evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
For dates of service prior to January 1, 2008, IHS providers that want to bill for surgeries on the ambulatory surgical center (ASC) list and receive the ASC rate must contact their designated A/B MAC (A). IHS providers are certified by one of several national accrediting organizations recognized by the Centers for Medicare and Medicaid Services (CMS) and meet the conditions for performing ASC procedures.  The IHS hospital outpatient departments are not certified as separate ASC entities. The ASC indication merely means that CMS approved them to bill for ASC services and be paid based on the ASC rates for services on the ASC list.  In order to bill for ASC services, the hospital outpatient department must meet the conditions of participation for hospitals defined in 42 CFR, Part 482.  Authority for Medicare to pay IHS hospital outpatient departments using the freestanding ASC rates was incorporated into Public Health Service regulations on December 27, 1989. The first IHS hospital requested to bill separately for ASC procedures at the appropriate ASC group payment amounts in March 1987.  HCFA (now CMS) approved payment of the ASC group payment amounts for dates of service on or after October 1, 1987. Previously, the hospital was reimbursed for ASC procedures at the Off ice of Management and Budget (OMB) negotiated all inclusive rate (AIR) for outpatient hospital services.  The rationale for approving this request was that the hospital was already JCAHO certified, encompassing the ability to perform outpatient surgical procedures, and that acute care hospitals providing surgical inpatient or outpatient services can perform any surgical procedures within their capacity and capability.   For dates of service prior to January 1, 2008, in order for IHS providers to bill for ASC  procedures and receive payment based on the ASC rates published in the Federal Register, the designated A/B MAC (A) must update the IHS/ASC cert indicator on the provider file to Y. A Y in this field indicates that the IHS provider or ASC is certified  under IHS and their claims should be processed through ASC Pricer, ensuring the IHS provider is paid based on the ASC price rather than the AIR. Reimbursement is made based on the AIR until the A/B MAC (A) updates the IHS/ASC cert indicator to a Y.
(Medicare Claims Processing Manual)
See 100.6 and 100.6.1 of this chapter for information on the payment policy and claims processing for ASC services.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs.  All IHS ASC providers, including hospital outpatient departments requesting payment based on freestanding ASC rates and ASCs affiliated with a hospital but operating as a distinct entity for the purpose of performing outpatient surgical services must enroll with and subm it their claims to the designated A/B MAC (B).   40.2.2 - Provider Enrollment with A/B MAC (A) - Services Under Arrangements  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  If an IHS provider is unable to provide all the servic es a beneficiary that is a registered outpatient of the provider needs, the provider may provide those services under arrangements, via a contract with another entity.  Section 1862(a)(14) of the Social Security Act prohibits payment for nonphysician ser vices furnished to hospital inpatients and outpatients unless the services are furnished by the hospital either directly or under an arrangement.  All services that are furnished by a hospital, either directly or under arrangement, to a registered hospital  outpatient during a hospital encounter are subject to the hospital bundling requirements.  42 CFR 482.12(e) spells out the criteria for contracted services as they apply to a hospitals COPS in the Medicare program.  The IHS providers governing body must  be responsible for services furnished in the provider whether or not they are furnished under contracts.  The governing body must ensure that the services performed under a contract are provided in a safe and effective manner.  The IHS provider must maint ain a list of all contracted services, including the scope and nature of the services provided.  Chapter 5, 10.3 of Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual sets forth general Under Arrangement guidelines.  The provider must exercise professional responsibility over the arranged -for services rather than merely serving as a billing conduit.
(Medicare Claims Processing Manual)
In accord with the above -cited law, regulation, and policy, IHS providers are responsible for furnishing medically necessary servi ces to their registered outpatients either directly or under arrangement.  Service unbundling is prohibited; only the provider can bill for services furnished to its inpatients and outpatients.  The CMS recommends that when services are provided under arrangements the contract should specify how much the IHS provider will pay for each contracted service.  The entity furnishing the services under arrangements with the provider must agree to accept the IHS providers payment as payment in full, and may not charge the beneficiary for such services.   The Office of the Inspector General is authorized to impose a civil money penalty against any individual who knowingly and willingly presents, or causes to be presented, a bill or request for payment, for items or s ervices furnished under Medicare, that is inconsistent with an arrangement under 1886(a)(1)(H) of the Social Security Act or is in violation of the requirement for an arrangement. See 42 CFR 1003 for more information on civil money penalties, assessments and exclusions.   40.3 - Provider Enrollment with DME MAC  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS providers and suppliers that do not currently have a supplier number and want to bill for DMEPOS items must enroll with the NSC.   Beginning July 1, 2005, IHS providers (including CAHs) and pharmacies were eligible to begin billing for DME.  The NSC must accept enrollment applications from IHS and tribally operated hospitals (including CAHs) or hospital -based facilities and pharmacies providing DME beginning April 1, 2005.  All IHS facilities and pharmacies, whether operated by the IHS or a tribe, enrolled by the NSC, shall meet all required standards as set forth in 42 CFR 424.57.  Compliance with the standards w ill be verified by the review procedures for all other DMEPOS suppliers except as discussed herein.   All IHS facilities and pharmacies, whether operated by the IHS or a tribe, shall be exempt from the comprehensive liability insurance requirements under 42 CFR 424.57(c)(10).
(Medicare Claims Processing Manual)
All IHS facilities and pharmacies, whether operated by the IHS or a tribe, shall be exempt from the comprehensive liability insurance requirements under 42 CFR 424.57(c)(10).   All IHS facilities and pharmacies, whether operated by the IHS or a tribe, shall be exempt from the requirement to provide any State licenses for their facility/business.  For example, if a DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a State that requires a bedding license, such license is not required.  However, if they provide a DMEPOS item that requires a licensed professional in order to properly provide the item, they shall  provide a copy of the professional license.  The licensed professional may be licensed in any State or have a Federal license.  For example, a pharmacy does not need a pharmacy license, but shall have a licensed pharmacist on staff.   Site visits shall be conducted for all facilities of the IHS enrolling as IHS suppliers.  For enrollment purposes Medicare recognizes those facilities operated by the IHS and those facilities operated by the tribes.   The IHS enrollment shall be in accordance with the instructi ons provided for all DMEPOS suppliers on the Form CMS -855S, except for the following clarifications.   Facilities operated by the IHS, including pharmacies are considered a Federal government organization.  An Area Director of the IHS must sign the 15 Certification Statement of the Form CMS -855S, be listed in 6 of the form and sign the letter required by 5 of the form which attests that the IHS will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.    Facili ties, including pharmacies that are tribally operated are considered tribal organizations.  The 15 Certification Statement of the Form CMS -855S must be signed by a tribal official who meets the definition of an authorized official in accordance with the p age 2 definitions shown on the Form CMS -855S.  The same authorized official must be listed in 6 of the Form CMS -855S and must sign the letter required by 5 of the form which attests that the tribe will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.
(Medicare Claims Processing Manual)
The CMS shall provide the NSC with a list of facilities of the IHS which distinguishes between IHS operated and tribally operated. On the list the NSC shall use the column entitled, FAC OPERATED BY, for this purpose.  Chapter 10 of Pub. 100- 08, Medicare Program Integrity Manual contains additional information on the Form CMS -855S.   NOTE:  Drugs furnished by tribally owned and operated facilities, including pharmacies that are covered under Medicare Parts A and B will continue to be covered and paid under the Medicare fee for service programs.  Facilities shall continue to bill their A/B MAC (A), A/B MAC (B) and DME MAC for these drugs after the implementation of Medicare Part D.   40.4 - NSC Supplier Number  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a DME Supplier, secure a Medicare supplier billing number and comply with the supplier standards  specified in 42 CFR 424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction rules. The NSC shall provide identifiers which identify IHS suppliers and IHS providers to facilitate proper reimbursement by DME MACs.   All IHS suppliers that do not have a supplier number for billing a DME MAC should complete a Form CMS -855S and obtain a supplier number from the NSC. There are two ways to obtain a supplier number from the NSC:   1) Facilities may call the NSC to request an application for Form CMS-855S. Once the facility has completed the Form CMS -855S, it shall be submitted to the NSC at the address indicated on the form; or  2) Alternatively, facilities may go to the CMS Web site, http://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/MedicareProviderSupEnroll/index.html  and download the Form CMS -855S.  The application may be completed and submitted to the NSC.
(Medicare Claims Processing Manual)
Pharmacies located in IHS providers must apply for and receive an NSC supplier number to bill for prescriptions.  50 - Reporting Requirements and Specifications  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  In order to facilitate report generation and data collection regarding IHS physicians, practitioners and services, the designated A/B MAC (B) shall assign PINs to each IHS physici an and practitioner in a manner that will allow the designated A/B MAC (B) to ascertain which facilities are IHS, Indian tribe or tribal organization. For example, the designated A/B MAC (B) may establish PINs that will allow the identification of each IHS facility, Indian tribe, and tribal organization facility. Providers request Unique Physician Identification Numbers (UPINs) from the registry.   PIN assignments will allow the identification of each IHS, Indian tribe, or tribal entity and the generation of the following reports from the PINs:   Names, locations and number of IHS entity enrollments;   Names, locations and number of Indian tribe or tribal entity enrollments;   Names, locations and number of individual practitioner enrollments;   Names and number of reassignments;   Receipt, pending and processing times for all applicants; and    Allowed charges and allowed frequencies, per quarter, by Current Procedural Terminology (CPT) code and modifier, for each provider.  NOTE: Beginning May 23, 2007, it is mandatory that the National Provider Identifier (NPI) be used in place of UPINs and PINs.   60 - Incentive Payments  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)
(Medicare Claims Processing Manual)
60 - Incentive Payments  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  In accordance with 1833(m) of the Act, IHS physicians who provide covered professional services in any rural or urban health professional shortage area (HPSA) are entitled to an incentive payment. IHS physicians providing services in either a rural or urban HPSA are eligible for a 10 percent incentive payment. It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although frequently this is the case. The key to the  incentive payment is where the service is actually provided (place of service).  For example, an IHS physician providing a service in his/her office, the patients home, or in a hospital qualifies for the incentive payment as long as the specific location  of the service is within an area designated as a HPSA. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 250.2, for information on billing and payment in a HPSA pertinent to A/B MAC (A) claims.   Section 413a of the MMA requires that a 5 perc ent bonus payment be established for physicians in a designated physician scarcity area (PSA).  Pub. 100 -04, Medicare Claims Processing Manual, Chapter 12, 90.4 and 90.5 contains more information on billing and payment in a PSA pertinent to A/B MAC (B) c laims. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 250.2.1, for information on billing and payment in a PSA pertinent to A/B MAC (A) claims.   A physician may be eligible for both the HPSA and PSA bonuses.  70 - Covered Medicare Part B Services That May Be Paid to IHS Providers, Physicians and Practitioners  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medicare Part B covers medically necessary expenses incurred for the following medical and other health s ervices:
(Medicare Claims Processing Manual)
Medicare Part B covers medically necessary expenses incurred for the following medical and other health s ervices:    Diagnostic x -ray tests, and other diagnostic tests;  Physician services;   Anesthesia services (anesthesiologist, certified registered nurse anesthetist);   Practitioner services (clinical nurse specialist, clinical psychologist, clinical social worke r, nurse mid -wife, nurse practitioner, physician assistant);   Drugs and biologicals incident to a physicians service;   X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;   Implantable prosthetic devices;   Drugs use d with infusion pumps;   Epoetin Alfa (EPO);   Clinical diagnostic laboratory tests;  Physical therapy, occupational therapy (OT), speech -language pathology and audiology services;   Ambulance services;   Medical Nutrition Therapy (MNT);   Diabetes self management tr aining (DSMT);   Telehealth; and   Hemophilia clotting factors for hemophilia patients competent to use these factors (without supervision).  80 - A/B MAC (B)  - Payment Policy and Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09 -11-06)  80.1 - A/B MAC (B)  - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, 432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.   The services that may be paid to IHS physicians and practitioners under the MPFS are as follows:
(Medicare Claims Processing Manual)
The services that may be paid to IHS physicians and practitioners under the MPFS are as follows:    Services for which payment is made under 1848 of the Act.  Section 1848(j)(3) defines physician services paid under the MPFS. Although anesthesia services are considered to be physician services, these services are not included on the physician fee schedule database. Anesthesia services are covered and are reimbursed using a separate payment method (see 1848(d)(1)(D)). Also, included are diagnostic tests (see 1861(s)(3)), covered drugs and biologicals furnished incident to a physician service (see 1861(s)(2)(A) and (b)) and DSMT services (see 1861(s)(2)(S)).    Services furnished by a physical therapist (which includes speech -language pathology services furnished by a provider of service) or occupational therapist as described in 1861(p) of the Act for which payment under Medicare Part B is made under the MPFS.   Services furnished by a registered dietitian or nutrition professional (meeting certain requirements) as defined in 105 of BIPA for MNT services for beneficiaries with diabetes or renal disease.    Screening mammography services are paid under the MPFS based on the BIPA provision when rendered in a physicians off ice.   Drugs provided by a physician in the office setting are paid using the ASP from the Medicare Part B Drug Pricing File supplied to all A/B MACs (A) and (B) by CMS.    Audiologists can directly bill Medicare but only for diagnostic tests.   Payment for telehealth services under Medicare Part B are covered as described in Pub. 100- 04, Medicare Claims Processing Manual, Chapter12, 190.   Services furnished by a practitioner described in 1842(b)(18)(C) of the Act for which payment under Medicare Part B is made under the MPFS. The specific non -physician practitioners included and the appropriate payment percentage of the fee schedule amount are described in the following table:
(Medicare Claims Processing Manual)
Practitioner Services  Percentage of Physician Payment  Certified Registered Nurse Anesthetist (medically directed)  50 percent  Certified Registered Nurse Anesthetist (non-medically directed)  100 percent  Clinical Nurse Specialist  85 percent  Clinical Psychologist  100 percent  Clinical Social Worker  75 percent  Nurse Mid -Wife  65 percent  Nurse Practitioner  85 percent  Nutrition Professional/ Registered Dietitian  85 percent  Occupational Therapist  100 percent  Physical Therapist  100 percent  Physician Assistant  85 percent   See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 12, for information on billing by physicians and practitioners.   Subject to national coverage determinations and local coverage determinations (LCDs), pay for services included in the MPFS database that have the following status indicators:    A = active   C = A/B MAC (B) -priced code   R = restricted coverage (if no relative value units (RVUs) are shown, service is A/B MAC (B) priced)   E = excluded from physician fee schedule by regulation   For mor e information on status indicators, see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 23, 30.2.2.   80.2 - A/B MAC (B)  - Claims Processing Requirements  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  1. Claims will be submitted by IHS physicians and practitioners using either the ASC X12 837 professional format or Form CMS-1500.  2. The designated A/B MAC (B) shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non- physician practitioners.   3. The designated A/B MAC (B) shall place the demonstration code 40 on all IHS physician and practitioner claims.   4. The effective date (date service was provided) for covered services to be paid is on or after July 1, 2001.  Timely claims filing requirements are not waived. Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, 70 contains more information on timely claims filing requirements.
(Medicare Claims Processing Manual)
5. The designated A/B MAC (B) shall process IHS physician and practi tioner claims using their LCD.  Refer to Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.5.1.1 for more information on LCDs.  The A/B MAC (B) has three options:   Develop LCDs specifically for IHS physician and practitioner claims;   Use existing LCDs for the State in which the A/B MAC (B) resides; or   Use existing LCDs for any State for which they process claims.   The designated A/B MAC (B) shall specify which LCD they will use for processing IHS physician and practitioner claims.   6. Payment is to be made based on the Medicare locality in which the services are furnished in accordance with current jurisdictional pricing guidelines.  7. The designated  A/B MAC (B) shall use the Medicare Part B Drug -Pricing File accessed at  http://www.cms.gov/site -search/search -results.html?q=drug%20pricing%20files .  However, if a drug or biological is not currently listed in the drug- pricing file, the designated  A/B MAC (B)  shall price the drug or biological utilizing current Medicare drug payment policy. (See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 17, 20.)  8.  The designated A/B MAC (B) shall train IHS physician and practitioner staff to complete correctl y Form CMS -1500 and the electronic formats.   The designated  A/B MAC (B)  shall return as unprocessable any claim with missing or incomplete information in accordance with Chapter 1, Section 80.3.2, Handling Incomplete and Invalid Claims.   9.  The IHS physicians and practitioners shall submit claims as if they were a group practice.    All IHS physicians and practitioners must apply for a group billing number via the normal processes. The designated A/B MAC (B) shall educate IHS physicians and practitione rs on these processes.
(Medicare Claims Processing Manual)
 All IHS physicians and practitioners must apply for a group billing number via the normal processes. The designated A/B MAC (B) shall educate IHS physicians and practitione rs on these processes.    All IHS physicians and practitioners who do not currently have Medicare billing numbers with the IHS, tribe, and tribal organization with the designated A/B MAC (B) shall apply for them via the normal processes described in 40.1 Provider Enrollment with A/B MAC (B) in this chapter.  The designated A/B MAC (B) shall educate IHS physicians and practitioners on these processes.  It is the IHS, tribes, and tribal organizations responsibility to notify their physicians and other practit ioners of the need for enumeration.  The IHS physicians and other practitioners must contact the designated A/B MAC (B) to initiate the enrollment process.   10. The designated A/B MAC (B) shall identify all IHS physicians and practitioners by their PINs. P INs shall be assigned in a manner that will allow the designated A/B MAC (B) to identify which facilities are IHS, tribes, or tribal organizations. All IHS physicians and practitioners will be assigned a UPIN in accordance with current practices. See 50 Reporting Requirements for more information about PINs and UPINs.   11. The designated A/B MAC (B) shall use all current edits (including current duplicate logic and Correct Coding Initiative edits) on claims from IHS physicians and practitioners. Medical re view will be done in accordance with current procedures.   The IHS physicians and practitioners need not submit line items for non- covered services. If non- covered services are billed, then the designated A/B MAC (B) shall process the line items for non- covered services and show on the remittance advice (RA) that Medicare did not cover the services.   12. The claim will post to history, update the deductible information, and update utilization. The deductible and coinsurance will apply. IHS physicians and pra ctitioners shall not collect the deductible or coinsurance from the beneficiary.