evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
100.8 - Making Payment Under Indemnification  (Rev. 1, 10- 01-03)  The contractor pays the indemnification amount if the provider, practitioner, or supplier does not make refund. It takes action to recover this amount as an overpayment from the provider, practitioner, or supplier. Also, it issues a letter of explanation t o the requester for indemnification. (See 100.10, Exhibit 2 and Exhibit 3.) It sends a copy of this notice to the provider, /practitioner or supplier. The fundamental points of the notice include:    Name of the provider, practitioner, or supplier and dates the services in question were rendered; and    the amount of the indemnification check that the requester is to receive.   100.9 - Limitation on Liability Determination Does Not Affect Medicare Exclusion  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A determination to limit the liability of the beneficiary, as well as a finding that the physicians or suppliers liability may be limited and program payment made, does not change noncovered items or services into covered items or services. This means th at the coverage question can still be raised as an issue at a level subsequent to an appeal determination that authorized program payment under 1879.  It also means that, for purposes of determining an amount in controversy for an appeal, payment made under 1879 should be disregarded because coverage is still at issue and the amount charged is still in controversy.  100.10 - Exhibits  (Rev. 1, 10- 01-03)  1.   Letter to Provider (Institutional Services).  2.   Letter to Beneficiary Who Requests Indemnification (Institutional Services).  3.   Letter to Someone Other Than Beneficiary Who Requests Indemnification.  4.   Letter to Practitioner or Supplier (Noninstitutional Services)  5.   Letter to Beneficiary Who Requests Indemnification (Noninstitutional Services)  6.   Letter to Someone Other Than Beneficiary Who Requests Indemnification (Noninstitutional Services)  7.   Form SSA -795, Statement of Claimant or Other Person.   Exhibit 1 - Letter to Provider  (Rev. 1, 10- 01-03)  To: Provider   Dear Administrator:
(Medicare Claims Processing Manual)
Exhibit 1 - Letter to Provider  (Rev. 1, 10- 01-03)  To: Provider   Dear Administrator:  Under 1879 of the Social Security Act, a Medicare beneficiary is relieved of the liability for certain noncovered services if the beneficiary did not know and could not reasonably have been expected to know that the items or services were not covered. Fur ther, the law provides that the provider is liable if it is found that the provider knew or could reasonably have been expected to know that the items or services were not covered by Medicare.   On (date of limitation on liability notice), your facility was notified that the services provided to (beneficiarys name) during the period (_________) to (_________) were not covered under Medicare and that you were liable for these items and services.   (Requesters name) has submitted evidence that establishes that he paid your facility (amount paid) for the services received by (beneficiarys name). Because your facility has collected payment from (requesters name) after being determined liable for the se services, 1879(b) of the Act requires that the Medicare program make direct payment (indemnification) to him for this amount, for which (beneficiarys name) is responsible.   A check in the amount of (amount of check) is being sent to (requesters name). This indemnification payment represents an overpayment to your facility and it will be withheld from future Medicare payments due you unless you advise this office that refund of the incorrect amount(s) has been made to (requesters name).   If you do not agree with the amount determined to have been paid you, please contact this office in writing within 15 days of the date of this letter.   Sincerely yours,   Exhibit 2 - Letter to Beneficiary Who Requests Indemnification  (Rev. 1, 10- 01-03)  Dear (Beneficiarys Name):   Your request for refund of improper payment under 1879 of the Social Security Act (the limitation on liability provision) for the noncovered services provided you at (name of provider) from (date) to (date) has been received.
(Medicare Claims Processing Manual)
Your request for refund of improper payment under 1879 of the Social Security Act (the limitation on liability provision) for the noncovered services provided you at (name of provider) from (date) to (date) has been received.   The evidence submitted establishes that, even though you were not responsible for the services you received, you paid (providers name) (amount paid) for the services. Your refund for these payments to (name of provider) has been calculated to be (indemnif ication amount). This figure represents full repayment for the charges you paid.   Your Medicare utilization record will not be charged where noncovered services were provided to you and you were determined not liable.  If you have any questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer to visit your local social security office, please take this letter with you.   Sincerely yours,   Exhibit 3 - Letter to Someone Other Than Beneficiary Who Requests Indemnification  (Rev. 1, 10- 01-03)  Dear (Persons Name):   Your request for refund of improper payment under Section 1879 of the Social Security Act (limitation of liability provision) for the noncovered services provided (beneficiarys name) at (name of provider) from (date) to (date) has been received.   It was determined that (beneficiarys name) was not liable for the services. The evidence you submitted establishes that you paid (provider) (amount paid) for the services provided (beneficiarys name). Your refund has been calculated to be (indemnification amount). This figure represents full repayment based on the expenses incurred by (beneficiarys name) in the amount of $(amount).   If you have any questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer, you may visit the local social security office. If you do, take this letter with you.  Sincerely yours,   Exhibit 4 - Letter to Practitioner or Supplier (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)
(Medicare Claims Processing Manual)
Sincerely yours,   Exhibit 4 - Letter to Practitioner or Supplier (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear ____________________:   Under 1879 of the Social Security Act, a Medicare beneficiary is relieved of the liability for certain categories of noncovered items or services submitted as assigned claims if the beneficiary did not know and could not reasonably be expected to know tha t the items or services would not be covered. Further, the law provides that the practitioner or supplier will be liable for the charges if it is found that he/she knew or could reasonably be expected to know that Medicare would not cover the items or services.   On (date of limitation on liability notification), you were notified that the following items or services provided to (name of beneficiary) were not covered and that you were liable for the charges for these items or services:   Description of Services  Date Provided   (Beneficiary or other person on behalf of beneficiary) has submitted evidence which establishes that he/she paid you $______ for the items or services described above. Since it has been determined that you are liable for the items or services, 1879(b) of the Act requires that the Medicare program  make payment (indemnification) to him/her for this amount. The amount of this payment will be treated as an overpayment to you and appropriate collection action will be taken unless you advise this office that refund has been made to (name of requester).   If you do not agree with the amount that (name of requester(s)) has established he/she paid you, please notify this office.
(Medicare Claims Processing Manual)
If you do not agree with the amount that (name of requester(s)) has established he/she paid you, please notify this office.   If we do not hear from you regarding the amount of the payment or that you will make refund directly by_____________ (15 days after date of this notice) payment will be made to (name of requester(s)) and action will be taken to collect the overpayment from  you.  If you disagree with this determination, you may request a redetermination. The bases for such a request are: (1) that the services you provided were reasonable and necessary; (2) that you did not know, and could not reasonably have been expected to know, that Medicare would not pay for the services; or (3) that you notified the beneficiary in writing, before the services were furnished, that Medicare likely would not pay for the services. The request for redetermination must be in writing, and it must be f iled within 120 days of the date you received the initial determination. If you have already received an adverse redetermination, you may request a reconsideration within 180 days of the date you received the redetermination. Our office will assist you if you need help in requesting a  redetermination or a reconsideration. You need not file another request for a redetermination or a reconsideration if you already have taken such action.   Exhibit 5 - Letter to Beneficiary Who Requests Indemnification (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear (Beneficiarys name):   Your request for indemnification (i.e., refund of improper payment) under 1879 of the Social Security Act (the limitation on liability provision) for the noncovered services provided you by (physicians/suppliers name) on (date) has been received.
(Medicare Claims Processing Manual)
The evidence submitted establishes that you paid (physician/supplier) (amount paid) for the noncovered services. It was determined upon redetermination that you were not liable for these charges. Your refund for these payments to (physician/supplier) has been calculated to be (indemnification amount). This figure represents full repayment for the charges you paid.   If your (physician/supplier) requests an appeal of this claim, it is possible that Medicare might find that your (physician/supplier) also did not know that Medicare would not pay for this service, or that this service should not have been denied. In that case, Medicare would pay your (physician/supplier) for this service. Also, you would be responsible for any deduc tible and coinsurance amounts. If this happens, you will receive a copy of the notice to your (physician/supplier).  Any future items or services of this type provided to you will be your responsibility because this is your notice that Medicare does not cover these services.   If you have further questions concerning this matter, please call this office. If you prefer to visit your social security office, please take this letter with you.   Exhibit 6 - Letter to Someone Other Than Beneficiary Who Requests Indemnification (Noninstitutional Services)  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Dear (Persons name):   Your request for indemnification (i.e., refund of improper payment) under 1879 of the Social Security Act (limitation on liability provision) for the noncovered services provided (beneficiarys name) by (name of physician/supplier) on (date) has been received.   It was determined upon redetermination that (beneficiarys name) was not liable for the charges.   The evidence establishes that you paid (physician/supplier) (amount paid) for the services provided (beneficiarys name). Your refund has been calculated to be (indemnification amount). This figure represents full repayment for the expenses incurred by (beneficiarys name).
(Medicare Claims Processing Manual)
If his/her (physician/supplier) requests an appeal of this claim, it is possible that Medicare might find that the (physician/supplier) also did not know that Medicare would not pay for this service, or that this service should not have been denied. In tha t case, Medicare would pay the (physician/supplier) for this service. Also, (beneficiarys name) would be responsible for any deductible and coinsurance amounts. If this happens, (beneficiarys name) will receive a copy of the notice to his/her (physician/ supplier).   Any future items or services of this type provided to (beneficiarys name) will be his/her responsibility because this is your notice that Medicare does not cover these services.   If you have further questions concerning the matters discussed in this letter or the amount of the check enclosed, please call this office. If you prefer to visit the social security office, please take this letter with you.   Exhibit 7 - Statement of Claimant or Other Person  (Rev. 1, 10- 01-03)  Link to an exhibit of the Form SSA -795,  Statement of Claimant or Other Person,  at:   http://www.ssa.gov/online/ssa -795.pdf .  110 - Contractor Instructions for Application of Limitation On Liability  (Rev. 1, 10- 01-03)  110.1 - Payment Under Limitation on Liability  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
110 - Contractor Instructions for Application of Limitation On Liability  (Rev. 1, 10- 01-03)  110.1 - Payment Under Limitation on Liability  (Rev. 1, 10- 01-03)  When it is determined during the course of a beneficiarys inpatient stay or during the patients course of home health visits, or during a patients course of treatment from a practitioner, physician or other supplier that the care is not covered but both the beneficiary and the provider of services are entitled to limitation on liability, the Medicare program may make payment for the noncovered services up to the date of notice and, if, for inpatient or home health services, the A/B MAC (A) or (HHH) deter mines that additional time is needed to arrange for post -discharge care, also for a grace period of l day after the date of notice to the provider or to the beneficiary, whichever is earlier. If it is determined that even more time is required in order to arrange post-discharge care, 1 additional grace period day may be paid for. (See 30 and 40 for definition of notice.)   When the provider is given notice as described in 40.1, it is required to advise the beneficiary in writing of the determination on the same date it received the A/B MAC (A) or (HHH) notice. Where the provider fails to give the beneficiary such timely notice, the beneficiary is protected from liability until the beneficiary receives the notice.
(Medicare Claims Processing Manual)
For example, if a SNF received the A/B MAC (A)s notice of noncoverage on February 15 but failed to advise the beneficiary until February 19, the beneficiary is protected from liability through February 19 -  the date on which the beneficiary first received  notice. However, the SNF is entitled to program payment only through the date -  February 15 - on which it received notice, and for whatever grace period is allowed thereafter. In a case in which a SNF received the A/B MAC (A)'s notice on February 15 but  failed to give the beneficiary notice until the next day -  February 16 -  the beneficiary and provider, if the A/B MAC (A) determines that additional time is needed to arrange post- discharge care, would be protected from liability under the grace period only for the additional day -  February 16 -  unless it is determined that even more time is required to arrange post-discharge care, in which case 1 additional grace period day may be paid for.   NOTE: The grace period is applicable only where circumstances have permitted program payment under 1879 of the Act, i.e., limitation on liability was applicable both to the beneficiary and the provider of services. Where the A/B MAC (A) or (HH H) concurs with a URCs decision that covered care has ended, any payments made during the grace period after the URCs notice are made under the authority of that statutory provision (1814 of the Act) rather than under 1879.  110.2 - When to Make Limitation on Liability Decisions  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A - Initial Claims
(Medicare Claims Processing Manual)
110.2 - When to Make Limitation on Liability Decisions  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A - Initial Claims   In implementing the limitation on liability provision, the contractor makes a coverage decision before making a limitation on liability decision. Section 1879 of the Act provides that limitation on liability can be allowed only in cases:  Where - (1) a determination is made that, by reason of 1862(a)(l) or (9) or by reason of a coverage denial described in subsection (g) of the Act, payment may not be made under Part A or Part B of this title for any expenses incurred for items or services furnished an individual by a provider of services... (Section 1879(a)(1) of the Social Security Act.)   NOTE:   Subsection (g) refers to home health service denials under 1814(a)(2)(C) and 1835(a)(2)(A), i.e., the patient is or was not confined to home; or the patient does or did not need skilled nursing care on an intermittent basis; and to hospice denials under 1861(dd)(3)(A) for services determined to be noncovered because the beneficiary was not te rminally ill.   Only after the contractor makes a decision that care is not reasonable or necessary, is custodial, is not reasonable and necessary for the palliation or management of terminal illness in hospice denials, or does not meet the homebound or intermittent nursi ng care requirements in home health service denials, or does not meet the terminally ill condition for hospice care, should a determination be made regarding limitation on liability. In every such case there will be two parts to the limitation on liability determination:  1. Whether and when the beneficiary knew or should have known that the services were noncovered, and  2. Whether and when the provider knew or should have known that the services were noncovered.   In any case where the provider gave the beneficiary notice that the services would be noncovered, the contractor will find that the provider knew that the services were noncovered.   B  Redetermination
(Medicare Claims Processing Manual)
In any case where the provider gave the beneficiary notice that the services would be noncovered, the contractor will find that the provider knew that the services were noncovered.   B  Redetermination   At the redetermination level, again the contractor first makes a determination on the coverage issue. It considers the question of limitation on liability, if applicable, only if the initial adverse coverage decision is wholly or partially affirmed. (See Chapter 29, Appeals of Claim Decisions, for discussion of the appeals process.)   110.3 - Preparation of Denial Notices (Rev. 3560, Issued: 07- 15-16, Effective: 10 -17-16, Implementation: 10- 17-16)  The provider and beneficiary notification procedures discussed in 30 and 40 for determining liability do not change the instructions for the preparation and issuance of denial notices in Medicare Claims Processing Manual, Chapter 21, Medicare Summary Notices.   Accordingly, in cases where the services are found to be custodial care or not reasonable and necessary, or in the case of HHA services, are denied for technical reasons under 1814(a)(2)(C) or 1835(a)(2)(A) of the Act, or in the case of hospice services, are denied for technical reasons under 1861(dd)(3)(A)  of the Act:   An MSN denying the service(s) is sent to the beneficiary in cases where only the beneficiary is entitled to limitation on liability for any part of the noncovered stay.  The notice advises the beneficiary of the beneficiarys entitlement to indemnification  (see 100.) in the event the provider seeks payment from the beneficiary for the noncovered services.  It uses MSN messages 50.36.2:
(Medicare Claims Processing Manual)
It appears that you did not know that we would not pay for this service, so you are not liable.  Do not pay your provider for this service. If you have paid your provider for this service, you should submit to this office three things: (1) a copy of this notice, (2) your providers bill, and (3) a receipt or proof that you have paid the bill.  You must file your written request for payment within 6 months of the date of this notice. Future services of this type provided to you will be your responsibility.  All denial notices explain any decision regarding limitation on liability for either the provider, practitioner, or supplier or the beneficiary.  (See Chapter 21, Medicare Summary Notices.)   All denial notices, where either the beneficiary or provider, practitioner, or supplier has been found liable, must state that the provider has a right to a redetermination.  Providers, practitioners, and suppliers do not receive a separate written notification or copy of the MSN.  Providers, practitioners, and suppliers must utilize the coding information (e.g., Remittance Advice Remark Codes) conveyed via the Remittance Advic e (RA) to ascertain reasons associated with Medicare claims determinations affecting payment and applicable appeal rights and/or appeals information.  110.4 - Bill Processing  (Rev. 3187, Issued: 02- 06-15, Effective: 03 -06-15, Implementation: 03- 06-15)  Where payment is made under the limitation on liability provision, because it was determined that both the provider, practitioner, or supplier and the beneficiary did not know and could not have been expected to know that services were not reasonable and necessary, the usual deductible and coinsurance amounts apply.  When payment under limitation on liability is made for noncovered services, the contractor processes the bill in the same manner as any payment bill for covered services. For institutional services, if both the beneficiary and the provider have liability w aived, the A/B MAC (A) charges the number of days or visits paid for under the limitation on liability provision to the beneficiarys utilization record. For noninstitutional services, it applies deductible and coinsurance, and, where applicable, statutory limits on services.