary for medical equipment and supplies for which Medicare does not pay on the basis of 1834(a )(17)(B), 1862(a)(1), 1834(j)(1), or 1834(a)(15) of the Social Security Act, must refund these amounts to the beneficiary. However, a refund is not required if, prior to furnishing the items or services, the supplier notified the beneficiary in writing that Medicare would not pay for the items or services and the beneficiary signed a statement agreeing to pay for them. After reviewing this claim, we have determined that you informed the beneficiary in advance that Medicare does not pay for the above item s or services and the beneficiary agreed to pay for them. Therefore, you are not required to make a refund in this case. The beneficiary has been sent a copy of this notice.   Paragraph 2. Refund Not Required -  Supplier Did Not Know That Medicare Would Not Pay For the Services
(Medicare Claims Processing Manual)
Paragraph 2. Refund Not Required -  Supplier Did Not Know That Medicare Would Not Pay For the Services   Under 1834(a)(18) and 1834(j)(4) of the Social Security Act, a supplier which does not accept assignment and collects any amounts from a Medicare beneficiary for medical equipment and supplies for which Medicare does not pay on the basis of 1834(a)(17)(B), 1862(a)(1), 1834(j)(1), or 1834(a)(15) of the Social Security Act, must refund these amounts to the beneficiary. However, a refund is not necessary if the supplier did not know, and could not reasonably have been expected to know, that Medicare does not pay for the items or services. After reviewing this claim, we find that you did not know, and could not reasonably have been expected to know, that Medicare would not pay for the above items or servic es. Therefore, you are not required to make a refund in this case. Upon your receipt of this notice, it is considered that you now have knowledge of the fact that Medicare does not pay for (description of item or service) similar conditions. The beneficiar y has been sent a copy of this notice.  Paragraph 3. Adverse Action on Denial -  Refund Required
(Medicare Claims Processing Manual)
Under 1834(a)(18) and 1834(j)(4) of the Social Security Act, a supplier which does not accept assignment and collects any amounts from a Medicare beneficiary for medical equipment and supplies for which Medicare does not pay on the basis of 1834(a)(17)( B), 1862(a)(1), 1834(j)(1), or 1834(a)(15) of the Social Security Act, must refund these amounts to the beneficiary. A refund is not required if (1) The supplier did not know, and could not reasonably have been expected to know, that Medicare would not pay for the items or services; or (2) The supplier notified the beneficiary in writing before furnishing the items or services that Medicare would not pay for the items or services and the beneficiary signed a statement agreeing to pay for them. After revi ewing this claim, we have determined that neither of these conditions is met in this case. You must therefore refund any amount you collected for these items or services within 15 days from the date you receive this notice. A refund must be made within 15 days from receipt of this notice for you to be in compliance with the law. The beneficiary has been sent a copy of this notice.   Suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties (up to $10,000 per item or service), assessments (three times the amount of the claim), and exclusion from the Medicare program.   NOTE:   For claims presented to the contractor prior to January 1, 1997, the amount of the civil money penalty is up to $2,000 per item or service and the assessment is not more than twice the amount claimed.   150.12 - Supplier Fails to Make Refund  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)
(Medicare Claims Processing Manual)
150.12 - Supplier Fails to Make Refund  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)  Under 1834(a)(18)(B) of the Act, a supplier which knowingly and willfully fails to make refund within the time limits in 150.4 may be subject to sanctions under 1128A the Act (i.e., civil money penalties (up to $10,000 per item or service), assessments (three times the amount of the claim), and exclusion from the Medicare program).  NOTE:   For claims presented to the contractor prior to January 1, 1997, the amount of the civil money penalty is up to $2,000 per item or service and the assessment is not more than twice the amount claimed.   Generally, the failure of a supplier to make a refund to a beneficiary comes to the contractors attention as a result of a beneficiary complaint or a referral from the Social Security Administration (SSA) or the CMS. Document beneficiary complaints and, i f necessary, contact the beneficiary to clarify the information in the complaint and determine the amount the beneficiary paid the supplier for the denied items or services. If the contractor determines that a supplier failed to make a refund, the contract or will contact the supplier in person or by telephone (if that is not feasible, contact the supplier by letter) to discuss the facts of the case. The contractor will attempt to determine why the amounts collected have not been refunded. Explain that the l aw requires that the supplier make a refund to the beneficiary and that if it fails to do so, the Secretary may impose civil money penalties, assessments, and exclusion from the Medicare program. Make a dated report of contact. Include the information rela yed to the supplier and the suppliers response. Re -contact the beneficiary in 15 days to determine whether the refund has been made. Do not make any referral to the CMS regional office until the supplier has been formally notified to refund the money and the suppliers appeal rights have been exhausted, or until the time limit for an appeal has passed.
(Medicare Claims Processing Manual)
150.13 - CMS Regional Office (RO) Referral Procedures  (Rev. 4250; Issued: 03- 08-10; Effective: 04 -08-19; Implementation: 04 -08-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   Prior to submitting any materials to the RO, the contractor will contact the RO to determine how to proceed in referring a potential sanction case.  When referring a sanction case to the region, include in the sanction recommendation (to the extent appropr iate) the following:  Background of the Subject   The subjects business name, address, Medicare beneficiary identifier, owners full name and Social Security Number, Tax Identification Number (if different), and a brief description of the subjects special field of medical equipment and supplies business .  Origin of the Case   A brief description of how the violations were discovered.   Statement of Facts   A statement of facts in chronological order describing each failure to comply with the refund requirements.   Documentation   Include copies of written correspondence and written summaries of any meetings or telephone contacts with the beneficiaries and the supplier regarding the suppliers failure to make refunds.  Include a listing of the following for each item or service not refunded to the beneficiary by the supplier (grouped by beneficiary):    Beneficiary Name and Medicare beneficiary identifier;    Claim Control Number;   Procedure Code (CPT -4 or HCPCS) of nonrefunded item or service;    Procedure Code modifier;    Date of Service;    Place of Service Code;    Submitted Charge;    Units (quantity) of Item or Service; and    Amount Requested to be Refunded.   Other Significant Issues   Include any information that may be of value to the RO while they review and possibly develop a case to impose sanctions.  150.14 - Imposition of Sanctions  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
Other Significant Issues   Include any information that may be of value to the RO while they review and possibly develop a case to impose sanctions.  150.14 - Imposition of Sanctions  (Rev. 1, 10- 01-03)  Section 1834(a)(18)(B) of the Act provides that if a supplier knowingly and willfully fails to make required refunds, the Secretary may impose the sanctions provided in 1842(j)(2)  of the Act in the same manner as such sanctions are authorized under 1128A  of the Act.  These include civil money penalties, assessments, and exclusion from the Medicare program for a period of up to five years.  The CMS RO will make the determination on whether to proceed in developing a monetary penalty or program exclusion ca se based upon a failure to make refunds.   150.15 - Suppliers Right to Recover Resaleable Items for Which Refund Has Been Made  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)  If the contractor denies Part B payment for an item of medical equipment or supplies on the basis of 1862(a)(1) , 1834(a)(17)(B), 1834(j)(1), or 1834(a)(15)  of the Act, and the beneficiary is relieved of liability for payment for that item under 1834(a)(18)  of the Act, the effect of the denial, subject to State law, cancels the contract for the sale or rental of the item and, if the item is resaleable or re -rentable, permits the supplier to repossess that item for resale or re- rental.  In the case of consumable items or any other items which are not fit for resale or re -rental and which cannot be made fit for resale or re -rental, suppliers are strongly discouraged from recovering these items since such actions reasonably could be viewed as purely punitive in nature.  If a supplier makes proper refund under 1834(a)(18) of the Act, Medicare rules do not prohibit the supplier from recovering from the beneficiary items which are resalable or re- rentable.
(Medicare Claims Processing Manual)
Alternatively, when the contract of sale or rental is cancelled on the basis described above, whether or not the supplier physically repossesses the resaleable or re -rentable item, the supplier may enter into a new sale or rental transaction with the benef iciary with respect to that item as long as the beneficiary has been informed of their liability.  If the circumstances which preclude payment for the item have been removed, e.g., the supplier has now obtained a supplier number, the supplier may submit to the contractor a new Part B claim based on the resale or re- rental of the item to the beneficiary.  If Part B payment is still precluded, the supplier can establish the beneficiarys liability for payment for the denied resold or re -rented item by giving the beneficiary an ABN notifying the beneficiary of the likelihood that Medicare will not pay for the item and obtaining the beneficiarys signed agreement to pay for the item.  The resale or re -rental of the item to the beneficiary does not change the fac t that the beneficiary is relieved of liability in connection with the original transaction.   Under the capped -rental method, if the contractor determines that the supplier is obligated to make a refund, the supplier must repay Medicare those rental payments that the supplier has received for the item.  However, the Medicare beneficiary must return  the item to the supplier.   200 - Expedited  Determinations of Inpatient Hospital Discharges        (Rev. 11210; Issued: 01- 21-2022; Effective: 04- 21-2022; Implementation: 04- 21-2022)   Medicare beneficiaries who are hospital inpatients have a statutory right to appeal to a BFCC- QIO for an expedited review when a hospital, with physician concurrence, determines that inpatient care is no longer necessary.   200.1 - Statutory Authority  (Rev. 11210; Issued: 01- 21-2022; Effective: 04 -21-2022; Implementation: 04- 21-2022)    Sections 1866(a)(1)(M),    1869(c)(3)(C)(iii)(III), and    1154(e) of the Act.