evekhm/cms_iom_500 huggingface dataset:
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Background of the Subject   The subjects business name, address, Medicare Identification Number, owners full name and Social Security Number, Tax Identification Number (if different), and a brief description of the subjects special field of medical equipment, supplies, or services.   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.   Written Correspondence and Written Summaries  Copies of any meetings or telephone contacts with the beneficiary and the supplier regarding the suppliers failure to make a refund.  List 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 non-refunded 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.  Additional Information  Any information that may be of value to the RO.   50.17  ABN Special Considerations  (Rev. 10862; Issued: 07- 14-21; Effective: 10 -14-21; Implementation: 10 -14-21)  A.  Obligation to Bill  Medicare   Upon receipt of an ABN, beneficiaries always have the right to ask the notifer to submit a claim to Medicare for an official payment decision.  A beneficiary must receive the item/service described in the ABN and choose Option 1 in order to request Medicar e claim submission.   Healthcare providers or suppliers should refer to Publication 100- 4, Chapter 1, Section 60 for instructions on submitting claims for statutorily non- covered items or services.   Note : Healthcare providers or suppliers will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiarys request by their choice of Option 2 on the ABN.  B.  Dually Eligible Individuals (Has a Qualified Medicare Beneficiary (QMB) Program and/or  Medicaid coverage)
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B.  Dually Eligible Individuals (Has a Qualified Medicare Beneficiary (QMB) Program and/or  Medicaid coverage)   Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.  The provider must strike through Option Box 1 as provided below:    OPTION 1. I want the  (D)  listed above.  You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesnt pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.   These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting cove rage and billing of dual eligible beneficiaries. If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination.   Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:    If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
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 If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.    If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary  liability.  Note: These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances. More information on dual eligible beneficiaries may be found at: https://www.cms.gov/Outreach -and-Education/Medicare- Learning- Network - MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glan ce.pdf   C.  Ambulance  Transports   Emergency or urgent situations  In general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress.  Forcing delivery of an ABN during an emergency may be considered coercive.  ABN usage in the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.  Non -emergent/urgent ambulance transport  If the provider or supplier wants to transfer liability to the beneficiary, issuance of the ABN is mandatory for ambulance transport services if all of the following 3 criteria are met::   1. The service being provided is a Medicare covered ambulance benefit  under 1861(s)(7) of the SSA and regulations under this section as stipulated in 42 CFR  410.40 -.41;  2. The healthcare provider or supplier believes that the service may be denied, in part or in full, as not reasonable and necessary under  1862(a)(1)(A) for the beneficiary on that particular occasion;  and  3. The ambulance service is being provided in a non -emergency situation.  (The patient is not under  duress.)
(Medicare Claims Processing Manual)
3. The ambulance service is being provided in a non -emergency situation.  (The patient is not under  duress.)   ABN issuance is mandatory only when a beneficiarys covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs.  If an ambulance transport is statutorily excluded from coverage because it fails to meet Medicares definition of the ambulance benefit, a voluntary ABN may be issued to notify the beneficiary of his/her financial liability as a courtesy.   D. Hospice   Mandatory use of the ABN is very limited for hospices.  Hospice providers are responsible for providing the ABN when required as listed below for items and services billable to hospice.  Hospices are not responsible for issuing an ABN when a hospice patien t seeks care outside of the hospices jurisdiction.  The three situations that would require issuance of the ABN by a hospice are:    Ineligibility because the beneficiary is not determined to be terminally ill as defined in 1879(g)(2) of the  Act; or   Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in  either 1862(a)(1)(A) or 1862(a)(1)(C); or    The level of hospice care is determined to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C), specifically for the management of the terminal illness and/or related  conditions.  Note:   It is the hospices responsibility to issue an ABN when a beneficiary who has elected the hospice benefit chooses to receive inpatient hospice care in a hospital that is not under contract with the hospice.  The hospice may delegate delivery of the ABN t o the hospital in these cases.   End of all Medicare covered hospice care
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End of all Medicare covered hospice care    When it is determined that a beneficiary who has been receiving hospice care is no longer terminally ill and the beneficiary is going to be discharged from hospice, the hospice may be required to issue the Notice of Medicare Non- coverage (NOMNC), CMS 10123.  If upon discharge the patient wants to continue rec eiving hospice care that will not be covered by Medicare, the hospice would issue an ABN to the beneficiary in order to transfer liability for the non -covered care to the beneficiary.  If no further hospice services are provided after discharge, ABN issuan ce would not be required.  ABNs are not required for Hospice Services in these situations:    Revocations -  Hospice beneficiaries or their representatives can revoke the hospice benefit.  Revocations are not considered terminations under liability notice policy since the beneficiary is exercising his/her own freedom of choice.  Therefore, no ABN is required.    Respite Care Beyond Five Consecutive Days -  Respite care is limited to five consecutive days under the Act.  When respite care exceeds five consecutive days, an ABN is not required since additional days of respite care are not part of the hospice benefit.  CMS encourages hospice providers to give the ABN as an optional notice to inform patients of financial liability when more than five days of respite care will be provided.   Transfers -  Beneficiaries are allowed one transfer to another hospice during a benefit period.  However, subsequent transfers within the same benefit period are not permitted.  In either case, an ABN is not required.    Failure to Meet the Face to Face Requirement -  The ABN must not be issued when the face to face requirement for hospice recertification is not met within the required timeframe.  Failure to meet the face to face requirement for recertification should not be misrepresented as a determination that the beneficiary is no longer terminally ill.    Room and Board Costs for Nursing Facility Residents -  Since room and board are not part of the hospice benefit, an ABN would not be required when the patient elects hospice and continues to pay out of pocket for long term care room and board.   E.  Comprehensive Outpatient Rehabilitation Facility (CORF)
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E.  Comprehensive Outpatient Rehabilitation Facility (CORF)   Since Comprehensive Outpatient Rehabilitation Facility (CORF) services are billed under Part B, CORF providers must issue the ABN according to the instructions given in this section.  The ABN is issued by CORFs before providing a service that is usually covered by Medicare but may not be paid for in a specific case because it is not medically reasonable and necessary.   When all Medicare covered CORF services are going to end, CORFs are required to issue a  notice regarding the beneficiarys right to an expedited determination called a NOMNC, CMS 10123.  Upon termination of all CORF care, the ABN would be issued only if the beneficiary wants to continue receiving some or all services that will not be covered by Medicare because they are no longer considered medically reasonable and necessary.  An ABN would not be issued if no further CORF services are provi ded.  F. Home Health Agency (HHA)   The following chart summarizes the statutory provisions related to ABN issuance for LOL purposes:   Application of LOL for the Home Health Benefit  Citation from the Act Brief Description of  Recommended Explanation          1862(a)(1)(A) Care is not reasonable and necessary  Medicare does not pay for care that is not medically reasonable and  1862(a)(9)  Custodial care is the only care delivered  Medicare does not usually pay for custodial care,      1879(g)(1)(A) Beneficiary is not homebound Medicare requires that a beneficiary cannot leave home (with certain exceptions) in order to cover services      1879(g)(1)(B) Beneficiary does not need skilled nursing care on an intermittent basis  Medicare requires part-time or intermittent need for skilled nursing care in order to cover        Triggering Events for ABN issuance by HHAs*   HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs.
(Medicare Claims Processing Manual)
Triggering Events for ABN issuance by HHAs*   HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs.   EVENT  DESCRIPTION  EXAMPLE  Initiation  An ABN must be issued to the beneficiary prior to receiving care that is usually covered by A beneficiary requires skilled nursing Medicare, but in this particular instance, it is not covered or may not be covered by Medicare because the care is not medically reasonable and  necessary, the beneficiary is not confined to his/her home (considered  homebound), or the beneficiary does not need skilled nursing care on an intermittent basis,  or the beneficiary is receiving custodial care  only.  wound care 3 times weekly; however, she is not confined to the home.  She wants the care done at her home by the HHA.   Reduction  Reductions involve any decrease in services or supplies, such as frequency, amount, or level of care, provided by the HHA and/or care that is part of the POC.  If a reduction occurs for an item or service that will no longer be covered by Medicare but the beneficiary wants to continue to receive the care and assume the financial charges, the HHA must issue the ABN prior to providing the non- covered items or servi ces. The beneficiary requires physical therapy (PT) for gait retraining 5 times per week for 2 weeks, then reduce to 3 times weekly for 2 weeks.  After 2 weeks of PT, the beneficiary wants to continue therapy 5 times a week even though this amount of therapy is  no longer medically reasonable and necessary.  The HHA would issue an ABN to the beneficiary so that he understands the situation and can consent to financial responsibility for the PT not covered by Medicare.  Termination  When an HHA expects that Medicare coverage will end for all items and services in total.   *If the beneficiary does not want the item or service that is being initiated, reduced, or terminated, no ABN is  required.  When an HHA performs an initial assessment of a beneficiary prior to admission but does not admit the beneficiary, an ABN is not required if there is no charge for the assessment.  However, if an HHA charges for an assessment, the HHA must provide notice to the beneficiary before perform ing and charging for this service.
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Since Medicare has specific requirements for payment of home health services, there may be occasions where a payment requirement is not met, and therefore, the HHA expects that Medicare will not pay for the services.  The HHA cannot use the ABN to transfer  liability to the beneficiary when there is concern that a billing requirement may not be met.  For example, a home health agency cant issue an ABN at initiation of home care services in order to charge the beneficiary if the healthcare provider face to f ace encounter requirement is not met. When all Medicare covered home health care is terminated, HHAs may sometimes be required to deliver the NOMNC, CMS - 10123.  The NOMNC informs beneficiaries of the right to an expedited determination by a Quality Improvement Organization (QIO) if they feel that termination of home health services is not appropriate.  If a beneficiary requests a QIO review upon receiving a NOMNC, the QIO will make a fast decision on whether covered services should end.  If the QIO decides that Medicare covered care should end and the patient wishes to continue receiving care from the HHA even though Medicare will not pay, an ABN must be issued to the beneficiary since this would be an initiation of non- covered care.   HHA Exceptions to ABN Notification  Requirements   ABN issuance is NOT required in the following HHA situations:    initial assessments (in cases where beneficiaries are not admitted) for which HHAs do not charge;    care that is never covered by Medicare under any circumstances (i.e., an HHA offers complimentary hearing aid cleaning and maintenance);    telehealth monitoring used as an adjunct to regular covered HH care;  or    non-covered items/services that are part of care covered in total under a Medicare bundled payment (e.g., HH prospective payment system (PPS) episode  payment).   60 - Home Health Change of Care Notice (HHCCN), Form CMS -10280 (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)
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This section provides the standards for use by home health agencies (HHAs) in implementing the Home Health Change of Care Notice (HHCCN), Form CMS -10280, requirements.  The HHCCN is issued to Original Medicare beneficiaries before reducing or terminating most ongoing care provided by the HHA.   HHCCN Quick Glance Guide  This is an abbreviated reference tool and is not meant to replace or supersede any of the directives contained in Section 60.  Notice Name  Home Health Change of Care Notice (HHCCN)  Notice Number  Form CMS -10280  Issued by  Home Health Agency (HHA) provider  Recipient  Original Medicare (fee for service) beneficiary receiving home health care  Pertinent Information  The HHCN replaces HHABN Option Box 2 and Option Box 3.  The Advance Beneficiary Notice of Noncoverage (ABN), CMS -R-131, replaces HHABN Option Box 1.  See section 50 for ABN information and instructions.  Change of care notice   Prior to the HHA reducing or discontinuing care listed in the beneficiarys plan of care (POC) for administrative reasons specific to the HHA on that occasion  Immediately on determination,   or if possible, provide enough time for the beneficiary to arrange to obtain the reduced or discontinued home health care service(s) from a different HHA.  No.  Prior to the HHA reducing or discontinuing Medicare covered care listed in the POC because of a physician ordered change in the plan of care or a lack of orders to continue the care  Notify the beneficiary before the actual reduction or discontinuation, if possible.  No.
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The HHCCN replaces the Home Health Advance Beneficiary Notice (HHABN), CMS -R-296, Option Box 2 and Option Box 3. Option Box 1 of the HHABN is replaced by the existing  Advance Beneficiary Notice of Noncoverage (ABN),CMS -R-131, which is detailed in Section 50 of this chapter.  HHAs should begin using the ABN and HHCCN in place of the HHABN as soon as possible since the HHABN will be discontinued.  The date for mandatory use of the HHCCN and ABN in place of the HHABN will be posted on the web link for home he alth notices at http://www.cms.gov/Medicare/Medicare -General -Information/BNI/index.html .   Table 1 HHA Notice Changes  Instead of:  Use:  HHABN Option Box 1  ABN (CMS -R-131) HHABN Option Box 2  HHCCN  HHABN Option Box 3  HHCCN   60.1 - Background on the HHCCN (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  HHAs have issued HHABNs related to the absence or cessation of Medicare coverage when a beneficiary had liability protection under 1879 of the Social Security Act (the Act) since 2002.  The HHABN gained additional notification capabilities in 2006 followi ng the U.S. Court of Appeals (2nd Circuit) decision in Lutwin v. Thompson, 361 F.3d 146; 2004 U.S. App. LEXIS 3774.   Following Lutwin , the HHABN was modified so that it could also be used by HHAs to notify beneficiaries receiving home health services of any care changes in accordance with the HHA conditions of participation (COPs) in 1891 of the Act.
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To account for this expanded use, the HHABN was revised to contain three interchangeable Option Boxes within the body of the notice designated as Option Box 1, Option Box 2, and Option Box 3.  Option Box 1 language was applicable to situations involving potential beneficiary liability for HHA services as directed by 1879 of the Act.  Option Box 2 or Option Box 3 was inserted into the HHABN form to notify beneficiaries of changes in a home health plan of care that are subject to the requirements of  1891 of the Act.   In order to streamline, reduce, and simplify notices issued to Medicare beneficiaries, the HHABN is being discontinued.  HHABN, Option Box 1, which is the liability portion of the notice, is replaced by the existing Advance Beneficiary Notice of Noncoverage (ABN), CMS -R-131.  The change of care notification portions of the HHABN, Option Box 2 and Option Box 3, is replaced by the newly approved HHCCN.  60.2 - Scope of the HHCCN  (Rev. 2781, Issued: 09- 06-13, Effective: 12 -09-13, Implementation: 12- 09-13)  A.  Statutory Authorization for HHCCN   The requirement to give an HHCCN is based on the HHA COPs in 1891 of the Act. The COPs are further implemented through Title 42 of the Code of Federal Regulations (CFR), Part 484.   1891(a)(1)(E) stipulates that beneficiaries have:   The right to be fully informed orally and in writing (in advance of coming under the care of the [home health] agency) of    all items and services furnished by (or under arrangement with) the agency for which payment may be made under this title,   the coverage available for such items and services under this title, title XIX or any other Federal program of which the agency is reasonably aware,   any charges for items and services not covered under this title and any charges the individual may have to pay with respect to items and services furnished by (or under arrangement with) the agency, and   any changes in the charges or items and services described in clause (i), (ii) or (iii).
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any changes in the charges or items and services described in clause (i), (ii) or (iii).   HHAs are required to use the HHCCN to notify the beneficiary of reductions and terminations in health care in accordance with Medicare COPs.   B.  HHAs and Other CMS Notices   HHAs will now use the Advanced Beneficiary Notice (ABN), Form CMS -R-131 for liability notification instead of the HHABN Option Box 1. The ABN and form instructions can be downloaded from the CMS website at: http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html   HHAs must continue to issue an expedited determination notice called the Notice of Medicare Provider Non -Coverage, (NOMNC), CMS -10123, if applicable, when all covered services are being terminated. Please see the FFS ED Notices link at:  http://www.cms.g ov/Medicare/Medicare- General -Information/BNI/FFSEDNotices.html for information on the delivery of expedited determination notices.  C.  HHCCN Issuers and Recipients   HHAs are the only type of Medicare provider that issues the HHCCN to notify the beneficiary of care changes involving reductions or terminations of items and/or services. The recipients of the HHCCN are beneficiaries enrolled in Original Medicare only. HHC CNs are not used in Medicare managed care.  When a beneficiary transitions to Medicare managed care from Original Medicare during a home health episode, HHCCN issuance is required only if there is a specific need to provide notification of changes in care as the transfer occurs.   Subcontractors may deliver HHCCNs under the direction of a primary HHA; however, notification responsibility, including effective delivery, always rests with the primary HHA. HHAs are always responsible for providing HHCCNs associated with the care that they provide. In the form instructions and instructions in this section, the term beneficiary is used to mean the beneficiary or the beneficiary's representative, as applicable.  For more inf ormation on representatives, see 40.3.5 and 40.3.4.3 of this chapter.