evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual Crosswalk)
Medical Necessityfor Oxygen 20          100.2.3.1 Scheduling and DocumentingRecertifications of Medical Necessity for Oxygen 20          100.2.3.2 HHA Recertification for HomeOxygen Therapy 20          100.2.3.3 Contractor Review of OxygenCertifications 20         100.3 B-02-031  Limitations on DMERCCollection of Information 20           110 A3-3629 General Billing Requirements -for DME, Prosthetics, Orthotic Devices, and Supplies 20        110.1 A3-3629 B-02-052,B-03-041  Billing/Claim Formats New Chap. New  Sect. Int.  Pub 13 Carrier Pub 14 OPT Pub09 HO Pub 10 HHA Pub 11 SNF Pub 12 Other Source Description 20           110.2 A3-3629 Application of DMEPOS FeeSchedule 20           110.3 B3-3011 Pre-Discharge Delivery ofDMEPOS for Fitting and Training 20 110.3.1        Conditions That Must Be Met 20 110.3.2        Date of Service for Pre-Discharge Delivery of DMEPOS 20         110.3.3  Facility Responsibilities Duringthe Transition Period 20           110.4 Frequency of Claims forRepetitive  Services (All Providers and Suppliers)  20         120 B3-3012 DMERCs  Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades  20    130 A3-3629  B3-4107.10 OPT 253.7 HO-441 HHA-463 SNF-260.4 (partial), SNF-264.4, SNF-533, SNF-534, AB-01-126  Billing for Durable Medical Equipment (DME) and Orthotic/ Prosthetic Devices New Chap. New  Sect. Int.  Pub 13 Carrier Pub 14 OPT Pub09 HO Pub 10 HHA Pub 11 SNF Pub 12 Other Source Description 20          130.1 A3-3629 Provider Billing for Prostheticand Orthotic Devices 20        130.2 A3-3629  B3-4107.8 Billing for Inexpensive or OtherRoutinely Purchased DME 20        130.3 A3-3629  B3-4107.8 Billing for Items RequiringFrequent and Substantial Servicing 20        130.4 A3-3629  B3-4107.8 Billing for Certain CustomizedItems 20  130.5 A3-3629
(Medicare Claims Processing Manual Crosswalk)
A3-3629  B3-4107.8 Billing for Items RequiringFrequent and Substantial Servicing 20        130.4 A3-3629  B3-4107.8 Billing for Certain CustomizedItems 20  130.5 A3-3629  B3-4107.8      Billing for Capped Rental Items (Other Items of DME) 20  130.6 A3-3629  B3-4107.7      Billing for Oxygen and Oxygen Equipment 20         130.6.1  Oxygen Equipment and ContentsBilling Chart 20           130.7 A3-3629 Billing for Maintenance andServicing  (Providers and Suppliers) 20          130.8 A3-3629 Installment Payments20           130.9 Showing Whether Rented orPurchased 20       140 Title-noXref   Billing for Supplies New Chap. New  Sect. Int.  Pub 13 Carrier Pub 14 OPT Pub09 HO Pub 10 HHA Pub 11 SNF Pub 12 Other Source Description 20        140.1 A3-3629 B-03-024,B-03-056  Billing for Supplies and Drugs Related to the Effective Use of DME 20     140.2 A3-3629 HO-228.3,  HHA-206.4, HHA-219.1, HHA-461 (partial) SNF-260.3  Billing for HHA Medical Supplies 20         140.3 B3-3045.7 Billing DMERC for HomeDialysis Supplies and Equipment 20          150 A3-3629 Institutional Provider Reportingof Service Units for DME and Supplies 20         160 A3-3660.6 Billing for Total ParenteralNutrition and Enteral Nutrition 20      160.1 A3-3660.6 HO-438,HO-229  HHA-403 SNF-544,SNF-559, SNF-260.4, SNF-261  Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients 20          160.2 A3-3660.6 SNF-368 Special Considerations for SNFBilling for TPN and EN Under Part B 20        170 AB-01-60,AB-01-126  Billing for Splints and Casts New Chap. New  Sect. Int.  Pub 13 Carrier Pub 14 OPT Pub09 HO Pub 10 HHA Pub 11 SNF Pub 12 Other Source Description 20          190 A3-3629  B3-5102 Contractor Application of FeeSchedule
(Medicare Claims Processing Manual Crosswalk)
New Chap. New  Sect. Int.  Pub 13 Carrier Pub 14 OPT Pub09 HO Pub 10 HHA Pub 11 SNF Pub 12 Other Source Description 20          190 A3-3629  B3-5102 Contractor Application of FeeSchedule and Determination of Payments and Patient Liability for DME Claims 20           200 B3-3010 Automatic Mailing/Delivery ofDMEPOS 20        210 B-03-055  CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay  20        220 No source  Appeals CMS requested x reference
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Medicare Claims Processing Manual  Chapter 33  Miscellaneous Hold Harmless Provisions   Table of Contents  (Rev. 739, 11- 01-05)  Transmittals for Chapter 33  1 - Overview  10 - Erroneous Program Guidance: Basis to Waive Penalty  10.1 -  Policy  10.2 -  Basic Conditions That Must Be Met To Waive Penalty  10.2.1 -  Guidance Was Erroneous  10.2.2 -  Guidance Issued by the Secretary or Contractor  10.2.2.1 -  Contractor Acted Within Scope of Authority  10.2.3 -  Guidance Was in Writing  10.2.4 -  Guidance Related to Item, Service, or Claim  10.2.5 -  Guidance Was Issued Timely  10.2.6 -  Provider Accurately Presented Circumstances in Writing  10.2.6.1 -  Alterna tive Basis for Satisfying the Presentation Condition 10.2.7 -  Provider Followed Guidance  10.2.8 -  Providers Reliance Was Reasonable  10.3 -  Penalty Considered 10.4 -  General Limitations on Scope  10.5 -  Notice of Penalty Waiver Policy  10.6 -  Request for a Penalty Waiver Determination  10.7 -  Jurisdiction  10.7.1 -  Jurisdiction re Error  10.7.2 -  Jurisdiction to Complete the Penalty Waiver Determination  10.8 -  Determining Whether the Guidance Was Erroneous  10.9 -  Completing the Penalty Waiver Determination  10.9.1 -  Timeliness of Request  10.9.2 -  Ripeness  10.9.3 -  Sufficient Information  10.9.4 -  Mootness  10.9.5 -  Required Conditions Other Than Error  10.9.6 -  Completing the Determination  10.10 -  Notice of the Penalty Waiver Determination  10.11 -  Reconsideration of the Penalty Waiver Determination  10.12 -  Recordkeeping  10.13 -  Reporting  10.14 -  Corrective Action  10.15 -  Effective Date  1 - Overview  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  This chapter addresses miscellaneous Medicare fee- for-service hold harmless provisions that are not addressed elsewhere.   10 - Erroneous Program Guidance: Basis to Waive Penalty (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)
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10 - Erroneous Program Guidance: Basis to Waive Penalty (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  This section addresses Medicare contractor implementation of waiver of penalty when the provider or supplier acted upon erroneous guidance from the Medicare program.   10.1 - Policy  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  A provider or supplier may be subject to one or more penalties with respect to certain acts or omissions related to the pro vider or suppliers participation in the Medicare program.  However, 903(c) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), which amended 1871(e) of the Social Security Act (the Act), establishes a basis to waive a pen alty in certain circumstances. Specifically, 903(c) provides that a provider or supplier shall not be subject to any penalty under an authority of Title XVIII of the Act or under an authority of Title XI of the Act (that relates to Title XVIII) if the bas is for imposing the penalty was an act or omission that resulted from the provider or supplier following erroneous guidance from the Medicare program.   The statute provides similarly for waiving interest on an overpayment that was caused by reliance upon e rroneous program guidance.  However, this section (i.e., 10 and its subsections) applies to the penalty provision only.  10.2  Basic Conditions That Must Be Met To Waive Penalty  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  Certain conditions must be met in order to invoke the 903(c) penalty waiver.  If all of the relevant conditions are met, then the provider or supplier will not be subject to a penalty for an act or omission that was caused by reliance on such guidance.  The following subsections specify the conditions that must be met to invoke the erroneous guidance penalty waiver.  10.2.1 - Guidance Was Erroneous (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)
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The first condition that must b e met is that the Medicare program guidance must have been erroneous.  The analysis of whether the guidance was erroneous must consider two standards and both standards must be met to conclude that the guidance was erroneous for the purpose of invoking the  provisions of this section.   The first standard is that the guidance was, in fact, erroneous at the time of the provider or suppliers act or omission that is the basis for the penalty at issue.  If there was no error in the guidance then a waiver of the penalty may not be granted.  The second standard is that the error must be material.  That is, the error must be the necessary cause of the provider or suppliers act or omission that is the basis for the penalty at issue.  If the error is one that would n ot have caused a reasonable, similarly situated provider or supplier to act or to refrain from acting in the manner that is the basis of the penalty, then the contractor must conclude that a 903(c) -type error is not present and must, therefore, conclude f urther that a penalty waiver under 903(c) may not be granted.   10.2.2  Guidance Was Issued by the Secretary or Contractor  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The second condition that must be met is that the guidance must have been issued by the Secretary or by a Medicare contractor.   Guidance issued by an officer or employee of the Centers for Medicare and Medicaid Services (CMS) is considered to have been issued by the Secretary.   For the purposes of impleme nting this section, the term Medicare Contractor means  any Medicare Administrative Contractor (MAC) or an eligible entity with a contract under 1893 of the Act, including but not necessarily limited to a Program Safeguard Contractor.   Guidance issued by any other type of contractor as not qualifying to invoke the penalty waiver unless such guidance is confirmed and communicated by CMS or by a Medicare contractor, as defined above, before the provider or suppliers act or omission that is the basis for t he penalty at issue.
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10.2.2.1 - Contractor Acted Within Scope of Authority  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  If a Medicare contractor issued the guidance, then the contractor must have been acting within the scop e of the contractors Medicare contract authority.   A Medicare contractor as defined in 10.2.2 shall be presumed to be acting within the scope of its Medicare contract authority (but only for the purpose of implementing this Section) if the guidance:   i) was issued by the contractor in the form of a general communication (e.g., a formally published contractor bulletin, a statement on the contractors Web site, etc.) or in the form of a communication directed to the particular provider or supplier that seeks to invoke the penalty waiver (or to such provider or suppliers billing agent, attorney, or other agent of such provider or supplier);   ii) addresses a matter that appears to be within the scope of Medicare fee- for-service (e.g., a provider or supplier m ay not presume that a communication pertaining to the Medicare Advantage Program or to the Medicare Part D drug benefit would also apply to the traditional Medicare fee- for-service program unless there is an express statement to such effect; similarly, a communication that addresses a contractors private- side health insurance business should not be relied upon for Medicare purposes); and  iii) addresses a matter that appears to be within the scope of responsibility for the type of Medicare contractor that issued the guidance (e.g., home health agencies enrolled in Medicare, which submit claims to a designated A/B MAC (HHH), may not presume that a DME MAC may instruct such agencies in matters related to claim submission (without some further explanation rega rding the DME MACs atypical involvement in home health agency billing matters).
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However, if the provider or supplier knew or should have known of any fact that would have caused a reasonable provider or supplier to doubt whether the contractor may have been acting outside the scope of its Medicare contract authority, then the provider or supplier may not rely on the foregoing presumption but, rather, must enquire of the issuing Medicare contractor whether the contractor is authorized to issue the particul ar guidance.  Reconfirmation by the Medicare contractor that it possesses such authority shall be sufficient to satisfy this condition.   See 10.2.8 regarding the related issue as to whether the provider or suppliers reliance on the guidance was reasonabl e.  10.2.3 - Guidance Was in Writing  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The third condition that must be met is that the guidance must have been in writing.   The Medicare guidance is considered to be in writing if a hardcopy, e -mail, facsimile, floppy disk, or other similar, tangible, reproducible instrument of communicating information is furnished to the provider or supplier.  The guidance must possess some form of authentication (e.g., a letterhead) or other i ndicia that shows that the item was issued by CMS or a Medicare contractor.   Also, a CMS or contractors Web site posting qualifies as a writing.   The provider or supplier has the burden of documenting the existence of the writing.   10.2.4 - Guidance Related to Item, Service, or Claim  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The fourth condition that must be met is that the guidance must relate to the furnishing of an item or service or to the submission of a claim for be nefits for furnishing such item or service with respect to the provider or supplier submitting such claim.
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Guidance related to any item or service furnished or not furnished to a Medicare beneficiary, regardless of whether the item or service is a Medicar e-covered item or service, is qualifying to meet the item or service prong of this condition.  Guidance related to submitting any filing, including but not necessarily limited to submitting an enrollment form, a claim, a cost report, a Certificate of Medic al Necessity (CMN), an Advance Beneficiary Notice (ABN), or additional documentation in support of any filing, is qualifying to meet the claim prong of this condition.   Guidance that is not directly related to the furnishing of an item or service or to the  submission of a claim is not within the scope of this Section.  Some guidances may require analysis to determine if they relate directly to such matters.  For example, a guidance that relates to Health Insurance Portability Accountability Act (HIPAA) comp liance, Clinical Laboratory Improvement Act (CLIA) compliance, copyright infringement (of, e.g., CPT coding and descriptors), institutional accreditation and individual licensure, State laws and regulations, Medicaid requirements, or other similar matters for which the legal authority is other than Title XVIII or Title XI of the Act, may not relate directly to the furnishing of an item or service or to the submission of a claim in the context of Medicare fee- for-service and must be analyzed to determine whether the guidance relates directly  to such actions in such context.   10.2.5 - Guidance Was Issued Timely  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The fifth condition that must be met is that the guidance under consideration must have been issued on or after July 24, 2003, and before the act or omission that was the basis for considering the imposition of the penalty.   10.2.6 - Provider Accurately Presented Circumstances in Writing (Rev. 739, Issued: 11- 01-05, Ef fective: 07 -24-03, Implementation: 01 -19-06)  The sixth condition that must be met is that the provider or supplier must have accurately and fully presented the circumstances (relating to the item, service, or claim) in writing to the Medicare contractor o r to CMS.   This condition is met if:
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The sixth condition that must be met is that the provider or supplier must have accurately and fully presented the circumstances (relating to the item, service, or claim) in writing to the Medicare contractor o r to CMS.   This condition is met if:   a) the presentation of circumstances was made by the provider or supplier or by a billing agent, attorney, or other agent acting on behalf of an expressly identified provider or supplier;   b) the presentation of circumstances was made, directly or indirectly, to the Medicare contractor or to the CMS component that issued the guidance upon which the provider or supplier relied;  c) the presentation of circumstances included all relevant and material facts (NOTE:   Although the burden is on the provider or supplier to present all relevant and material facts, if the contractor or CMS component that issued the guidance took notice of certain facts in issuing such guidance, then the contractor implementing this section shall also take notice of such facts as if they had been presented by the provider or supplier.);   d) the circumstances were presented accurately, i.e., there was no material ambiguity or misstatement of fact; and   e) the presentation was m ade in writing (the term writing is to be broadly construed as specified in 10.2.3).  10.2.6.1 - Alternative Basis for Satisfying the Presentation Condition  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The presentation  condition described 10.2.6 shall be deemed to be met if the guidance was communicated generally to all providers and/or suppliers or to a class of providers or suppliers to which the affected provider or supplier belongs rather than having been issued i n response to a specific presentation of circumstances by the provider or supplier that is facing the imposition of the penalty.   10.2.7 - Provider Followed Guidance  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)
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10.2.7 - Provider Followed Guidance  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The seventh c ondition that must be met is that the provider or supplier must have followed the guidance provided by the Medicare contractor or by CMS.  The provider or suppliers act or omission must have been in substantial, but not necessarily complete, accord with t he terms of the guidance.  Deviation from the guidance, if immaterial, would not necessarily be disqualifying.  But even a small deviation from the guidance, if material, could be disqualifying.  In general, the greater the specificity of the guidance, the  greater must be the provider or suppliers close adherence to such guidance.  In addition, the provider or suppliers act or omission in following the guidance must be either the same act or omission that is the basis of the penalty or must be the direct,  but not necessarily the immediately proximate cause of such act or omission.   10.2.8 - Providers Reliance Was Reasonable  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  The eighth condition that must be met is that the provider or suppliers reliance on the guidance provided by the Medicare contractor or by CMS must have been reasonable.  A Medicare program communication (which qualifies as a writing) that was issued to the provider or supplier (specifically, or as part of a class, or to all providers and suppliers generally, that is directly on point with respect to the matter presented by the provider or supplier, and that purports to speak definitively to such matter, creates a rebuttable presumption that the provider or suppliers reliance was reasonable.   However, if the communication, by its own terms, does not purport to be definitive, i.e., it contains relevant and material speculations, disclaimers, a set of possibilities, or other equivocal language, or a request for additional information, such that a reasonable provider or supplier would consider that a further exchange of views or a further presentation of facts, or an additional inquiry was warranted, then no such rebuttable presumption is created.
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Also, certain electronically transmitted communications, such as e- mail, although qualifying as a writing, may, in a particular circumstance, be so sparse in content or informal in manner of expression, or may be sent by an individual who is not likely to be authorized t o furnish the type of guidance that was issued, that a reasonable provider or supplier would question whether reliance on the guidance, without further inquiry or confirmation, would be reasonable.   Further, the guidance must appear accurate on its face to  any reasonable, similarly situated provider or supplier.  One circumstance when it would not be reasonable to rely on a particular guidance is when such guidance is in direct conflict with a then current, Medicare program issuance that is applicable in th e circumstance addressed by the guidance (unless the guidance itself references such official issuance in terms of supersession or resolving an apparent conflict).  Another circumstance when it would not be reasonable to continue to rely on a particular guidance is when the guidance, once accurate (or arguably so), has been superseded by new policy that has been communicated by a program issuance to which the provider or supplier was or should have been privy.  A provider or suppliers reliance on a particu lar guidance may become questionable or may be determined to be unreasonable if a claim or other filing that was submitted pursuant to such guidance is returned as unprocessable, is denied in whole or in part, is challenged, rejected, or if, in any in othe r way, a Medicare program communication or other act or omission by CMS or a Medicare contractor would indicate to a reasonable provider or supplier that continued reliance on such guidance would be unreasonable without confirming the continuing validity of the guidance.   If the provider or supplier had received notice of the erroneous nature of the prior guidance, then such provider or supplier shall be bound by the terms of such subsequent notice and may not thereafter rely on the prior, erroneous guidanc e.  10.3 - Penalty Considered  (Rev. 739, Issued: 11- 01-05, Effective: 07- 24-03, Implementation: 01 -19-06)  In the context of this section, the term penalty is to be broadly construed to include, but not necessarily limited to, a civil money penalty, an a ssessment, a sanction, a suspension, a termination, or other, similar penalty.
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Examples of matters that are illustrative of a penalty under this section include but are not necessarily limited to: specified remedies under 1819(h)(2)(B),), a sanction under 1833(h)(5)(D), a penalty under 1834(j)(2)(A)(iii), sanctions under 1842(j)(2), 1842(k) or 1842(n)(3), intermediate sanctions under 1846, sanctions under 1848(g)(1)(B), and actions under 1866(b)(2), 1866(d) or 1866(i).   The 10% penalty for fil ing a stale assigned claim, although also illustrative of a penalty under this section, is also subject to the broader conditions for waiver under 1848(g)(4)(B) of the Act.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1, 70.8.8 et seq.  Although the erroneous -guidance -based penalty waiver of 903(c) applies to all penalties that may be imposed by CMS, this section applies only to those penalties for which implementation has been or may hereafter be delegated to one or more Medicare contr actors.  Moreover, the foregoing identification of penalties, which are illustrative of 903(c) penalties, does not constitute a delegation to contractors to impose such penalties.  Any such delegation would be made in provisions relating to the policies a nd procedures specific to such penalties or in other program issuances.  Accordingly, whether a contractor may grant a penalty waiver in a particular matter will depend, in part, on whether the contractor has been delegated the authority to impose the pena lty itself (whether as a standing matter or under a specific, ad hoc delegation on a particular matter or in a particular circumstance).