evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Even if a hospital or CMHC does not meet the criteria for reconciliation in 10.7.2.1, subject to approval of the central and regional offices, the Medicare contractor has the discretion to request that a hospital or CMHCs OPPS outlier payments in a cost reporting period be reconciled if the hospitals most recent cost and charge data indicate that the OPPS outlier payments to the hospital were significantly inaccurate.  The Medicare contractor sends notification to the regional office and central office v ia the address and email address provided in 10.11.3.1.  Upon approval of the central and regional office that a hospital or CMHCs outpatient outlier claims need to be reconciled, Medicare contractors should follow the instructions in 10.7.2.4.  10.7.2.3 - Time Value of Money  (Rev. 2242, Issued: 06- 17-11, Effective: 07 -01-11, Implementation: 07- 01-11)  Effective for hospital outpatient services furnished in the first cost reporting period on or after January 1, 2009, at the time of any reconciliation under 10.7.2.2, OPPS outlier payment may be adjusted to account for the time value of money of any adjus tments to OPPS outlier payments as a result of reconciliation.  As described in 42 CFR 419.43(d)(6)(ii), the time value of money is applied from the midpoint of the hospital or CMHCs cost reporting period being settled to the date on which the CMS Central  Office receives notification from the Medicare contractor that reconciliation should be performed.   If a hospital or CMHCs OPPS outlier payments have met the criteria for reconciliation, CMS will calculate the aggregate adjustment using the instructions below concerning reprocessing claims and determine the additional amount attributable to the time value of money of that adjustment.  The index that is used to calculate the time value of money is the monthly rate of return that the Medicare trust fund earns.  This index can be found at http://www.ssa.gov/OACT/ProgData/newIssueRates.html .  The following formula is used to calculate the rate of the time value of money:
(Medicare Claims Processing Manual)
The following formula is used to calculate the rate of the time value of money:   (Rate from Web site as of the midpoint of the cost report being settled / 365) * # of days from that midpoint until date of reconciliation.  NOTE : The time value of money can be a positive or negative amount depending if the provider is owed money by CMS or if the provider owes money to CMS.  For purposes of calculating the time value of money, the date of reconciliation is the day on which the CMS Central Office receives notification.  This "date of reconciliation" is based solely on the date CMS Central Office receives notification and not on the date that reconciliation is approved by the CMS Central and Regional Offices.  This date is either the postmark from the written notification sent to the CMS Central Office via mail by the Medicare contractor, or the date an email was received from the Medicare contractor by the CMS Central Office, whichever is first.   The following is an example of the procedures for reconciliation and computation of the adjustment to account for the time value of money:    EXAMPLE:   Cost reporting period:  01/01/2009 -  12/31/2009  Midpoint of cost reporting period:  07/01/2009   Date of reconciliation:  12/31/2010  Number of days from midpoint until date of reconciliation:  548  Rate from Social Security Web site:  4.625%   Overall ancillary CCR used to pay actual original claims in cost reporting period:  0.40 (This CCR could be from the tentatively settled 2006 or 2007 cost report.)   Final settled operating CCR from 01/01/2009 -  12/31/2009 cost report:  0.50 Total OPPS outlier payout in 01/01/2009 -  12/31/2009 cost reporting period:  $600,000  Because the CCR fluctuated from 0.40 at the time the claims were originally paid to 0.50 at the time of final settlement and the provider has an OPPS outlier payout greater than $500,000, the criteria have been met to trigger reconciliation.  The Medicare contractor notifies the CMS Central and Regional Offices.   The Medicare contractor reprices the claims in accordance with the process in 10.7.2.4 below.  The repricing indicates the revised outlier payments are $700,000.   Using the values above, the rate that is used for the time value of money is determined:
(Medicare Claims Processing Manual)
Using the values above, the rate that is used for the time value of money is determined:    (4.625 / 365) * 548 = 6.9438%   Based on the claims reconciled, the provider is owed $100,000 ($700,000 -  $600,000) for the reconciled amount and $6,943.80 for the time value of money.   10.7.2.4 - Procedures for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments  (Rev.  4233, Issued: 02- 08-19, Effective: 03 -12-19, Implementation: 03- 12-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The following is a step- by-step explanation of the procedures that Medicare contractors are to follow if a hospital (or CMHC) is eligible for outlier reconciliation:   1) The Medicare contractor sends notification to the CMS Central Office (not the hospital or CMHC), via the street address and email address provided in 10.11.3.1 and to the CMS Regional Office that a hospital or CMHC has met the criteria for OPPS outlier re conciliation.  Medicare contractors shall include in their notification the provider number, provider name, cost reporting begin date, cost reporting end date, total outlier payments in the cost reporting period, the CCR or weighted average CCR from the time the claims were paid during the cost reporting per iod eligible for reconciliation and the final settled CCR.   2) If the Medicare contractor receives approval from the CMS Central Office and Regional Office that OPPS outlier reconciliation is appropriate, the Medicare contractor follows steps 3- 14 below.  NOTE : Hospital and CMHC cost reports will remain open until their claims have been processed for OPPS outlier reconciliation.
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3) The Medicare contractor shall notify the hospital or CMHC and copy the CMS Regional Office and Central Office in writing and via email (through the address provided in 10.11.3.1) that the hospital or CMHCs OPPS outlier claims are to be reconciled.   4) Prior  to running claims in the FISS Lump Sum Utility*, Medicare contractors shall update the applicable provider record in the Outpatient Provider Specific File (OPSF) by entering the final settled CCR from the cost report in Outpatient Cost to Charge Rat io field.  No other elements in the OPSF shall be updated for the applicable provider records in the PSF that span the cost reporting period being reconciled aside from the CCR.   *NOTE : The FISS Lump Sum Utility is a Medicare contractor tool that, depending on the elements that are input, will produce an extract that will calculate the difference between the original PPS payment amounts and revised PPS payment amounts into a Microsoft A ccess generated report.  The Lump Sum Utility calculates the original and revised payments offline and will not affect the original claim payment amounts as displayed in various CMS systems (such as NCH).    5) Medicare contractors shall ensure that, prior to running claims through the FISS Lump Sum Utility, all pending claims (e.g., appeal adjustments) are finalized for the applicable provider.   6) Medicare contractors shall only run claims in the Lump Sum Utility that meet the following criteria:    TOB 12X, 13X, 34X, 75X, 76X or any TOB with a condition code 07   Claim has a line item date of service of January 1, 2009 or later that also contains a Pay Method Flag of 0   Previous claim is in a paid status (P location) within FISS   Cancel date is blank   7) The Medicare contractor reconciles the claims through the OPPS Pricer software and not through any editing or grouping software.   8) Upon completing steps 3 through 7 above, the Medicare contractor shall run the claims through the Lump Sum Utility.  The Lump Sum Utility will produce an extract, according to the elements in Table 1 below.  NOTE :  The extract must be importable by Microsoft Access or a similar software program (Microsoft Excel).
(Medicare Claims Processing Manual)
9) Medicare contractors shall upload the extract into Microsoft Access or a similar software program to generate a report that contains elements in Table 1.  Medicare contractors shall ensure this report is retained with the cost report settlement work papers.   10) For hospitals paid under the OPPS, the Lump Sum Utility will calculate the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17).  If the difference between the original and revised outlier amount  is positive, then a credit amount (addition) shall be issued to the provider. If the difference between the original and revised outlier amount is negative , then a debit amount (deduction) shall be issued to the provider.   11) Medicare contractors shall determine the applicable time value of money amount by using the calculation methodology in 10.7.2.3.  If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a negative amount then the time value of money is also a negative amount. If the difference between the original and revised outlier amount (calculated by the Lump Sum Utility) is a positive amount then the time value of money is also a positive amount.   Similar to step 10, if the time value of money is positive, then a credit amount (addition) shall be issued to the provider.  If the time value of money is negative, then a debit amount (deduction) shall be issued to the provider.  NOTE : The time value of money is applied to the difference between the original outlier amount (value code 17) and the revised outlier amount (value code 17).
(Medicare Claims Processing Manual)
12) For cost reporting periods beginning before May 1, 2010, under cost report 2552-96, the Medicare contractor shall record the original outlier amount from Worksheet E, Part B, line 1.02 (prior to the inclusion of line 54 of Worksheet E, Part B), the outlier  reconciliation adjustment amount (the difference between the original and revised outlier amount (calculated by the Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 51 and 53 on line s 50- 54, of Worksheet E, Part B of the cost report (NOTE :  the amounts recorded on lines 50, 51, 53 and 54 can be positive or negative amounts per the instructions above).  The total outlier reconciliation amount (Worksheet E, Part B, line 54) shall be included on Worksheet E, Part B, line 1.02.  For complete i nstructions on how to fill out these lines see 3630.2 of the Provider Reimbursement Manual, Part II.   For cost reporting periods beginning on or after May 1, 2010, under cost report 2552- 10, the Medicare contractor shall record the original outlier amount from Worksheet E, Part B, line 4 (prior to the inclusion of line 94 of Worksheet E, Part B), the outli er reconciliation adjustment amount (the difference between the original and revised outlier amount (calculated by the Lump Sum Utility),  the total time value of money, the rate used to calculate the time value of money and the sum of lines 91 and 93 on lines 90- 94, of Worksheet E, Part B of the cost report (NOTE : the amounts recorded on lines 90, 91, 93 and 94 can be positive or negative amounts per the instructions above).  The total outlier reconciliation amount (Worksheet E, Part B, line 94) shall be included on Worksheet E, Part B, line 1.02.   13) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.
(Medicare Claims Processing Manual)
13) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.   14) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) elements to their original values (that is, the CCRs used to pay the claims) in the applicable provider records in the PSF to ensure an accurate history is maintained. Specifically, for hospitals paid under the OPPS, Medicare contractors shall enter the original  CCR in PSF field 25 -Operating Cost to Charge Ratio.   Medicare contractors shall contact the CMS Central Office via the address and email address provided in 10.11.3.1 with any questions regarding this process.   Table 1:  Data Elements for FISS Extract
(Medicare Claims Processing Manual)
List of Data Elements for FISS Extract  Provider #  Medicare beneficiary identifier  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  List of Data Elements for FISS Extract  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  Difference between these amounts  Original C TOT PAY (claim page 14) Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG
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Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41 -43 - indicator indicating the claim is MSP; Y = MSP, blank = no MSP  Reason Code  HMO -IME Indicator  Filler
(Medicare Claims Processing Manual)
10.8 - Geographic Adjustments  (Rev. 1, 10- 03-03) A-01-93  Adjustments for differences in wages across geographical areas are made using inpatient hospital PPS wage index (post -reclassification, post -floor).   It is estimated that 60 percent of the group payment represents labor -related costs and are subject to the geographic adjustment.  10.8.1 - Wage Index Changes  (Rev. 1, 10- 03-03) A-02-026 XIII, A -01-144  Refer to the CMS Web site http://www.cms.gov/medicare/hopsmain.htm  for wage index change information.  10.9 - Updates  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    Section 1833(t) of the Social Security Act (the Act) as amended by 4533 of the  Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare prospective payment system for hospital outpatient services, including partial hospitalization and intensive outpatient services; Certain Part B services furnished to hospital inpati ents who have no Part A coverage; Partial hospitalization and intensive outpatient services furnished by CMHCs; Hepatitis B vaccines and their administration, splints, cast, and antigens provided by HHAs that provide medical and other health services; Hepatitis B vaccines and their administration provided by CORFs; and Splints, casts, and antigens provided to hospice patients for treatment of non-terminal illness.    By statute, CMS is required to review and revise the APC groups, relative payment rates, wage adjustments, outlier payments and other adjustments required under the OPPS on an annual basis.  These annual updates are made final through the publication of pr oposed and final rules in the Federal Register.  The annual update Federal Register rules can be accessed on the OPPS Web site at:   http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/HospitalOutpatientPPS/
(Medicare Claims Processing Manual)
In addition to the annual update at the beginning of each calendar year, we also update the OPPS on a quarterly basis to account for mid- year changes such as adding new passthrough drugs and/or devices, adding new treatments and procedures to the new techn ology APCs, removing procedures from the inpatient list, and recognizing new HCPCS codes that may be added during the year.  The quarterly updates are issued as Recurring Update Notifications.  The quarterly Recurring Update Notifications can be found in P ub. 100- 21, Recurring Update Notification, which can be accessed at the  following Web site:  http://www.cms.gov/Regulations -andGuidance/Guidance/Manuals/Internet -Only -Manuals -IOMs.html     10.10 - Biweekly Interim Payments for Certain Hospital Outpatient Items and Services That Are Paid on a Cost Basis, and Direct Medical Education Payments, Not Included in the Hospital Outpatient Prospective Payment System (OPPS)  (Rev. 1, 10- 03-03) A-01-32  For hospitals subject to the OPPS, payment for certain items that are not paid under the OPPS, but which are reimbursable in addition to OPPS, are made through biweekly interim payments subject to retrospective adjustment based on a settled cost report.  These payments include:    Direct medical education payments;   Costs of nursing and allied health programs;    Costs associated with interns and residents not in an approved teaching program as described in 42 CFR 415.202;    Teaching physicians costs attributable to Part B services for hospitals that elect cost-based reimbursement for teaching physicians under 42 CFR 415.160;    CRNA services;    For hospitals that meet the requirements under 42 CFR 412.113(c) , the reasonable costs of anesthesia services furnished to hospital outpatients by qualified nonphysician anesthetists (i.e., certified registered nurse anesthetists and anesthesiologists assistants) employed by the hospital or obtained under arrangements ;   Bad debts for uncollectible deductibles and coinsurance;    Organ acquisition costs paid under Part B.
(Medicare Claims Processing Manual)
 Bad debts for uncollectible deductibles and coinsurance;    Organ acquisition costs paid under Part B.   For hospitals that are paid under the OPPS, interim payments for these items attributable to both hospital outpatients, as well as inpatients whose services are paid under Part B of the Medicare program are made on a biweekly basis.  The A/B MAC (A) determ ines the amount of the biweekly payment by estimating a hospitals reimbursement amount for these items for the cost reporting period by using:    Medicare principles of cost reimbursement for cost -based items; and    Medicare rules for determining payment for graduate medical education for direct medical education, and dividing the total annual estimated amount for these items into 26 equal biweekly payments.  The estimated annual amount is based on the most current data available.  Biweekly interim payments are reviewed and, if necessary, adjusted at least twice during the reporting period, with final settlement based on a submitted cost report.
(Medicare Claims Processing Manual)
The estimated annual amount is based on the most current data available.  Biweekly interim payments are reviewed and, if necessary, adjusted at least twice during the reporting period, with final settlement based on a submitted cost report.  Because hospitals subject to the OPPS have not received payment for these items attributable to services furnished on or after August 1, 2000, the date the OPPS was implemented, the first payment to each hospital included all the payments due to the hospital retroactive to August 1, 2000.  Thereafter, A/B MACs (A) continue to make payment on a biweekly basis.  Each payment is made two weeks after the end of a  biweekly period of services.  The A/B MAC (A) was required to make retroactive payments and begin making biweekly interim payments to all hospitals that are due these payments no later than 60 days after March 8, 2001.  These biweekly payments may be combined with the inpatient biweekly payments that the A/B MAC (A) makes under 2405.2 of the Medicare Provider Reimbursement Manual (CMS Pub.15- I).  However, if a single payment is made, for purposes of final cost report set tlement, they must maintain records to separately identify the amount of the hospitals combined payment that is paid out of the Part A or Part B trust fund.  10.11 - Calculation of Overall Cost -to-Charge Ratios (CCRs) for Hospitals Paid Under the Outpatient Prospective Payment System (OPPS) and Community Mental Health Centers (CMHCs) Paid Under the Hospital OPPS  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  10.11.1 - Requirement to Calculate CCRs for Hospitals Paid under OPPS and for CMHCs  (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)