Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections (Rev. 10862, 07-14-21) Transmittals

Medicare Claims Processing Manual

Chapter 30 - Financial Liability Protections

(Rev. 10862, 07-14-21)

Transmittals

10 - Financial Liability Protections (FLP) Provisions

20 - Limitation On Liability (LOL) Under §1879 Where Medicare Claims Are Denied

20.1 - LOL Coverage Denials to Which the Limitation on Liability Applies

20.2 - Denials When the LOL Provision Does Not Apply

20.2.1 - Categorical Denials

30 - Determining Liability for Disallowed Claims Under §1879

30.1 - Beneficiary’s Knowledge and Liability

30.1.1 - Other Evidence of Knowledge

30.2 - Healthcare Provider or Supplier Knowledge and Liability

30.2.1 - Evidence of Healthcare Provider or Supplier Knowledge

30.2.2 - Medical Record Evidence of Healthcare Provider or Supplier

30.2.3 - Acceptable Standards of Practice
30.3 – The Right to Appeal
30.4 - Fraud, Abuse, Patently Unnecessary Items and Services
40 - Written Notice as Evidence of Knowledge
40.1 - Sources of Written Notice
40.2 - Written Notice Standards
40.2.1 - Other Written Notice Standards
40.2.2 - Written Notice Special Considerations
40.3 - Medical Emergency or Otherwise Under Great Duress Situations
40.4- Emergency Medical Treatment and Active Labor Act (EMTALA)

Situations

 

50.2.1 - Optional ABN Uses

50 - Advance Beneficiary Notice of Non-coverage (ABN)
50.1 - ABN Scope
50.2 - ABN Uses

50.3 - Issuance of the ABN

50.4 - ABN Triggering Events
50.5 - ABN Standards
50.6 - Completing the ABN
50.7 - Retention Requirements
50.8 - ABN Delivery Requirements
50.8.1 – Options for Delivery Other than In-Person
50.9 - Effects of Lack of Notification, Medicare Review and Claim Adjudication
50.10 - Using ABNs for Medical Equipment and Supplies Claims When Denials
Under §1834(a)(17)(B) of the Act (Prohibition Against Unsolicited Telephone
Contacts) Are Expected
50.11 - ABNs for Medical Equipment and Supplies Claims Denied Under
§1834(j)(1) of the Act (Because the Supplier Did Not Meet Supplier Number
Requirements)
50.12 - ABNs for Claims Denied in Advance Under §1834(a)(15) of the Act
50.13 - ABN Standards for Upgraded Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS)
50.14 - ABNs for items listed in a DMEPOS Competitive Bidding Program (CBP)
50.15 - Collection of Funds and Refunds
50.15.1 - Physicians’ Services RR
50.15.2 - DMEPOS RR Provision for Claims for Medical Equipment and
Supplies
50.15.3 - Time Limits and Penalties for Healthcare Providers and
Suppliers in Making Refunds
50.15.4 - Supplier’s Right to Recover Resalable Items for Which Refund
Has Been Made
50.16 - CMS Regional Office (RO) Referral Procedures
50.17 - ABN Special Considerations
60 - Home Health Change of Care Notice (HHCCN), Form CMS-10280
60.1 - Background on the HHCCN
60.2 - Scope of the HHCCN
60.3 - Triggering Events for HHCCN/ Written Notice
60.4 - Completing the HHCCN
60.5 - HHCCN Delivery
70 - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN)
70.1 - SNF ABN Standards
70.2 - Situations in Which a SNF ABN Should Be Given

70.3 - Situations in Which a SNF ABN Is Not Needed to Transfer Financial Liability to
the Beneficiary
70.4 - SNF ABN Specific Delivery Issues
70.5 - Special Rules for SNF ABNs
70.6 - Establishing When Beneficiary Is On Notice of Non-coverage
70.6.1 - Source of Beneficiary Notification
80 - Hospital ABNs (Hospital-Issued Notices of Noncoverage - HINN)
100 - Indemnification Procedures for Claims Falling Within the Limitation on Liability
Provision
100.1 - Contractor and Social Security Office (SSO) Responsibility in
Indemnification Claims
100.2 - Conditions for Indemnification
100.3 - Development and Documentation of Indemnification Requests
100.3.1 - Proof of Payment

100.4 - Beneficiary Requests Indemnification, but Had No Financial Interest in
the Claim

100.5 - Questionable Indemnification Requests Procedure
100.6 - Determining the Amount of Indemnification
100.7 - Notifying the Provider, Practitioner, or Supplier
100.8 - Making Payment Under Indemnification

100.9 - Limitation on Liability Determination Does Not Affect Medicare
Exclusion

100.10 - Exhibits
Exhibit 1 - Letter to Provider
Exhibit 2 - Letter to Beneficiary Who Requests Indemnification
Exhibit 3 - Letter to Someone Other Than Beneficiary Who Requests

Indemnification

Exhibit 4 - Letter to Practitioner or Supplier (Noninstitutional Services)
Exhibit 5 - Letter to Beneficiary Who Requests Indemnification
(Noninstitutional Services)
Exhibit 6 - Letter to Someone Other Than Beneficiary Who Requests
Indemnification (Noninstitutional Services)
Exhibit 7 - Statement of Claimant or Other Person
110 - Contractor Instructions for Application of Limitation On Liability
110.1 - Payment Under Limitation on Liability 

110.2 - When to Make Limitation on Liability Decisions
110.3 - Preparation of Denial Notices
110.4 - Bill Processing
110.5 - Contractor Review of ABNs
110.5.1 - General Rules
110.5.2 - Situations in Which Contractor Review of ABNs is Indicated
110.5.3 - Other Reasons for Contractor Request for Copies of ABNs
120 - Contractor Specific Instructions for Application of Limitation on Liability
120.1 - Documentation of Notices Regarding Coverage
120.2 - Availability of Coverage Notices to Operating Personnel
120.3 - Applicability of Limitation on Liability Provision to Claims for Outpatient
Physical Therapy Services Furnished by Clinics
120.4 - Limitation on Liability Notices to Beneficiaries From Contractors
120.5 - Contractor Redeterminaions or Reconsiderations in Assignment Cases
Conducted at the Request of Either the Beneficiary or the Assignee
120.5.1 - Guide Paragraphs for Contractors to Use Where §1879 Is
Applicable at Redetermination Level

130 - A/B MAC (A) and (HHH) Specific Instructions for Application of Limitation on
Liability

130.1 - Applicability of the Limitation on Liability Provision to Claims for
Ancillary, Outpatient Provider and Rural Health Clinic Services Payable Under
Part B
130.1.1 - Determining Beneficiary Liability in Claims for Ancillary and
Outpatient Services
130.1.2 - Determining Provider Liability in Claims for Ancillary and
Outpatient Services
130.2 - Prior Hospitalization and Transfer Requirements for SNF Coverage as
Related to Limitation on Liability
130.3 - Application of Limitation on Liability to SNF and Hospital Claims for
Services Furnished in Noncertified or Inappropriately Certified Beds
130.4 - Determining Liability for Services Furnished in a Noncertified SNF or
Hospital Bed
140 - Physician Refund Requirements (RR) Provision for Nonassigned Claims for
Physicians Services Under §1842(l) - Instructions for Contractors and Physicians
140.1 - Services Furnished Before October 1, 1987
140.2 - Services Furnished Beginning October 1, 1987
140.3 - Time Limits for Making Refunds140.4 - Situations Where a Refund Is Not Required

140.5 - Appeal Rights
140.6 - Processing Initial Denials
140.6.1 - Initial Beneficiary Notices
140.6.2 - Initial Physician Notices
140.7 - Processing Beneficiary Requests for Appeal
140.8 - Processing Physician Requests for Appeal
140.8.1 - Appeal of the Denial or Reduction in Payment
140.8.2 - Beneficiary Given ABN and Agreed to Pay
140.8.3 - Physician Knowledge
140.9 - Guide Paragraphs for Inclusion in Appeal Determination
140.10 - Physician Fails to Make Refund
140.11 - OIG Referral Procedures
140.12 - Imposition of Sanctions
150 - DMEPOS Refund Requirements (RR) Provision for Claims for Medical Equipment
and Supplies under §§1834(a)(18), 1834(j)(4), and 1879(h) - Instructions for Contractors
and Suppliers
150.1 - Definition of Medical Equipment and Supplies
150.1.1 - Unassigned Claims Denied on the Basis of the Prohibition on

Unsolicited Telephone Contacts

150.1.2 - Unassigned Claims Denied on the Basis of Not Being
Reasonable and Necessary
150.1.3 - Unassigned Claims Denied on the Basis of Failure of the
Supplier to Meet Supplier Number Requirements
150.1.4 - Assigned Claims Denied on the Basis of the Prohibition on
Unsolicited Telephone Contacts
150.1.5 - Assigned Claims Denied on the Basis of Failure of the Supplier
to Meet Supplier Number Requirements
150.1.6 - Assigned Claims Denied on the Basis of Not Being Reasonable
and Necessary
150.2 - Items and Services Furnished on an Unassigned Basis on or After January
1, 1995
150.3 - Items and Services Furnished On an Assigned Basis On or After January
1, 1995
150.4 - Time Limits for Making Refunds
150.5 - Supplier Knowledge Standards for Waiver of Refund Requirement 

150.5.1 - Knowledge Standards for §1862(a)(1) Denials
150.5.2 - Knowledge Standards for §1834(a)(15) Denials
150.5.2.1 - Denial of Payment in Advance
150.5.2.2 - When a Request for an Advance Determination of
Coverage Is Mandatory
150.5.2.3 - When a Request for an Advance Determination of
Coverage Is Optional
150.5.2.4 - Presumption for Constructive Notice
150.5.2.5 - Presumption When Advance Determination was
Requested
150.5.2.6 - Presumption for Listed Overutilized Items
150.5.2.7 - Presumption for Listed Suppliers
150.5.2.8 - Presumption for Medical Necessity
150.5.2.9 - Presumption About Beneficiary Knowledge
150.5.3 - Knowledge Standards for §1834(a)(17)(B) Denials
150.5.4 - Knowledge Standards for §1834(j)(1) Denials
150.5.5 - Additional Knowledge Standards for All Medical Equipment and
Supplies Denials
150.6 - Advance Beneficiary Notice Standards for Waiver of Refund Requirement
150.7 - Appeal Rights
150.8 - Processing Initial Denials
150.9 - Processing Beneficiary Requests for Appeal
150.10 - Processing Supplier Requests for Appeal
150.10.1 - Appeal of the Denial of Payment
150.10.2 - Beneficiary Given Advance Beneficiary Notice and Agreed to
Pay
150.10.3 - Supplier Knowledge
150.11 - Guide Paragraphs for Inclusion in Appeal Determination
150.12 - Supplier Fails to Make Refund
150.13 - CMS Regional Office (RO) Referral Procedures
150.14 - Imposition of Sanctions
150.15 - Supplier’s Right to Recover Resaleable Items for Which Refund Has
Been Made
200 - Expedited Review Process for Hospital Inpatients in Original Medicare
200.1- Scope of the Instructions

200.2 - Special Considerations

200.3 - Notifying Beneficiaries of their Right to an Expedited Review
200.3.1 - Delivery of the Important Message from Medicare
200.3.2 - The Follow-Up Copy of the Signed Important Message from
Medicare
200.4 - Rules and Responsibilities when a Beneficiary Requests an Expedited

 
Review
200.4.1 - The Role of the Beneficiary and Liability
200.4.2 - The Responsibilities of the Hospital
200.4.3 - The Role of the QIOs
200.4.4 - Effect of a QIO Expedited Determination
200.5 - General Notice Requirements
200.5.1 - Number of Copies
200.5.2 - Reproduction
200.5.3 - Length and Page Size
200.5.4 - Contrast of Paper and Print
200.5.5 - Modification
200.5.6 - Font
200.5.7 - Customization
200.5.8 - Retention of the Notices
200.6 - Completing the Notices
200.6.1 - Translated Notices
200.6.2 Exhibit 1 - An Important Message from Medicare (CMS-R-193)
and Form Instructions
200.6.3 Exhibit 2 - The Detailed Notice of Discharge (CMS 10066) and
Form Instructions
220 - Hospital Requested Expedited Review
220.1 - Responsibilities of the Hospital
220.2 - Responsibilities of the QIO
220.3 - Effect of the Hospital Requested Expedited Determination
220.4 - General Notice Requirements
220.5 - Exhibit 3 - Model Language Notice of Hospital Requested Review (HRR)
240 - Preadmission/Admission Hospital Issued Notice of Noncoverage (HINN)
240.1 - Delivery of the Preadmission/Admission HINN

 240.2 - Notice Delivery Timeframes and Liability

240.3 - Timeframes for Submitting a Request for a QIO Review
240.4 - Results of the QIO Review
240.5 - Effect of the QIO Review
240.6 - Exhibit 4 - Model Language Preadmission/Admission Hospital Issued
Notice of Noncoverage
260 - Expedited Determinations of Provider Service Terminations
260.1 - Statutory Authority
260.2 - Scope
260.2.1 - Exceptions
260.3 - Notice of Medicare Non-Coverage
260.3.1 - Alterations to the NOMNC
260.3.2 - Completing the NOMNC
260.3.3 - Provider Delivery of the NOMNC
260.3.4 - Required Delivery Timeframes
260.3.5 - Refusal to Sign the NOMNC
260.3.6 - Financial Liability for Failure to Deliver a Valid NOMNC
260.3.7 - Amending the Date of the NOMNC
260.3.8 - NOMNC Delivery to Representatives
260.3.9 - Notice Retention for the NOMNC
260.3.10- Hours of NOMNC Delivery
260.4 - Expedited Determination Process
260.4.1 - Beneficiary Responsibilities
260.4.1.1 - Timeframe for Requesting an Expedited Determination
260.4.1.2 - Provide Information to QIO
260.4.1.3 - Obtain Physician Certification of Risk (Home Health
and CORF services only)
260.4.2 - Beneficiary Liability During QIO Review
260.4.3 - Untimely Requests for Review
260.4.4 - Provider Responsibilities
260.4.5 - The Detailed Explanation of Non-Coverage
260.5 - QIO Responsibilities
260.5.1 - Receive Beneficiary Requests for Expedited Review