evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Below is a more expansive list of examples of categorical denials:   Statutory Provision   (section  of the Act) Description  1862(a)(12)  Dental care and dentures (in most cases).  1862(a)(13)  Routine foot care and flat foot care.  1862(a)(19)  Services under a physicians private contract.  1862(a)(3)  Services paid for by a governmental entity that is not Medicare.  1862(a)(4)  Health care received outside of the U. S. not covered by Medicare.  1862(a)(11)  Services by immediate relatives.  1862(a)(5)  Services required as a result of war.  1862(a)(2)  Services for which there is no legal obligation to pay.  1862(a)(21)  Home health services furnished under a plan of care, if the agency does not submit the claim.  1862(a)(16)  Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997.  1862(a)(17)  Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need).  1862(a)(14)  Physicians services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangement with the hospital.  1862(a)(18)  Items and services furnished to an individual who is a resident of a skilled nursing facility or of a part of a facility that includes a skilled nursing facility, unless they are furnished under arrangements by the skilled nursing facility.  1862(a)(15)  Services of an assistant at surgery without prior approval from the peer review organization.  1862(a)(20)  Outpatient occupational and physical therapy services furnished incident to a physicians services.  1862(a)(22)  Claims submitted other than in an electronic form specified by the Secretary, subject to the exceptions set forth in 1862(h) of the Act.  Statutory Provision
(Medicare Claims Processing Manual)
(section  of the Act) Description  1862(a)(23)  Claims for the technical component of advanced diagnostic imaging services described in 1834(e)(1)(B) of the Act for which payment is made under the fee schedule established under 1848(b) of the Act and that are furnished by a supplier (as defined in 1861(d) of the Act), if such supplier is not accredited by an accreditation organization designated by the Secretary under 1834(e)(2)(B) of the Act.  1862(a)(24)  Claims for renal dialysis services (as defined in 1881(b)(14)(B) of the Act) for which payment is made under such section unless such payment is made under such section to a provider of services or a renal dialysis facility for such services.    30 - Determining Liability for Disallowed Claims Under 1879  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  When a Medicare contractor determines that a review under the LOL provisions is appropriate under 20 of this chapter, the Medicare contractor must next determine who is liable, based on who knew, or should have known that Medicare was going to deny paymen t on the item or service.  In order to make this determination, the contractor must take the following steps:    NOTE:  If both the beneficiary and the healthcare provider or supplier are found to have knowledge, the beneficiary will be held liable.   Determine whether the beneficiary is liable.  Evidence must show that the beneficiary knew or should have known the item and/or service would not be covered.  Knowledge:  * Is established when the healthcare provider or supplier gives a valid ABN, Form CMS -R-131 or other written notice.  * May  be established when the beneficiary receives notice of a recent claim denial for the same item or service.
(Medicare Claims Processing Manual)
* The Medicare program shall not make a payment to the beneficiary.  * The beneficiary can appeal both the coverage issue, and the contractors determination of beneficiary liability for the cost of the non-covered item or service.  If the beneficiary is not found liable, then the Medicare contractor should determine if the healthcare provider or supplier is liable  Evidence must show that the healthcare provider/  supplier knew or should have known the item and/or service would not be covered.   * Had actual knowledge of the non- coverage of item and/or service in a particular case;  * Could reasonably have been expected to have such knowledge; or * The  beneficiary was shown not to have knowledge (found not liable).  * The Medicare program shall not make a payment to the healthcare provider or supplier.  * The healthcare provider or supplier can appeal both the coverage issue, and the contractors determination of healthcare provider or supplier liability for the cost of the non- covered item or service.  If the healthcare provider or supplier is not found liable, the Medicare program will accept liability.  30.1 - Beneficiarys Knowledge and  Liability                                        (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Beneficiary knowledge standards vary between the 1879 LOL provision and the two Refund Requirement (RR) provisions as shown in the table below.   Provision  Description  Beneficiary Knowledge  Limitation On Liability   1879(a)(2) of the Act requires that the beneficiary did not know, and could not reasonably have been expected to know, that payment would not be made* * *, for items or services that are excluded from coverage.    Knowledge based on written notice having been provided to the beneficiary.   Knowledge based on any other means from which it is determined that the beneficiary knew, or should have known, that payment would not be made.  Medical Equipment and Supplies RR
(Medicare Claims Processing Manual)
1834(a)(18)(A)(ii) of the Act [which is incorporated by reference into 1834(j)(4) and 1879(h) of the Act] requires that before the item was furnished, the patient was informed that payment under this part may not be made for that item and the patient has agreed to pay for that item, that is, for medical equipment and supplies denied on the basis of 1834(a)(17)(B), 1834(j)(1), 1834(a)(15), or 1862(a)(1) of the Act.   Knowledge must be evidenced by a signed written notice and agreement to pay personally in case of a denial.  Physician RR  1842(l)(1)(C)(ii) of the Act requires that before the service was provided, the individual was informed that payment under this part may not be made for the specific service and the individual has agreed to pay for that service, that is, for physician services that are denied because they were not reasonable and necessary under 1862(a)(1) of the Act.   Knowledge must be evidenced by a signed written notice and agreement to pay personally in case of a denial.   Knowledge is determined on a case by case basis.  In certain circumstances, being in receipt of a valid ABN or other written notice does not guarantee that the beneficiary had knowledge that an item or service would not be covered.  For instance, in a case  where a beneficiary received a valid ABN and then, upon initial determination, the claim was paid as covered, that original ABN cannot be used as evidence of knowledge for future claims relating to a similar or reasonably comparable item or service, since  the original ABN was belied by the favorable payment decision.   In reviewing a determination of liability on appeal, a beneficiarys allegation that s/he did not know, in the absence of evidence to the contrary, is acceptable evidence for LOL purposes.   30.1.1 - Other Evidence of Knowledge  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)
(Medicare Claims Processing Manual)
30.1.1 - Other Evidence of Knowledge  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  While 42 CFR 411.404 provides criteria for beneficiary knowledge based on written notice , 1879(a)(2)  of the Act specifies only that knowledge  must not exist in order to apply the LOL provision.  If it is clear and obvious that a beneficiary in fact did know, prior to receiving an item or service, that Medicare payment for that item or service would be denied, the administrative presumption favorable to the beneficiary is rebutted.  For example, if the beneficiary admits that s/he had prior knowledge that payment for an item or service would be denied, no further evidence is required.   In the case in which the Medicare contractor has such evidence of prior knowledge on the beneficiarys part, the beneficiary must be held liable under the LOL provision, even if no written notice was given by the appropriate source.   30.2 - Healthcare Provider or Supplier Knowledge and Liability        (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  In order to determine whether the healthcare provider or supplier had prior knowledge that the item and/or service furnished to the beneficiary would likely be denied or whether knowledge of the denial could have been expected, the Medicare contractors review the information they maintain and/or disseminate to a particular healthcare provider or supplier and the denials relevant facts.   If the healthcare provider or supplier cannot show that the beneficiary received proper written notice, the healthcare provider or supplier will be presumed to have knowledge (and, thereby, liability) unless s/he can prove that s/he did not know, and could not reasonably have been expected to know, that Medicare would not pay for the item and/or service.  If the healthcare provider or supplier can make such a convincing showing, the Medicare contractor will find that the healthcare provider or supplier did not have the requisite knowledge and Medicare will be liable for the payment.
(Medicare Claims Processing Manual)
30.2.1 - Evidence of Healthcare Provider or Supplier Knowledge  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  In accordance with regulations at 42 CFR 411.406, evidence that the healthcare provider or supplier did, in fact, know or should have known that Medicare would not pay for an item or service includes:    A Medicare contractors prior written notice to the healthcare provider or supplier of Medicare denial of payment for similar or reasonably comparable item or service.  This also includes notification of Quality Improvement Organization (QIO) screening criteria specific to the condition of the beneficiary for whom the furnished item and/or service are at issue and of medical procedures subject to preadmission review by the QIO.  Instructions for application of  the LOL provision to QIO determinations are in the QIO Manual;    Medicares general notices to the medical community of Medicare payment denial of item or service under all or certain circumstances (such notices include, but are not limited to, manual instructions, bulletins, and Medicare contractors written guidance );    Provision of the item and service being inconsistent with acceptable standards of  practice in the local medical community.    Written notification from the healthcare provider or suppliers utilization review committee informing the healthcare provider or supplier that the item and/or service was not covered;    The healthcare provider or supplier issuing a written notice of the likelihood of Medicare payment denial for an item and/or service to the beneficiary; or    The healthcare provider or supplier being previously notified by telephone and/or in writing that an item or service is not covered or that coverage has ended.   If any of the circumstances described above exists, a healthcare provider or supplier is held to have knowledge.   30.2.2 - Medical Record Evidence of Healthcare Provider or Supplier Knowledge  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  The healthcare provider or supplier is also accountable for information contained in the beneficiarys medical records, such as the beneficiarys medical chart, attending physicians notes, or similar records.  When the medical records clearly show that the beneficiary received only non- covered services as described in the Medicare Benefit Policy Manual, the healthcare provider or supplier will be presumed to have knowledge of non- coverage.
(Medicare Claims Processing Manual)
Examples:    A physician clearly indicated in the beneficiarys medical record that the patient no longer needed the services or the level of care provided;    The physician indicated the patient could be discharged;    The attending physician refused to certify or recertify the beneficiarys need for a particular level of care covered by Medicare because he/she determined that the patient does not require a covered level of care; or    The contractor requested additional medical evidence after a certain number of days to determine whether continued coverage is warranted.  However, the healthcare provider or supplier did not submit the evidence within the stipulated time.   30.2.3 - Acceptable Standards of Practice  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  When an item and/or service furnished do not meet locally acceptable standards of practice, the healthcare provider or supplier is considered to have known that Medicare payment would be denied.  Because healthcare provider and supplier licensure is premis ed on the assumption that they are knowledgeable about locally acceptable standards of practice, healthcare providers and suppliers are presumed to have knowledge about locally acceptable standards of practice for liability determinations.  No other eviden ce of knowledge of local medical standards of practice is necessary.    In order to determine what acceptable standards of practice exist within the local medical community, Medicare contractors will rely on the following:     published medical literature;1   a consensus of expert medical opinion;2 and   1 Published medical literature refers generally to scientific data or research studies that have been published in peer -reviewed medical journals or other specialty journals that are well recognized by the medical profession, such as the New England Jour nal of Medicine and the Journal of the American Medical Association. 2Consensus of expert medical opinion might include recommendations that are derived from technology assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or the American College of Physicians, or findings published by the Institute of Medicine.    consultations with their medical staff, medical associations, including local medical societies, and other health experts.
(Medicare Claims Processing Manual)
NOTE:   A healthcare provider or supplier may indicate on the claim (via Occurrence Code 32 or the applicable Healthcare Common Procedure Coding System code modifier (i.e. GA, GX, ext.) on contractor claims) that they gave the beneficiary a valid written notice before furnishing the item and/or service.  In that instance, the Medicare contractor will hold the beneficiary, not the healthcare provider or supplier liable for the denied charges.  If it is determined that the written notice was invalid, the contr actor will override the GA code, and the healthcare provider or supplier will be found liable.  30.3  The Right to Appeal  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  The beneficiary, healthcare provider, or supplier has the right to appeal both the issue of coverage for the claim and determination of liability.  For purposes of determining the amount in controversy for an appeal of the coverage determination, payment m ade under 1879 of the Act should be disregarded.  For more information see Chapter 29 of this manual, Appeals of Claims Decisions. 30.4 - Fraud, Abuse, Patently Unnecessary Items and Services  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Generally, the protection under the FLP provisions cannot be afforded to a healthcare provider or supplier if a formal finding of fraud or abuse has been made with regard to a healthcare providers or suppliers billing practices.  In cases where a formal finding of fraud or abuse is made, an immediate finding of liability for the healthcare provider or supplier results.  Abuse exists when a healthcare provider or supplier furnishes item and/or service that are inconsistent with accepted sound medical pract ices, are clearly not within the concept of reasonable and necessary as defined by law or regulations, and, if paid for, would result in an unnecessary financial loss to the program.  The Medicare contractor will also make an immediate finding of liability  in situations where a healthcare provider or supplier furnishes items and/or services that are so patently unnecessary that all healthcare providers or suppliers could reasonably be expected to know that they are not covered.
(Medicare Claims Processing Manual)
40 - Written Notice as Evidence of Knowledge  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  One regulatory basis for determining beneficiary knowledge can be found at 42 CFR 411.404.  Under these regulations, there is a presumption that the beneficiary knew, or could reasonably have been expected to know, that Medicare payment for an item or service would be denied if written notice was given to the beneficiary that the items or services were not covered.  A written notice that a beneficiary received may be considered as evidence of prior knowledge with respect to such same or similar item(s) and/or service(s) that is denied Medicare payment for the same reason in both cases.   In accordance with 42 CFR 411.404, a written notice of Medicare denial of payment must contain sufficient information to enable the beneficiary to understand the basis for the denial of the item and/or service that otherwise might be paid for, that Medicare certainly or probably will not pay for in that particular occasion.   The written notice allows the beneficiary to:    make an informed decision whether or not to receive the item and/or service, and    better participate in his/her own health care treatment decisions.    If the healthcare provider or supplier expects payment for the item and/or service to be denied by Medicare, the healthcare provider or supplier must advise the beneficiary in advance that, in its opinion, the beneficiary will be personally and fully responsible for payment.  To be personally and fully responsible for payment means that the beneficiary will be liable to make payment out -of-pocket, through other insurance coverage (e.g., employer group health plan coverage), or through Medicaid or other Federal or non -Federal payment source.    40.1 - Sources of Written Notice  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Generally, the written notice of the likelihood of Medicare payment denial (e.g. an ABN, Form CMS -R-131) should be furnished to the beneficiary:    By a healthcare provider or supplier before the item and/or service is furnished;
(Medicare Claims Processing Manual)
 By a healthcare provider or supplier before the item and/or service is furnished;    After the Medicare contractor, during the course of the beneficiarys stay, advised the healthcare provider or supplier that covered care had ceased;    By a healthcare provider or supplier utilization review committee that, on admission or during the patients stay, advised that the beneficiary  no longer required covered care;    By the Medicare contractor; or    By a qualified notifier so that the beneficiary may have confidence in and rely upon the accuracy and credibility of the notice.  40.2 - Written Notice Standards  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)   The healthcare provider or supplier should issue a written notice each time, and as soon as, it makes the assessment that Medicare payment certainly or probably will not be made in order to transfer potential financial liability to the beneficiary.  A healthcare provider or supplier, should notify a beneficiary by means of timely and effective delivery of a written notice document to a qualified recipient.  Any written notice should meet the following written notice standards as evidence of the beneficiary s knowledge for the purposes of the FLP provisions, except as otherwise explicitly specified.  A notification which does not meet the following written notice standards may be ruled invalid and may not serve to protect the interests of the notifier.    A written notice will not be considered as acceptable evidence of knowledge if the written notice is:   Unreadable, illegible, or otherwise incomprehensible, or the individual beneficiary is incapable of understanding the written notice due to the particular circumstances (even if others may understand);    Given during any emergency, or the beneficiary is under great duress, or the beneficiary is, in any way, coerced or misled by the notifier, by the contents of the written notice, and/or by the manner of delivery of the written notice;    Routinely given to all beneficiaries for whom the notifier furnishes items and/or services;    No more than a statement to the effect that there is a possibility that Medicare may not pay for the items or services; or    Delivered to the beneficiary more than one year before the items and/or services are furnished.
(Medicare Claims Processing Manual)
 No more than a statement to the effect that there is a possibility that Medicare may not pay for the items or services; or    Delivered to the beneficiary more than one year before the items and/or services are furnished.   NOTE:  A previously furnished written notice is acceptable evidence of written notice for current items and/or services if the previous written notice cites similar or reasonably comparable items and/or services for which denial is expected on the same basis in both cases.  A written denial (on the same basis in both cases) of payment from a Medicare contractor for a claim for the same or similar item and/or service received by the beneficiary is acceptable evidence of written notice for current item and/or servi ce.
(Medicare Claims Processing Manual)
Written Notice Standard  Description  Proper Written Notice Documents   An approved standard form (e.g., Form CMS -R-131); or   A CMS approved model notice language (e.g., Form CMS -10055)  Qualified Notifiers  Notifiers are generally the healthcare provider or supplier that furnished or ordered the item(s) and/or service(s).  Capable Recipient  The beneficiary must:   Be able to read, understand, act on his/her rights, and comprehend the notice;    Be issued the written notice in a manner that allows her/him to comprehend the contents of the written notice.  (e.g., when the  beneficiary (or authorized representative) is unable to read the notice due to a disability such as blindness, visual impairment or deafness) This can be done by  a verbal or electronic reading of the notice, by providing the written notice in Braille or large print, or by the use of other assistive technology.  The notifier should document any actions taken to assist with the delivery of the written notice on the notice; and   Be afforded the verbal or written assistance in other languages to assist in understanding the notice.  If a translator who can speak the beneficiarys language is not available, the notifier should assist by calling 1 -800-MEDICARE so a customer service re presentative can connect the beneficiary with the Language Line for translation services.   Identification of Notifier  The header of the written notice must identify the notifier or notifier(s).  In situations where the notifier is not the billing entity, it is permissible to enter the names of more than one entity in the header of the notice.   Written Notice Standard  Description   If the header identifies the entity or person that obtained the written notice, rather than the entity or person that is billing for the item and/or service, the Medicare contractor will consider the written notice form to be valid so long as it was otherw ise properly executed.   40.2.1 - Other Written Notice Standards  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  A.  Timeliness   Written notice delivery: