evekhm/cms_iom_500 huggingface dataset:
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A patient on admission to a hospital or skilled nursing facility may refuse to request Medicare payment and agree to pay for the services out of their own funds or from other insurance.  Such patients may have a philosophical objection to Medicare or may f eel that they will receive better care if they pay for services themselves or they are paid for under some other insurance policy.  The patients impression that another insurer will pay for the services may or may not be correct, as some contracts express ly disclaim liability for services covered under Medicare.  Where the patient refuses to request Medicare payment, the provider should obtain a signed statement of refusal wherever possible. If the patient (or his representative) is unwilling to sign, the provider should record that the patient refused to file a request for payment but was unwilling to sign the statement of refusal.   In any event, there is no provision that requires a patient to have covered services paid for under Medicare if the patient refuses to request payment.  Therefore, a provider may bill an insured patient who positively and voluntarily declines to request Me dicare payment.  However, if such a person subsequently requests payment by Medicare (because another insurance will not pay or for another reason) and requests payment under the health insurance program within the prescribed time limit, the provider must submit a Medicare claim, and refund to the patient any amounts the beneficiary paid in excess of the permissible charges.   Where a patient who has declined to request payment dies, the right to request payment may be exercised by the legal representative of the estate, by any of the persons or institutions mentioned in the second paragraph of 50.1.3, by a person or institution which paid part or all of the bill, or in the event a request could not otherwise be obtained, by an authorized official of the provider.  This permits payment to the provider for services that would not otherwise be paid for and allows a refund to the estate or to a person or institution that paid the bill on behalf of the deceased.   See 70 for filing claims for payment and for associated time limits.   The provider may charge the beneficiary for covered services where the beneficiary refuses to file.   50.1.6 - When Beneficiary Statement is Not Required for Physician/Supplier Claim (Rev. 980, Issued: 06- 14-06, Effective: 10 -01-06, Implementation: 10- 02-06)  A.  Enrollee Signature Requirements
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A.  Enrollee Signature Requirements   A request for payment signed by the enrollee must be filed on or with each claim for charge basis reimbursement except as provided below.  All rules apply to both assigned and unassigned claims unless otherwise indicated.  1. When no enrollee signature required:   a. Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee.   b. Unassigned claim submitted by a public welfare agency on a bill which is paid.  c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.   2. When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.   3. When another person may sign on behalf of the enrollee:   a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.   b. Enrollee physically or mentally unable to transact business:  The request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing the enrollee care or support, or of a governmental agency providing him/her assistance.   c. Enrollee physically or mentally unable to transact business and full documentation is supplied that the enrollee has no one else to sign on his behalf:  The physician, supplier, or clinic may sign.  d. Enrollee deceased and bill paid or liability assumed:  Person claiming payment should sign.  If Form CMS-1500 was signed before the enrollee dies, claimant should sign separate request for underpayment.  4. When request retained in file may cover extended future period:  a. Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.   b. Authorization in files of organization approved under 30.2.8.3 covers all services paid for by that organization under that procedure.  c. Assignment in the files of group practice prepayment plan covers services furnished by the plan during the period of the enrollees membership.  d. Assignment in the files of a participating provider (hospital, SNF, home health agency, outpatient physical therapy or speech-language pathology provider or comprehensive rehabili tation facility) or ESRD facility covers physician services for which the provider or facility is authorized to bill, and may cover the physician services furnished in the provider or facility as follows:
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 Inpatient services - effective for period of confinement.  Outpatient services - effective indefinitely.   e. Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of durable medical equipment) or qualified reassignee under 30.2 is effective indefinitely.   B.  Physician (Supplier) Signature Requirement   The rules below apply to both assigned and unassigned claims unless otherwise indicated. 1. In a claim for services furnished by an individual physician (or supplier), the physician may:  a. In an unassigned claim, provide an itemized bill on his own letterhead - no physician signature required.  A Form CMS-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physicians own letterhead.  b. Sign item 31 of Form CMS-1500.  c. Sign one time certification letter for machine -prepared claims submitted on other than paper vehicles.  d. Authorize an employee (e.g., nurse, secretary) to enter the physicians signature in item 31 of the Form CMS -1500.   i.   Manually ii.  By stamp -facsimile or block letters  iii. By computer   e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physicians signature in item 31 of the Form CMS -1500, followed by the agents name, title, and organization (e.g., a billing agent might enter by stamp Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service).  Alternatively, the agent may simply enter the physicians signature.   2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for the services of the physician, the entity may:   a. In an unassigned claim, provide an itemized bill on its letterhead- no signature necessary. A Form CMS -1500 on which the name or identification code of the billing entity has been stamped or preprinted in item 8 is the equivalent of the reassignees own let terhead.   b. Have authorized official sign in item 25 of the Form CMS -1500 (item 13 of Form CMS -1554, item 6 of Form CMS -1556).
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b. Have authorized official sign in item 25 of the Form CMS -1500 (item 13 of Form CMS -1554, item 6 of Form CMS -1556).   c. Have authorized official sign one -time certification letter for machine -prepared claims submitted on other than paper vehicles.  d. Have authorized employee, e.g., a secretary, enter authorized officials signature in item 25 of the Form CMS -1500 (item 13 of Form CMS -1554, item 6 of Form CMS -1556) as in 1d.  e. Have nonemployee agent enter authorized officials signature in item 25 of the Form CMS -1500 (item 13 of Form CMS -1554, item 6 of Form CMS -1556) as in 1.e.  50.1.7 - Definition of a Claim for Payment  (Rev. 3086, Issued: 10- 03-14, Effective:  ICD -10: Upon Implementation of ICD -10, ASC X12: January 1, 2012, Implementation  ICD- 10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   For those billing A/B MACs (B) and DME MACs, a claim does not have to be on a form but may be any writing submitted by or on behalf of a claimant, which indicates a desire to claim payment from the Medicare program in connection with medical services of a specified nature furnished to an identified enrollee. It is not necessary that this submission be recorded on a CMS claim form, that the services be itemized or that the information submitted be complete (e.g., a note from the enrollees spouse, or a bill for ancillary services in a nonparticipating hospital, could count as a claim for payment).   The writing must contain sufficient identifying information about the enrollee to permit the obtaining of any missing information through routine methods, e.g., file check, microfilm reference, mail or telephone contact based on an address or telephone num ber in file.  Where the writing is not submitted on a claims form, there must be enough information about the nature of the medical or other health service to enable the contractor with claims processing jurisdiction to determine that the service was appar ently furnished by a physician or supplier.
(Medicare Claims Processing Manual)
The definition of a part B claim for purposes of timely filing is any writing submitted by or on behalf of a claimant, which indicates a desire to claim payment from the Medicare program for medical services of a specified nature to an identified enrollee.   For example, a note from the enrollees spouse or a bill for ancillary services in a nonparticipat ing hospital could constitute a claim for payment.   If such a claim is mailed or delivered to SSA, CMS or to any A/B MAC (A or B) within the time limit, the claim is filed timely provided the necessary claims information (e.g., Form CMS -1490S and itemized bill in the case of an enrollee -filed claim) is submitted within the time limit or, if later, within six months after the end of the month in which the claimant is advised to furnish it, e.g., if the notice is provided February 2, the claim must be filed by close of business August 31.  See Statement of Int ent instructions in 70.7.  Note that electronic claims must be in the appropriate HIPAA standard format.  Refer to section 2 of this chapter as well as chapters 24 and 25 for more information.  50.1.8 - Establishing Date of Filing - Postmark Date - Carriers  (Rev. 1, 10- 01-03) A3-3305.2, A3- 3305.3
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Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, legal holiday, or other day all or part of which is a non- work -day for Federal employees because of Federal statute or executive order, the claim will be considered timely if it is filed on the next workday.  Where the claim is submitted to the carrier by mail, if it is material and to the advantage of the provider, the claim can be considered filed on the day the envelope was postmarked in the United States.  Thus, where an undated claim is received by the car rier in the mail early in the month after the filing date, the envelope should, if practical, be retained.  If, in such a case, an envelope with a legible postmark is not available, a 7- day tolerance will usually apply.  For example, a claim for services p rovided in May 2000 received by a carrier on or before January 10, 2002, may be presumed by the carrier, in the absence of evidence to the contrary, to have been mailed on or before January 2, 2002, (which is the date the time limit expires because it is the first Federal workday after Saturday, December 31).  This rule will be applicable where the claim was mailed within the contiguous 48 States and the District of Columbia and received by a carrier within such States.  In other cases, the reasonable tolerance may be longer and will depend on the usual mailing time under the particular circumstances.   50.2 - Frequency of Billing for Providers  (Rev. 1231; Issued:  04-27- 07; Effective:  12 -03-07; Implementation:  12 -03-07)  Different types of providers are paid based on different payment policies depending upon the circumstance of the provider.  These payment policies are described in detail in the chapters related to the provider type.  The following billing requirements are to strike a balance between program administration efficiency and maintaining cash flow for providers.  Standard System Maintainer (SSM) shall ensure that providers adhere to these requirements.   50.2.1  Inpatient Billing From Hospitals and SNFs  (Rev. 1946; Issued: 04- 15-10; Effective Date:  10 -01-02; Implementation Date: 07-06-10 for Analysis, Design and Coding and 10-04-10 for Testing and Implementation)   Non PPS Hospitals and SNFs
(Medicare Claims Processing Manual)
Non PPS Hospitals and SNFs   Inpatient services in TEFRA hospitals (i.e., hospitals excluded from inpatient prospective payment system (PPS), cancer and childrens hospitals) and SNFs are billed:   Upon discharge of the beneficiary;  When the beneficiary benefits are exhausted;   When the beneficiarys need for care changes; or   On a monthly basis.  Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.   Providers shall submit a bill to the FI when a beneficiary in one of these hospitals ceases to need a hospital level of care (occurrence code 22).  FIs shall not separate the occurrence code 31 and occurrence span code 76 on two different bills.  Each bill must include all applicable diagnoses and procedures. However, interim bills are not to include charges billed on an earlier claim since the From date on the bill must be the day after the Thru date on the earlier bill.   SNF providers shall follow the billing instructions provided in Chapter 6 (SNF Inpatient Part A Billing), Section 40.8 (Billing in Benefits Exhaust and No-Payment Situations) for proper billing in benefits exhaust and no- payment situations.   PPS Hospitals   Inpatient acute -care PPS hospitals, inpatient rehabilitation facilities (IRFs), long term care hospitals (LTCHs) and inpatient psychiatric facilities (IPFs) may interim bill in at least 60 -day intervals. Subsequent bills must be in the adjustment bill format. Each bill must include all applicable diagnoses and procedures.   All inpatient providers will also submit a bill when the beneficiarys benefits exhaust.  This permits them to bill a secondary insurer when Medicare ceases to make payment.  Initial inpatient acute care PPS hospital, IRF, IPF and a LTCH interim claims mus t have a patient status code of 30 (still patient).  When processing interim PPS hospital bills, providers use the bill designation of 112 (interim bill -  first claim).  Upon receipt of a subsequent bill, the FI must cancel the prior bill and replace it wi th one of the following bill designations:    For subsequent interim bills, bill type 117 with a patient status of 30 (still patient); or
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 For subsequent interim bills, bill type 117 with a patient status of 30 (still patient); or   For subsequent discharge bills, bill type 117 with a patient status other than 30. (See Chapter 25 for a list of valid patient discharge status codes)   All inpatient providers must submit bills when any of the following occur, regardless of the date of the prior bill (if any):    Benefits are exhausted;   The beneficiary ceases to need a hospital level of care (all hospitals);   The beneficiary falls below a skilled level of care (SNFs and hospital swing beds); or   The beneficiary is discharged.   Effective December 3, 2007, when a beneficiarys Medicare benefits exhaust in an IPF or an LTCH, the hospital is allowed to submit a no pay bill (TOB 110) with a patient status code 30 in 60 day increments until discharge.  They no longer have to continual ly adjust bills until physical discharge or death.  The last bill shall contain a discharge patient status code.   These instructions for hospitals and SNFs apply to all providers, including those receiving Periodic Interim Payments (PIP).  Providers should continue to submit no- pay bills until discharge.   NOTE :  For stays that necessitate the reporting of more than ten OSCs (i.e., more OSCs than the claim formats allow), Long Term Care Hospitals, Inpatient Psychiatric Facilities, and Inpatient Rehabilitation Facilities shall refer to instructions provided in Chapter 32, section 74.3 of this manual.  50.2.2 - Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services (Rev. 2092, Issued: 11- 12-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Repetitive Part B services furnished to a single individual by providers that bill institutional claims shall be billed monthly (or at the conclusion of treatment).  The instructions in this subsection also apply to hospice services billed under Part A, though they do not apply to home health services.  Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review.  Services repeated over a span of time and billed with the following revenue codes are defined as repetitive services:
(Medicare Claims Processing Manual)
Type of Service  Revenue Code(s)  DME Rental  0290  0299  Respiratory Therapy  0410, 0412, 0419  Physical Therapy  0420  0429  Occupational Therapy  0430  0439  Speech -Language Pathology  0440  0449  Skilled Nursing  0550  0559  Kidney Dialysis Treatments  0820  0859  Cardiac Rehabilitation Services  0482, 0943  Pulmonary Rehabilitation Services  0948   Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.   Where there is an inpatient stay, or outpatient surgery, or outpatient hospital services subject to OPPS, during a period of repetitive outpatient services, one bill for repetitive services shall nonetheless be submitted for the entire month as long as the  provider uses an occurrence span code 74 on the monthly repetitive bill to encompass the inpatient stay, day of outpatient surgery, or outpatient hospital services subject to OPPS.  CWF and shared systems must read occurrence span 74 and recognize the ben eficiary cannot receive non -repetitive services while receiving repetitive services, and consequently, is on leave of absence from the repetitive services.  This permits submitting a single, monthly bill for repetitive services and simplifies Contractor re view of these bills.  The following is an illustration explaining this scenario:    Any items and/or services in support of the repetitive service shall be reported on the same claim even if the revenue code(s) reported with those supported services are not on the repetitive revenue code list ( NOTE:   Supporting items and/or services are those in which are needed specifically in the performance of the repetitive service.  Examples may include disposable supplies, drugs or equipment used to furnish the repetitive service).
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However, to facilitate APC recalibration, do not report unrelated one- time, non- repetitive services that have the same date of service as a repetitive service (even if both the non -repetitive service and the repetitive service are paid under OPPS).  If a n on-repetitive OPPS service is provided on the same date as a repetitive service, report the non -repetitive OPPS services, along with any packaged and/or services related to the non-repetitive OPPS service, on a separate OPPS claim.  For example, if a chemo therapy drug is administered on a day a repetitive service is also rendered, report the chemotherapy drug, its administration, its related supplies, etcetera, on a separate claim from the monthly repetitive services claim.  Similarly, as shown below in the  illustration, Example: Monthly Repetitive Billing Procedure, a physical therapy treatment (which is a repetitive service because it is reported under a revenue code on the repetitive service list) is administered on the same day an outpatient consultation and a CT scan are Occurrence Span  Code   |     From    |    Through           74           7/12/05       7/16//05 MONTHLY REPETITIVE BILL  INPATIENT BILL  Statement Covers Period            From     |     Through            7/12/05        7/16/05  Leave of Absence Carve -Out Example  Statement Covers Period  From     |    Through                  7/01/05        7/31/05 Line Item Service Date  1) 7/04/05 2) 7/11/05 3) 7/18/05 4) 7/25/05   furnished, report the physical therapy service on the claim with the other physical therapy services provided during the applicable month.  Report the visit for the consultation and the CT scan on a separate claim.
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furnished, report the physical therapy service on the claim with the other physical therapy services provided during the applicable month.  Report the visit for the consultation and the CT scan on a separate claim.    Revenue codes usually reported for chemotherapy and radiation therapy are not on the list of revenue codes that may only be billed monthly.  Therefore, hospitals may bill chemotherapy or radiation therapy sessions on separate claims for each date of servic e.  However, because it is common for these services to be furnished in multiple encounters that occur over several weeks or over the course of a month, hospitals have the option of reporting charges for those recurring services on a single bill, as though they were repetitive services.  If hospitals elect to report charges for recurring, non- repetitive services (such as chemotherapy or radiation therapy) on a single bill, they must also report all charges for services and supplies associated with the recur ring service on the same bill.  The services may all be reported on the same claim or billed separately by date of service as illustrated below:   Example: Monthly Repetitive Billing Procedure  1.Physical Therapy  2.Outpatient Consultation  3.CT Scan  Monthly Repetitive Bill 7/4/05     7/11/05 7/18/05 7/18/05  7/18/05 Outpatient Bill  Line Item Service Date  Line Item Service Date    Indian Health Service Hospitals, Maryland hospitals, as well as hospitals located in Saipan, Guam, American Samoa, and the Virgin Islands are not subject to OPPS.  In addition, hospitals that furnish only inpatient Part B services are also exempt from OPPS. Bills for ambulatory surgery in these hospitals shall contain on a single bill all services provided on the same day as the surgery except kidney dialysis services, which are billed on a 72X bill type.  Non- ASC services furnished on a day other than the day of surgery shall not be included on the outpatient surgical bill.  See Chapter 16 for clinical diagnostic lab services paid under the fee schedule when included with outpatient bills for other services.  Contractors periodically review bills from providers known to be furnishing repetitive services to determine if they are billing more frequently than proper.  Techniques that may be used are:    Sample review of bills to determine if most are for a monthly period (by using from and thru dates or number of services).  This may be done manually or electronically. Contractors may rely on informal communications from their medical review staff, and   Contractors should educate providers that bill improperly. Contractors shall: