evekhm/cms_iom_500 huggingface dataset:
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The ASCA law allows for there to be exceptions for which a provider, or other claim submitter, is permitted to send his/her claims to Medicare on paper.  Refer to Chapter 24 90- 90.5.4 for more information regarding ASCA exceptions.   02.2.1 - Paper Formats for Institutional Claims  (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)   The required format for submitting institutional claims to Medicare on paper is the CMS - 1450 form.  Refer to chapter 25 for more information, including how to complete this form.  In addition, where needed, additional instruction is provided throughout this manual for submitting paper claims.   02.2.2 - Paper Formats for Professional and Supplier Claims  (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)   The required format for submitting professional and supplier claims to Medicare on paper is the CMS -1500 claim form.  Refer to chapter 26 for more information, including how to complete this form.  In addition, where needed, additional instruction is provi ded throughout this manual for submitting paper claims.  02.3 - Remittance Advices  (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)
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Another of the electronic health care transactions for which HIPAA requires the Secretary to adopt a standard is the remittance advice.  The standard adopted is the ASC X12 Health Care Claim Payment/Advice (835).  The current HIPAA version, including the implementation guide, is listed in Chapter 24.  Throughout this manual, you may see references to this standards short form, ASC X12 835 remittance advice.  More information about this transaction and its implementation guide can be found in chapters 22 and 24.  10 - Jurisdiction for Claims  (Rev. 1, 10- 01-03)  In general  FIs have jurisdiction for providers and institutional suppliers. Examples of institutional suppliers are renal dialysis facilities, comprehensive outpatient rehabilitation facilities, rural health clinics, and federally qualified health centers.  In gener al, carriers have jurisdiction for physicians and other individual practitioners, and for labs that are not a part of hospital, ambulance suppliers, ASCs, DME suppliers, and IDTFs.   See 10.1 -  10.2 for more detail.   10.1 - A/B MACs (Part B) and DME MAC Jurisdiction of Requests for Payment  (Rev. 10840; Issued: 06- 11-21; Effective: 07 -12-21; Implementation: 07 -12-21)  B3-3100  A/B MACs (Part B) have jurisdiction for all claims from the following:   Physicians;   Other individual practitioners;   Groups of physicians or practitioners;   Labs not part of a hospital;   Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the A/B MAC (Part A);   Ambulatory surgical centers (ASCs); and   Independent diagnostic testing facilities (IDTFs).   Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have jurisdiction for claims from the following:   Nonimplantable  durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) (including home use);    Suppliers of enteral and parenteral products other than to inpatients covered under Part A;    Oral drugs billed by pharmacies; and
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 Suppliers of enteral and parenteral products other than to inpatients covered under Part A;    Oral drugs billed by pharmacies; and    Method II home dialysis (for dates of service prior to January 1, 2011).  Note:  Please refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis for dates of service on and after January 1, 2011.   The CMS maintains a list of which HCPCS codes are under DME MAC only jurisdiction or dual DME MAC/Part B MAC jurisdiction and issues updates to DME MACs and A/B MACs (Part B) as needed (Usually quarterly). Any other codes not listed as DME MAC only or dual DME MAC/Part B MAC jurisdiction shall be A/B MAC (Part B) only jurisdiction.    There are four DME MACs each of which is assigned specific States.   A/B MACs (Part B) typically process Part B fee-for- service claims for services furnished in specific geographic areas (e.g., a State). However, a single A/B MAC (Part B) processes all physician/supplier claims for railroad retirement beneficiaries. (See 1 0.1.3 for claims for Part B medical services performed outside the U.S. for individuals who reside in the U.S.).   The rules for determining jurisdiction are the same whether a claim is assigned or nonassigned (see 30.3 for assignment rules).   Further information on A/B MACs (Part B) and DME MACs for specific geographic areas is available on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Contracting/Medicare- Administrative -Contractors/Who- are-the- MACs  .  Most skilled nursing facilities submit claims to the A/B MACs (Part A). However, a nonparticipating skilled nursing facility (SNF) is considered a supplier and its claims are submitted to the appropriate A/B MACs (Part B) under its own Medicare supplier number.   10.1.1 - Payment Jurisdiction among A/B MACs (Part B)  for Services Paid Under the Physician Fee Schedule and Anesthesia Services   (Rev.  4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)
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(Rev.  4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)  The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is governed by the payment locality where the service is furnished and will be based on the ZIP code. Though a number of additional services appear on the MPFS database, these payment jurisdiction rules apply only to those services actually paid under the MPFS and to anesthesia services.  (For example, it does not apply to clinical lab, ambulance or drug claims .)
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Effective for claims received on or after April 1, 2004, A/B MACs (Part B) must use the ZIP code of the location where the service was rendered to determine A/B MACs (Part B) jurisdiction over the claim and the correct payment locality.  Effective for dates of service on or after October 1, 2007, except for services provided in POS Home, if they are not already doing so, A/B MACs (Part B) shall use the CMS ZIP code file along with the ZIP code submitted on the claim with the address that represents where the service was performed to determine the correct payment locality.  (See section 10.1.1B for instructions on processing services rendered in POS Home -12 and section 10.1.1.1 for instructions on when a 9-digit ZIP code is required.)  When a physician, practitioner, or supplier furnishes physician fee schedule or anesthesia services in payment localities that span more than one A/B MAC (Part B)s service area (e.g., provider has separate offices in multiple localities and/or multiple A/ B MACs (Part B)), separate claims must be submitted to the appropriate area A/B MACs (Part B) for processing. For example, when a physician with an office in Illinois furnishes services outside the office setting (e.g., home, hospital, SNF visits) and that  out-of-office service location is in another A/B MAC (Part B)s service area (e.g., Indiana), the A/B MAC (Part B) which processes claims for the payment locality where the out of office service was furnished has jurisdiction for that service.  It is the A/B MAC (Part B) with the correct physician fee schedule pricing data for the location where the service was furnished. In the majority of cases, the physician fee schedule or anesthesia services provided by physicians are within the same A/B MAC (Part B) jurisdiction that the physicians office(s) is/are located.
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Although pricing rules for services paid under the MPFS remain in effect, effective for claims with dates of service on or after January 25, 2005, suppliers (including laboratories, physicians, and independent diagnostic testing facilities (IDTFs) must bil l their A/B MAC (Part B) for the technical component and professional component of diagnostic tests that are subject to the anti- markup payment limitation, regardless of the location where the service was furnished.  Beginning in 2005, and in each subseque nt calendar year (CY) through 2013, CMS provided A/B MACs (Part B) with a national abstract file containing Healthcare Common Procedural Coding System (HCPCS) codes that are payable under the MPFS as anti -markup tests for the year.  In addition, CMS made q uarterly updates to the abstract file to add and/or delete codes, as needed, in conjunction with the MPFSDB quarterly updates.   Beginning in 2014, CMS adopted a more streamlined approach to providing the A/B MACs with the HCPCS codes payable under the MPF S as anti -markup tests for the year.  The national abstract file was discontinued and an Anti -markup (formerly Purchased Diagnostic) Test Indicator, to identify HCPCS codes payable under the MPFS as anti -markup tests for the year, was added to the MPFS payment file.  Quarterly updates to the Anti -Markup Test Indicator are made directly to the MPFS Payment file. As with all other services payable under the MPFS, the ZIP code of the locality in which the service was furnished determines the payment amount.  R efer to 30.2.9 of this chapter for information on the anti -markup payment limitation as it applies to supplier billing requirements.   A. Multiple Offices
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A. Multiple Offices   In states with multiple physician fee schedule pricing localities or where a provider has multiple offices located in two or more states, or there is more than one A/B MAC (Part B) servicing a particular state, physicians, suppliers and group practices wit h multiple offices in such areas must identify the specific location where office -based services were performed. This is to insure correct claim processing jurisdiction and/or correct pricing of MPFS and anesthesia services. The A/B MAC (Part B) must ensur e that multiple office situations are cross -referenced within its system. If a physician/group with offices in more than one MPFS pricing locality or a multi -contractor state fails to specify the location where an office- based service was furnished, the A/B MAC (Part B) will return/reject the claim as unprocessable.   Physicians, suppliers, and group practices that furnish physician fee schedule services at more than one office/practice location may submit their claims through one office to the A/B MAC (Part B) for processing. However, the specific location where the se rvices were furnished must be entered on the claim so the A/B MAC (Part B) has the ZIP code, can determine the correct claims processing jurisdiction, and can apply the correct physician fee schedule amount.  B. Service Provided at a Place of Service Other than Home- 12 or Office -11  For claims submitted prior to April 1, 2004, in order to determine claims jurisdiction, Medicare approved charges, Medicare payment amounts, Medicare limiting charges and beneficiary liability, Part B fee -for-service claims for services furnished in other than in an office setting or a beneficiarys home must include information specifying where the service was provided.   Effective for claims received on or after April 1, 2004, claims for services furnished in all places of service other than a beneficiarys home must include information specifying where the service was provided.  A/B MACs (Part B) must use the address on t he beneficiary files when place of service (POS) is home -  12, or any other mechanism currently in place to determine pricing locality when POS is home  12.  A/B MACs (Part B) shall take this same action for any other POS codes they currently treat as POS  home.
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Effective for claims processed on or after October 5, 2009, for services rendered in POS home - 12, or for any other POS the contractor currently treats as POS home, when alerted by the shared system that a 9- digit ZIP code is required according to the CMS ZIP Code file, and a 9 -digit ZIP code is not available on the beneficiary file, the contractor shall determine that ZIP code by using the United States Postal Service Web site.  They shall use that ZIP code to determine the correct payment locality for the  claim for pricing purposes.   A/B MACs (Part B) processing these claims shall take necessary steps to ensure that the claims for services rendered in the physical location for which they are the MAC are priced and processed correctly applying appropriate edits as necessary.   Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional claim format, submission of the complete address of where the service was performed is required regardless of where the serv ice was performed.  This information should be entered on the claim per the Implementation Guide for the current version.  Contractors shall use that ZIP code to determine correct payment locality.   Effective January 1, 2011 for claims processed on or after January 1, 2011 on paper claims submitted on the CMS -1500 form, submission of the ZIP code of where the service was provided will also be required for all POS code and contractors shall use that ZIP code to determine correct payment locality.   For paper and electronic claims, when a global diagnostic service code is billed (e.g. no modifier TC and no modifier 26), the address where the technical component was performed shall be reported on the claim (this only applies to global services with separat e technical component/professional component). Global billing does not apply to anti-markup tests because the technical and professional component must be billed separately when the anti -markup payment limitation applies.   Refer to Pub 100- 04, Chapter 35, Section 10.2.1 and 10.2.2 for more information on global billing and separate technical and professional billing.   Contractors shall make no changes for claims submitted on the 4010A1 format as they pertain to POS Home and determining pricing locality.  Contractors shall require the submission of the 9- digit ZIP code when required per the CMS ZIP Code file.   C. Outside A/B MAC (Part B) Jurisdiction
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C. Outside A/B MAC (Part B) Jurisdiction   If A/B MACs (Part B) receive claims outside of their jurisdiction, they must follow resolution procedures in accordance with the instructions in 10.1.9. If they receive a significant volume or experiences repeated incidences of misdirected Medicare Physici an Fee Schedule or anesthesia services from a particular provider, an educational contact may be warranted.   D. HMO Claims   For services that HMOs are not required to furnish, A/B MACs (Part B) process claims for items or services provided to an HMO member over which they have jurisdiction in the same manner as they process other Part B claims for items or services provided by physicians or suppliers. Generally, the physician/supplier who provides in -plan services to its HMO members submits a bill directly to the HMO for payment and normally does not get involved in processing the claim. However, in some cases, claims for servic es to HMO members are also submitted to A/B MACs (Part B), e.g., where claims are received from physicians for dialysis and related services provided through a related dialysis facility.   10.1.1.1 - Claims Processing Instru ctions for Payment Jurisdiction  (Rev.  4473, Issued: 12- 6-19; Effective: 3 -9-20; Implementation: 3 -9-20)  A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)   Note that the following instructions do not apply to services rendered at POS home -12. For services rendered at POS home  12, use the address on the beneficiary file for the beneficiarys home (or wherever else the beneficiary information is currently being stored) to determine pricing locality.  ( See 10.1.1 for changes to processing for services rendered at POS home  12.)
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for changes to processing for services rendered at POS home  12.)  For pricing purpose, contractors shall use the ZIP code of where the service was performed.  Contractors shall locate that information according to the Implementation Guide of the 4010/4010A1 version of the ASC X12 837 professional claim format.  EXCEPTION:   For DME MAC claims - Effective for claims received on or after 1/1/05, the Standard System shall not evaluate the 2010AA loop for a valid place of service. If there is no entry in the 2420C loop or the 2310D loop, the claim shall be returned as unprocessable.   If the Pay -To Provider Name and Address loop 2010AB is not the same as the Billing Provider, both will be entered. If the Service Facility Location loop 2310D is not the same as the Billing Provider or the Pay-To Provider, the Service Facility Location loop 2310D (claim level) will be entered. Price the service based on the ZIP code in Service Facility Location loop 2310D, unless the 2420C (line level) is also entered. In that case, price the service based on the ZIP code in the Service Facility Location lo op 2420C (line level) for that line.  If the POS code is the same for all services, but the services were provided at different addresses, each service shall be submitted with the appropriate address information for each service.  This will provide a ZIP code to price each service on the claim .  B. Entering the Address of Where a Service was Performed on the 5010 Version of the ASC X12 837 Professional Claim  Following the requirements of the implementation guide of the 5010 version of the ASC X12 837professional claim, the complete address of where a service was performed shall be entered.  Pay the service based on the ZIP code of the address of where the service was performed based on the appropriate entry on the claim.  See 30.2.9 and Chapter 12 for information on anti-markup tests.  C.  Paper Claims Submitted on the Form CMS -1500
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Note that for claims processed on the Form CMS-1500 prior to January 1, 2011, the following instructions do not apply to services rendered at POS home  12 or any other places of service contractors consider to be home. (See 10.1.1.1)  It is acceptable for claims to contain POS home and an additional POS code. No service address for POS home needs to be entered for the service rendered at POS home in this situation as the address will be drawn from the beneficiary file (or wherever else the A/B MAC (Part B) is currently storing the beneficiary information) and the information on the claim will apply to the other POS.   Except for the situation described above, the provider shall submit separate claims for each POS.  The specific location where the services were furnished shall be entered on the claim.  Use the ZIP code of the address entered in Item 32 to price the claim .  If multiple POS codes are submitted on the same claim, treat the claim as unprocessable and follow the instructions in 80.3.1.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: M77  MSN: 9.2  Effective January 1, 2011, for claims processed on or after January 1, 2011, submitted on the Form CMS -1500 paper claim, i t will no longer be acceptable for the claim to have more than one POS.  Separate claims must be submitted for each POS.  Contractors shall treat claims submitted with more than one POS as unprocessable and follow the instructions in 80.3.2.1.1.  If the contractor receives a fee -for-service claim containing one or more services for which the MPFS payment locality is in another A/B MAC (Part B)s jurisdiction, handle in accordance with the instructions in 10.1.9.  If you receive a significant volume or experience repeated incidences of misdirected Medicare Physician Fee Schedule claims/services from a particular provider, an educational contact may be warranted. Handle misdirected claims/services for HMO enrollees in accordance with 10.1.1.C and D.
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D. Determining the Correct Payment Locality for Services Paid Under the Medicare Physician Fee Schedule (MPFS) and Anesthesia Services When Rendered in a Payment Locality that Crosses ZIP Code Areas   Per the instructions above, Medicare A/B MACs (Part B) have been directed to determine the payment locality for services paid under the MPFS and anesthesia services by using the ZIP code on the claim of where the service was performed.  It has come to the attention of CMS that some ZIP codes fall into more tha n one payment locality.  The CMS ZIP Code file uses the convention of the United States Postal Service, which assigns these ZIP codes into dominant counties.  In some cases, though the service may actually be rendered in one county, per the ZIP code it is assigned into a different county.  This causes a payment issue when each of the counties has a different payment locality and therefore a different payment amount.  Note that as the for services which have the Anti-markup Test Indicator on the MPFS, the 9-digit ZIP code requirements will also apply to those codes.  Effective for dates of service on or after October 1, 2007, CMS shall provide a list of the ZIP codes that cross localities as well as provide quarterly updates when necessary.  The CMS ZIP Code file shall be revised to two files:  one for 5-digit ZIP code s (ZIP5) and one for 9-digit ZIP codes (ZIP9).  Providers performing services paid under the MPFS, anesthesia services, or any other services as described above, in those ZIP codes that cross payment localities shall be required to submit the 9- digit ZIP c odes on the claim for where the service was rendered.  Claims for services payable under the MPFS and anesthesia services that are NOT performed in one of the ZIP code areas that cross localities may continue to be submitted with 5 -digit ZIP codes.  Claims  for services other than those payable under the MPFS or anesthesia services may continue to be submitted with 5 -digit ZIP codes.