evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
130.1.1 - Determining Beneficiary Liability in Claims for Ancillary and Outpatient Services  (Rev. 594, Issued: 06- 24-05, Effective: 07 -01-05, Implementation: 07- 01-05)  A presumption will be made that the beneficiary did not know that items or services are not covered unless there is evidence to the contrary. Indication on the claim that the beneficiary received proper advance beneficiary notice before receiving the nonco vered ancillary, outpatient, or rural health clinic services is evidence to the contrary which rebuts the presumption in the beneficiarys favor. The definitions of proper advance beneficiary notice to the beneficiary are set forth in 40.3. Note that if the reason liability is at issue coincides with the end of coverage for a period of care in specific settings -- inpatient hospital, skilled nursing, home health, hospice or comprehensive outpatient rehabilitation facilities -- notification un der the expedited determination process will be required as of July 1, 2005.  See CR#3903 for preliminary information on the expedited process, including its interaction with liability notice policy (i.e., ABNs).  130.1.2 - Determining Provider Liability in Claims for Ancillary and Outpatient Services  (Rev. 1, 10- 01-03)  The procedures in 30.2 apply for determining liability for providers. A provider may have its liability waived in an individual claim if it can establish that it did not know and could not have been expected to know that Medicare would not make payment for the items or services .  130.2 - Prior Hospitalization and Transfer Requirements for SNF Coverage as Related to Limitation on Liability  (Rev. 1, 10- 01-03)  In order to qualify for post -hospital extended care services, the individual must meet the prior hospitalization and transfer requirements discussed in Coverage of Extended Care Services Under Hospital Insurance, Chapter 8 of the Medicare Benefit Policy Manual. The following sections discuss the relationship of these requirements to the limitation on liability provision.   A.  Three- Day Prior Hospitalization
(Medicare Claims Processing Manual)
A.  Three- Day Prior Hospitalization   Before Medicare can pay for post -hospital extended care services, it must determine whether the beneficiary had a prior qualifying hospital stay of at least three consecutive calendar days. When a beneficiarys liability for a hospital stay is waived, the hospital days to which the limitation on liability applies cannot be used to satisfy the 3- day prior hospitalization requirement, since the services rendered during the days in question were found noncovered because they were not considered reasonable and necessary or because they constituted custodial care. (See Coverage of Extended Care (SNF) Services Under Hospital Insurance, Chapter 8, of the Medicare Benefit Policy Manual for determining whether the 3 -day prior hospitalization requirement is met.) If  a beneficiarys hospital stay was partially covered, the A/B MAC (A) considers the covered portion of the stay in determining whether the SNF prior hospitalization requirement is met.   B.  Transfer Requirements   1.  Transfer Period   The A/B MAC (A) applies the limitation on liability provision where it determines that all the SNF care received during the period serving to satisfy the transfer requirements described in Coverage of Extended Care Services Under Hospital Insurance, Chap ter 8 of the Medicare Benefit Policy Manual, either constituted custodial care or was not reasonable and necessary.   Where the A/B MAC (A) determines that only the beneficiarys liability can be waived, the limitation on liability applies through the date of the notice to the beneficiary including any inpatient days beyond the transfer period. If the provider is also ent itled to limitation on liability and program payment is possible under the limitation on liability provision, such payment is appropriate through the date of the notice and, if the A/B MAC (A) determines that additional time is needed to arrange for post -discharge care, for up to 24 hours after the date of notice to the provider or the beneficiary, whichever is earlier. If the A/B MAC (A) determines that even more time is needed to arrange post -discharge care, up to 24 additional hours may be paid for. (See  50.)
(Medicare Claims Processing Manual)
Where a beneficiary who is entitled to limitation on liability starts to require and receives reasonable and necessary or noncustodial services only after the expiration of the SNF transfer period, the beneficiary nevertheless may have his/her liability waived for days where such services were rendered, in addition to those days waived during the noncovered transfer period but only through the date of notice to the beneficiary . If the provider is also entitled to limitation on liability, program payment may be made under the limitation on liability provision through the date of notice of noncoverage and, if the A/B MAC (A) determines that additional time is needed to arrange for post -discharge care, for a grace period of l day thereafter. If the A/B MAC (A) determines that even more time is needed to arrange post -discharge care, 1 additi onal grace period day may be paid for. (See 50.) This payment is made because it is inequitable to waive liability for noncovered services rendered during the transfer period but not for a period thereafter (prior to notice) during which the beneficiary needed and received an otherwise covered level o f care.   2.  Delayed Transfer Due to Medical Appropriateness   The law also provides for an extension of the usual 30- day time limit for transfer where the patients condition makes it medically appropriate. (Coverage of Extended Care Services Under Hospital Insurance, in the Medicare Benefit Policy Manual, Chapter 8.) However, if the A/B MAC (A) determines that such an extension is not allowable because an interval of more than 30 days for transfer to a SNF was not medically appropriate, it denies the SNF services because the transfer requirement was not met. The li mitation on liability provision is not applicable in such a case.   130.3 - Application of Limitation on Liability to SNF and Hospital Claims for Services Furnished in Noncertified or Inappropriately Certified Beds  (Rev. 4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  A.  General
(Medicare Claims Processing Manual)
A.  General   Payment for SNF and hospital claims may not be denied solely on the basis of a beneficiarys placement in a non- certified portion of the same institution that also includes a participating SNF or hospital. When requested by the beneficiary or his/her authorized representative, a provider must submit a claim to the A/B MAC (A) for services rendered in a non -certified bed. When the A/B MAC (A) reviews a claim for services rendered in a non -certified bed, it first determines whether the beneficiary consented t o the placement. (See subsection C.) If the A/B MAC (A) finds that the beneficiary consented, it denies the claim. If it finds that the beneficiary did not consent, it determines whether there are any other reasons for denying the claim. (See subsection D.) If there is another reason for denying the claim, the A/B MAC (A) denies it. However, if none of the reasons for denial exist, beneficiary liability must be waived as provided under 1879(e)  of the Act and a further determination must be made as to whether the provider, rather than the Medicare program, must accept liability for the services in question. (See Coverage of Extended Care Services Under Hospital Insurance in the Medicare Benefi t Policy Manual, Chapter 8.)   B.  Provider Notice Requirements   When a SNF or hospital places a patient in a noncertified or inappropriately certified portion of the institution because it believes the patient does not require a covered level of care, or for any other reason, it must notify the patient (or authorized r epresentative) in writing that services in a noncertified or inappropriately certified bed are not covered. The provider uses the appropriate notice specified in 70 for SNFs or swing beds, 80 for inpatient hospitals, to advise the beneficiary of its decision to place him/her in a noncertified bed, using language such as:
(Medicare Claims Processing Manual)
We are placing you in a part of the institution that is not appropriately certified by Medicare because (you do not require a level of care that will qualify as skilled nursing care/or covered hospital services under Medicare)/(or state any other reasons f or the noncertified bed placement). Nonqualifying services furnished a patient in a noncertified or inappropriately certified bed are not payable by Medicare. However, you may request us to file a claim for Medicare benefits. Based on this claim, Medicare will make a formal determination and advise whether any benefits are payable to you.   (For related general billing requirements, see Chapter 1, 60 of this manual, or other chapters specific to the benefit being billed: Chapter 3 for inpatient hospitals and swing beds, Chapter 6 for swing bed PPS and inpatient SNFs, and Chapter 7 for outpatient SNFs.)   C.  Determining Beneficiary Consent
(Medicare Claims Processing Manual)
C.  Determining Beneficiary Consent   The CMS presumes that the beneficiary did not consent to being placed in a noncertified bed. In order to rebut the presumption of lack of consent, the provider must indicate on the bill the date it provided the beneficiary with an ABN notifying the benefic iary that the accommodations would no longer be covered; and requested the beneficiarys signed acknowledgement (on the ABN) of having received such a statement. Moreover, in any case in which a Medicare beneficiary gives his/her consent to placement in a noncertified bed, the provider must, if requested by the A/B MAC (A) (contemplated only at an appeal level of claim processing), submit a copy of the ABN signed by the beneficiary to the A/B MAC (A), for a determination of the ABNs validity. The ABN must be signed by the beneficiary (provided he/she is competent to give such consent) or by the beneficiarys authorized representative. If the beneficiary or his/her authorized representative refuses to sign the form, the provider may annotate the file to indi cate it presented the ABN to the beneficiary (or his/her authorized representative), but the beneficiary refused to sign. As long as the providers ABN notifies the beneficiary of the likely Medicare noncoverage, the beneficiarys refusal to sign the ABN does not render it invalid. (See 40.3.4.6.)  If any of the above requirements is not met, the A/B MAC (A) automatically determines the ABN is defective.
(Medicare Claims Processing Manual)
When the A/B MAC (A) receives a claim with an indication that the provider has provided the beneficiary or his/her authorized representative, with an ABN, the A/B MAC (A) denies the claim and notifies the beneficiary that 1879 limitation on liability cann ot be applied because of the beneficiarys valid consent to be cared for in a noncertified or inappropriately certified bed.  If the A/B MAC (A) determines that the ABN is not valid, the A/B MAC (A) processes the claim in accordance with 130.4.  If the beneficiary appeals the initial denial, the A/B MAC (A) obtains the ABN from the provider and determines whether it is valid. If the A/B MAC (A) determines that the ABN is invalid, it notifies the provider and the beneficiary that payment may be made to the extent that all other requirements are met.   D.  Determining Whether Other Requirements for Payment are Met   Denials still are appropriate for any of the following reasons. The A/B MAC (A) must undertake the development needed to permit a determination as to whether:    The patient did not receive or require otherwise covered hospital services or a covered level of SNF care;    The benefits are exhausted;    The physicians certification requirement is not met;   There was no qualifying 3- day hospital stay (applicable to SNFs only); or    Transfer from the hospital to the SNF was not made on a timely basis. (However, if transfer to an institution which contains a participating SNF is made on a timely basis, a claim cannot be denied solely on the grounds that the transfer requirement is not met because the bed in which the beneficiary is placed is not a certified SNF bed.)   The A/B MAC (A) denies cases falling within these categories under existing procedures. Also, if the beneficiary receives care in a totally nonparticipating institution, denial on the grounds that the beneficiary was not in a participating SNF or hospital is still appropriate.
(Medicare Claims Processing Manual)
130.4 - Determining Liability for Services Furnished in a Noncertified SNF or Hospital Bed  (Rev .4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  The A/B MAC (A) presumes that the provider properly notified the beneficiary of noncoverage, and that the beneficiary assented, if the claim includes the proper indicators of liability notification.   The following development occurs only if the beneficiary appeals the A/B MAC (A)s decision that the beneficiary may not have liability waived because the provider gave him/her timely notice that Medicare would not cover the accommodation; and that he/she consented to being placed in a noncertified bed.   A.  Beneficiary Liability   If the A/B MAC (A) determines that the beneficiary did not consent to placement in a noncertified portion of the same institution that also includes the participating facility (see 130.3.C ), and that no other basis for denial of the claim exists (see 130.3.D ), it finds the beneficiary not liable under 1879 of the Act.  B.  Provider Liability   If the beneficiary is found not liable under 1879, liability may rest with the provider, or with the program. Liability rests with the Medicare program, unless any of the following conditions exist, in which case the provider is liable for the services.   The provider did not give timely written notice to the beneficiary of the implications of receiving care in a noncertified or inappropriately certified bed as discussed in 130.3.B ;  The provider failed to provide the beneficiary with an appropriate ABN and/or did not attempt to obtain a valid consent statement from the beneficiary. (See 130.3.C .); or
(Medicare Claims Processing Manual)
The provider failed to provide the beneficiary with an appropriate ABN and/or did not attempt to obtain a valid consent statement from the beneficiary. (See 130.3.C .); or  The A/B MAC (A) determined from medical records in its claims files that it is clear that the beneficiary required and received services equivalent to a covered level of SNF care, or that constituted covered hospital services, and the provider had no reaso nable basis for placing the beneficiary in a noncertified bed. Following are examples of situations in which it would be found that the provider did in fact have a reasonable basis to place a beneficiary in a noncertified bed:     EXAMPLES:    The A/B MAC (A), a QIO, or Utilization Review Committee had advised the provider that the beneficiary did not require a covered level of SNF care or covered hospital services preadmission/admission;    The beneficiarys attending physician specifically advised the provider (verified by documentation in the medical record) that the beneficiary no longer required a covered level of care or services; note that if covered care had previously existed, effecti ve July 1, 2005, notification under the expedited determination process would be required (see 20);    A beneficiary not requiring covered services had a change in his/her condition that later required a covered level of care or services and the provider had no certified bed available (of course, the SNF transfer requirement must be met, see the Medicare Benefit Policy Manual, Chapter 8.); or    The A/B MAC (A) has other sufficient evidence to determine that the provider acted in good faith but inadvertently placed the beneficiary in a noncertified bed.  140 - Physician Refund Requirements (RR) Provision for Nonassigned Claims for Physicians Services Under 1842(l) - Instructions for Contractors and Physicians  (Rev. 1587, Issued: 09- 05-08, Effective: 03 -03-08, Implementation: 03- 01-09)
(Medicare Claims Processing Manual)
Following are the procedures for implementing 1842(l)  of the Act. Under 9332(c) of OBRA 1986 (P.L. 99- 509), which added 1842(l) to the Act, new liability protections for Medicare beneficiaries affect nonparticipating physicians.   140.1 - Services Furnished Before October 1, 1987  (Rev. 1, 10- 01-03)  Before October 1, 1987, a physician who did not accept Medicare assignment was permitted to collect from a Medicare beneficiary his/her full charge for services which were subsequently denied because they were not reasonable and necessary under 1862(a)(1)  of the Act, even though the beneficiary may not have known that Medicare would not pay for the services. This was in contrast to the rules applicable to assigned claims. Where a physician agrees to accept assignment (either on an individual claims basis o r by entering into a Medicare participation agreement), the physician is effectively precluded by the indemnification procedures under the limitation of liability provision from receiving payment for services that are not reasonable and necessary if it is established that the physician knew or should have known that Medicare would not pay for the services and the beneficiary did not. However, under the limitation of liability provision, program payment may be made to the physician if neither the physician nor the patient knew, nor could reasonably have been expected to know, that Medicare would not pay for the items and services.   140.2 - Services Furnished Beginning October 1, 1987  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  Under 1842(l) of the Act, effective for services furnished on or after October 1, 1987, nonparticipating physicians who  1. Do not accept assignment,  2. Do not claim payment after the death of the beneficiary, and   3. Do not bill under the indirect payment procedure must refund to beneficiaries any amounts collected for physicians services which are denied because they are not reasonable and necessary under 1862(a)(1) .
(Medicare Claims Processing Manual)
3. Do not bill under the indirect payment procedure must refund to beneficiaries any amounts collected for physicians services which are denied because they are not reasonable and necessary under 1862(a)(1) .  This provision is applicable in any case in which the contractor denies payment or reduces the level of payment on the basis of 1862(a)(1). In the latter situation, there is, in effect, a denial of the more extensive service or procedure on the basis that  it is not reasonable and necessary under 1862(a)(1), even though Medicare payment is made for the less extensive service or procedure (e.g., an intermediate office visit is allowed as a brief office visit). Where a reduction in the level of payment occurs, the physician must refund to the beneficiary any amounts he/she collects which exceed his/her maximum allowable actual charge (MAAC) for the less extensive procedure. Of course, in the unusual case where the physicians MAAC for the less extensive service equals or exceeds his/her actual charge for the more extensive service, no refund is required.
(Medicare Claims Processing Manual)
Section 1842(l) of the Act applies only to physicians services subject to the Medicare Economic Index (MEI). Certain services, such as those involving injections that can be given by a paramedical person other than a physician (e.g., pneumococcal and hepa titis vaccine injections) which may be denied under 1862(a)(1) are not physicians services for purposes of the MEI. Therefore, denials of payment on the basis of 1862(a)(1)(B) of the Act for those services are not subject to 1842(l) refund requirements . Additionally, services of physician extenders (e.g., physicians assistants, nurse practitioners, MEDEXes, etc.) are not physicians services and are not subject to 1842(l) refund requirements. The application of 1842(1) refund requirements on the corr ect statutory basis, i.e., only on the basis of 1862(a)(1), and only to physicians services subject to the MEI, is essential. Incorrect application improperly takes away physicians rights to bill beneficiaries for denied services and incurs unnecessary expenses for review, development, and appeals.  140.3 - Time Limits for Making Refunds  (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)  A required refund must be made within specified time limits. Physicians who knowingly and willfully fail to make refund within these time limits may be subject to civil money penalties and/or exclusion from the Medicare program. Under 1842(1)  , a refund of any amounts collected must be made to the beneficiary within the following time limits:    If the physician does not request an appeal of the initial denial or reduction in payment within that time, the refund must be made to the beneficiary within 30 days after the date the physician receives notice of the initial determination. (See 140.6 for notice requirements.); or    If the physician requests an appeal within 30 days of receipt of the notice of the initial determination, the refund must be made to the beneficiary within 15 days after the date the physician receives the notice of the appeal determination.
(Medicare Claims Processing Manual)
 If the physician requests an appeal within 30 days of receipt of the notice of the initial determination, the refund must be made to the beneficiary within 15 days after the date the physician receives the notice of the appeal determination.   140.4 - Situations Where a Refund Is Not Required  (Rev. 1, 10- 01-03)  Under 1842(1), a refund is not required of the physician if either of the following conditions is met:   1. The physician did not know and could not reasonably have been expected to know that Medicare would not pay for the services because they were not reasonable and necessary.  To determine whether the physician knew, or could reasonably have been expected to know, use the rules for determining physician liability under 1879.  (See 30.2.); or   2. Before the service was furnished, the physician notified the beneficiary in writing of the likelihood that Medicare would not pay for the specific service and, after being so informed, the beneficiary signed a statement agreeing to pay the physician for the service.   To qualify for waiver of the refund requirements of 1842(1), the advance notice to the beneficiary must be in writing, must clearly identify the particular service, must state that the physician believes Medicare is likely to deny payment  for the particular service, and must give the physicians reason(s) for his/her belief that Medicare is likely to deny payment for the service. The Advance Beneficiary Notice (ABN, Form CMS -R-131), given in compliance with 40.3 and 50, satisfies the statutory requirements for the physicians advance notice and the beneficiarys agreement to pay.   140.5 - Appeal Rights (Rev. 1186, Issued:  02- 23-07; Effective:  01 -01-06; Implementation:  05 -23-07)