evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If the Beneficiary submits a claim on the English or Spanish Form CMS-1490S (version 01/05) on or after April 1, 2019, manually return the Form CMS-1490S (version 01/05) claim to the beneficiary, and include a copy of the Form CMS-1490S (version 01/18), along with a letter instructing the beneficiary to complete and return the Form CMS-1490S (version 01/18) for processing within the time period prescribed in 70.5.    If a beneficiary submits a claim on the Form CMS -1500, manually return the Form CMS -1500 claim to the beneficiary, and include a copy of the Form CMS-1490S, along with a letter instructing the beneficiary to complete and return the Form CMS -1490S for processing within the time period prescribed in 70. 5, above.  Include in the letter a description of missing, invalid or incomplete items required for the Form CMS -1490S that were not included with the submitted Form CMS -1500 or were invalid.  4) Retain Medicare claims records using the following disposition rules.  DISPOSITION:   1. Carriers who Microform Claims   a)  Hardcopy Records - Cut off no later than the close of the calendar year (CY) in which paid. The hardcopy claim must be retained in accordance with the following:   (1)  If a corresponding master microfilm has been made and verified, transfer to a Federally -approved records storage facility or hold onsite. Destroy after a total retention of 3 years after the close of the CY in which paid.  (2)  If a corresponding master microform record has NOT been made and verified, transfer to a Federally -approved records storage facility or hold onsite. Destroy after a total retention of 6 years and 3 months after the close of the CY in which paid.  b)  Microform Records   The master microform record must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which paid.  2. Carriers Who Do Not Microfilm Claims Records
(Medicare Claims Processing Manual)
b)  Microform Records   The master microform record must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which paid.  2. Carriers Who Do Not Microfilm Claims Records   Cut off at the close of the calendar year (CY) in which paid, then transfer to a Federally -approved records storage facility. Destroy after a total retention of 6 years and 3 months. Earlier cutoff and transfer is authorized. However, the records must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which payment is made.   a)  Hardcopy Records - The hardcopy must be retained onsite until the microform has been verified. Cut off at the close of the calendar year in which paid; transfer hardcopy to a Federally -approved records storage facility only if there is a corresponding master microfilm record that can be retained for the period indicated in b. below; otherwise, the hardcopy shall be retained until the 6 years and 3 months period is reached. Earlier cutoff and transfer is authorized.  However, the hardcopy must be retained for a total retention of 3 years after the close of the calendar year in which paid.  b)  Microform Records - The master microform records must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which payment is made.  When returning a beneficiary submitted claim, the contractor shall inform the beneficiary that the provider or supplier is required by law to submit a claim on behalf of the beneficiary (for services that would otherwise be payable), and that in order to s ubmit the claim, the provider must enroll in the Medicare program.  In addition, contractors shall encourage beneficiaries to always seek non -emergency care from a provider or supplier that is enrolled in the Medicare program.  If a beneficiary receives services from a provider or supplier that refuses to submit a claim to the A/B MAC or carrier, on the beneficiarys behalf, (for services that would otherwise be payable by Medicare), and/or refuses to enroll in the Medicare progr am, the beneficiary should:  (1) Notify the contractor in writing that the provider or supplier refused to submit a claim to Medicare and/or refused to enroll in Medicare, and
(Medicare Claims Processing Manual)
(2) Submit a complete Form CMS -1490S with all supporting documentation.  The contractor shall process and pay the beneficiarys claim if it is for a service that would be payable by Medicare were it not for the provider or suppliers refusal or inability to submit the claim and/or enroll in Medicare.  Claims shall be adjudicate d based on whether the service provided is covered or non-covered/excluded rather than on the providers enrollment status. If f or a covered service, the claim shall be processed and the allowed amount reimbursed to the beneficiary, if appropriate. If for a non -covered/excluded service, the claim shall be processed and denied with an appropriate MSN message.  For sanctioned/excluded and opt-out providers the following MSN messaging is recommended:   Sanctioned/Excluded provider:  A sanctioned or excluded provider is an individual or business excluded from participation in the Medicare program for a stated period of time as a result of fraudulent activity, program abuse, or impermissible conduct as determined by OIG.  CMS will pay the first claim submitted by a beneficiary for the services of a sanctioned/excluded physician or practitioner and immediately notify the sanctioned/excluded physician or practitioner of the exclusion.   CMS will not pay a claim for sanctioned/excluded physician or practitioner services more than 15 days after the date on the notice to the physician or practitioner, or after the effective date of the exclusion, whichever is later.  Under no circumstance may Medicare payment be made to any entity, including beneficiaries, for services rendered by such providers after the first claim is paid.  An example of language that may be considered:  MSN Message 21.27  English Services provided by a Medicare sanctioned/excluded provider.  No Medicare payment may be made.   Spanish Los servicios fueron brindado por un proveedor excludo de Medicare, por lo tanto Medicare no pag por los servicios.  Opt-Out physicians and practitioners:
(Medicare Claims Processing Manual)
Spanish Los servicios fueron brindado por un proveedor excludo de Medicare, por lo tanto Medicare no pag por los servicios.  Opt-Out physicians and practitioners:  Medicare payment may be made for the claims submitted by a beneficiary for the services of an opt out physician or practitioner when the physician or practitioner did not privately contract with the beneficiary for services that were not emergency care services or urgent care services and that were furnished no later than 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare (see 42 C.F.R. 405.435(c)).  Therefore, if the beneficiary submits a claim for a service that was furnished by an opt out physician or practitioner, then the carrier must contact the opt out physician or practitioner in order to ascertain whether the beneficiary entered into a private contract with the opt out physician or practitioner. (Note: The carrier should obtain a copy of the private contract from the opt out physician/practitioner before denying the beneficiarys claim if the beneficiary did, in fact, enter into a private contract with the physician or practitioner.) If the beneficiary did not enter into a private contract with the physician or practitioner and the beneficiary did not receive notice from the carrier that the physician opted out of Medicare, then Medicare payment may be made to the beneficiary for the non -emer gency and/or non-urgent care services (assuming that the services would otherwise be payable).  On the other hand, if the beneficiary did enter into a private contract with the physician or practitioner for the services or received services from the physician/practitioner 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare, then no Medicare payment may be made. Medicare has instructed opt out physicians and practitioners that private contract language must include beneficiary instruction precluding the beneficiary from billing Medicare for these services.  An example of language that may be considered:  MSN Message 21.26  English Claim denied because services were provided by an Opt-Out physician or practitioner. No Medicare payment may be made.
(Medicare Claims Processing Manual)
Spanish La reclamacin fue denegada porque los servicios fueron brindados por un mdico  proveedor que decidi no participar en Medicare, por lo tanto, Medicare no pag por los servicios.   Contractors shall maintain documentation of beneficiary complaints involving violations of the mandatory claims submission policy and a list of the top 50 violators, by State, of the mandatory claim submission policy.  Contractors are encouraged to educate providers and suppliers that they must be enrolled in the Medicare program before they submit claims for services furnished or supplied to any Medicare beneficiary.   The above policy, including the NPI requirement, is not applicable for foreign beneficiary claims submitted for covered services.  These claims should be processed using guidelines for foreign claims.  The above policy, including the NPI requirement, is not applicable to beneficiary claims submitted to DMEMACs for durable medical equipment, prosthetics, orthotics, and supplies.  These claims should be processed by DMEMACs using current procedures.  C. Exception When Physician, Other Practitioner, or Supplier Is Excluded From Participating in Medicare Program
(Medicare Claims Processing Manual)
Section 1848(g)(4) of the Social Security Act requires physicians, other practitioners, or suppliers to submit claims to Medicare carriers for services furnished after September 1, 1990.  This does not  apply to physicians, other practitioners, or suppliers who have been excluded from participating in the Medicare program.  Physicians, other practitioners, and suppliers who have been excluded from the Medicare program are prohibited from submitting claims or causing claims to be submitted.  See the Medicare Program Integrity Manual for procedures concerning claims submitted by an excluded practitioner, his/her employer, or a beneficiary for services or items provided by an excluded physician, other practitioner, or supplier.  Carriers must maintain the systems capability to identify claims submitted by excluded physicians, other practitioners, or suppliers as well as items or services provided, ordered, prescribed, or referred by an excluded party.  When an excluded physician, other practitioner, or supplier has not submitted a claim on behalf of the beneficiary and/or the beneficiary has submitted the claim themselves, do not  send a notification letter to the physician, other practitioner, or supplier warning of civil monetary penalties due to noncompliance with 1848(g)(4)(A) of the Act.  Instead, follow the instructions in the Program Integrity Manual.  70.8.8.7  Notification Letters  (Rev. 1588; Issued:  09-05- 08; Effective/Implementation Date:  08 -18-08)  A. The letter sent to the beneficiary should explain why the claim is being returned including an explanation of the corrections needed in order to process the claim.  Also, include an explanation of the statutory requirement that providers and suppliers must  submit claims for all covered services provided to Medicare beneficiaries.  The letter should also provide the beneficiary with instructions on what should be done if the provider or supplier refuses to enroll with Medicare and/or submit the claim.
(Medicare Claims Processing Manual)
B. A letter shall also be sent to the provider or supplier explaining the statutory requirement for submitting claims for all services rendered to Medicare beneficiaries.  The letter should explain to the provider or supplier that they are required to enroll with the Medicare program before a claim can be submitted.  Finally the letter should include language explaining the penalties for failure to comply with the mandatory claims submission requirements.  70.8.8.8 - Violations That Are Not Developed For Referral  (Rev. 420, Issued:  12- 30-04, Effective:  01/31/05, Implementation:  01/31/05)   Claim submission violations need not be developed on beneficiary- submitted Form CMS -1490S claims that include approved charges for services performed on or after September 1, 1990 in the following situations:   o Used DME purchases from private sources;   o Cases in which a physician/supplier does not possess information essential for filing a MSP claim.  Assume this is the case if the beneficiary files a MSP claim and encloses the primary insurer's payment determination notice and there is no indication that the service provider was asked to file but refused to do so;   o Services paid under the indirect payment procedure;  o Foreign claims; and  o Other unusual or unique situations that you evaluate on a case -by-case basis.
(Medicare Claims Processing Manual)
NOTE:   It is unlikely that knowing, willful, and repeated noncompliance will apply in the above situations.  80 - Carrier and FI Claims Processing Timeliness  (Rev. 1, 10- 01-03) A3-3600, A3- 3600.1, B3 -13306, HO -401, HO -401A, HH -462, B2- 5240.11 Carriers and FIs must establish control records for timely claims processing as described below. 80.1 - Control and Counting Claims  (Rev. 1, 10- 01-03) The carrier or FI will consider claims as received for timely processing purposes from the date of their receipt.  Improperly completed claims that it returns are considered received for timely processing purposes when received again, properly completed.  A.  Provider Billing Via Terminal or Equivalent  If the provider bills via remote terminal with on -site (in the provider) editing or if the carrier or FI otherwise can communicate edit results to it electronically, the carrier or FI establishes a control record when the bill passes its consistency edits. B.  Manual Hardcopy Claim/Bills and Electronic Claim/Bills  The carrier or FI establishes a control record when it enters the initial claim into its system.  The claim is counted for administering timely billing and payment only if it passes carrier or FI edits to the extent a pending record can be established.  The date received is the date the carrier or FI received the claim properly completed, passing all carrier or FI edits, even if entered into its system on a later date.  C.  Bills Returned to Provider If the carrier or FI returns the bill and retains a claim record to minimize data entry cost when returned, the receipt date is corrected when the bill is properly completed and passes carrier or FI edits.  D.  Bills Requiring Medical Information  When a carrier or FI requests medical documentation, it retains the bill as a pending record until it either pays, denies, or rejects (in the case of FIs) it.  Returning cases for review by the PRO is not a request for medical documentation.  Claims that f ail initial carrier or FI edits because required medical reports or other required attachments are not included are also not requests for medical documentation. E.  Adjustment and Cancel Bills  An adjustment request bill is a correction to a claim previously processed.  The carrier or FI establishes a control record for it.  The carrier or FI counts adjustments as received and pending only when they pass carrier or FI edits.  The carrier
(Medicare Claims Processing Manual)
Adjustment and Cancel Bills  An adjustment request bill is a correction to a claim previously processed.  The carrier or FI establishes a control record for it.  The carrier or FI counts adjustments as received and pending only when they pass carrier or FI edits.  The carrier or FI assigns the date received in its mailroom as the receipt date for hospital and MSP adjustment requests. The carrier or FI counts adjustment bills as processed when no further action by it is required.  The final action taken on the adjustment request bill depends upon the situation.  80.2 - Definition of Clean Claim  (Rev. 1, 10- 01-03) HO- 401.D, A3- 3600.1, B2- 5240.11.A  A clean claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis.  Clean claims must be filed in the timely filing period.  The following bullets are some examples of what are considered clean claims :  Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);  Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).   Claims not approved for payment by CWF within 7 days of the FIs original claim submittal for reasons beyond the carriers, FIs or providers control (e.g., CWF system/communication difficulties);  CWF out -of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;   Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carriers or FIs instructions;   Are developed on a postpayment basis; and,   Have all basic information necessary to adjudicate the claim, and all required supporting documentation 80.2.1 - Receipt Date  (Rev. 273, Issued 08- 13-04, Effective: 07 -01-04, Implementation: 07- 06-04) A3-3600.1- Item 7  The receipt date of a claim is the date
(Medicare Claims Processing Manual)
- Receipt Date  (Rev. 273, Issued 08- 13-04, Effective: 07 -01-04, Implementation: 07- 06-04) A3-3600.1- Item 7  The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim).  The receipt date is used to: determine if the claim was timely filed (see 70.3), determine the payment floor for the claim (see 80.2.1.2), determine the payment ceiling on the claim (see 80.2.1.1) and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.  A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date.  A paper claim that is received after 5:00 p.m., or after the contractors routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.  A paper claim is considered as received if it is delivered to the contractors place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractors place of business by its routine close of business time.  If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box sit e. As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.  Electronic claims transmitted directly to
(Medicare Claims Processing Manual)
providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.  Electronic claims transmitted directly to a contractor, or to a clearinghouse with which the contractor contracts as its representative for the receipt of its claims, by 5:00 p.m. in the contractors time zone, or by its closing time if it routinely closes  between 4:00 p.m. and 5:00 p.m., must likewise be considered as received on that day even if the contractor does not upload or process the data until a later date.  NOTE:  The differentiation between HIPAA -compliant and HIPAA -non-compliant electronic claim s that is specified in 80.2.1.2 with respect to applying the payment floor, does not apply to establishing date of receipt.  Use the methodology described above to establish the date of receipt for all electronic claims.  Paper and electronic claims that do not meet the basic legibility, format, or completion requirements are not considered as received for claims processing and may be rejected from the claims processing system.  Rejected claims are not considered as received until resubmitted as corrected, complete claims.  The contractor may not use the data entry date, the date of passage of front -end edits, the date the document control number is assigned, or any date other than the actual calendar date of receipt as desc ribed above to establish the official receipt date of a claim.  The following permissive exception applies to establishment of receipt date:  Where its system or hours of operation permit, a contractor may, at its option, classify a paper or electronic claim received between its closing time and midnight, or on a Satur day, Sunday, holiday, or during an emergency closing period as received on the actual calendar date of delivery or receipt.  Unless a contractor closes its place of business early in an isolated situation due to an emergency, the contractors cutoff time f or establishing the receipt date may never be earlier than 4:00 p.m. A contractor may not make system changes, extend its hours of operation, or incur significant additional costs solely to begin to accommodate late receipt of claims if not already equipped to do so. The cutoff time for paper claims may not exceed the cutoff time for electronic claims. However, the cutoff time for electronic claims may exceed the cutoff