Franciscan Catholic & BRGeneral "I am dead. My internal organs do not exist" Non-COVID emergencies flexibility to support beneficiaries in Louisiana

 

Detailed information regarding non-COVID emergencies giving us the flexibility to support our beneficiaries in Louisiana

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4. The APA is also the most important medicine association in the world with over 38,800 Dr.
5. members specializing in the identification, treatment, hindrance and analysis of mental sicknesses.
6. APA’s vision is to make sure access to quality psychiatrical medicine and treatment.
7. For additional data please visit World Wide Web.psychiatry.org. Media Contacts Erin James Scott Connors, 202-609-7113 econnors@psych.org Press Line, 202-459-9732By the tip of this coaching module, learners are going to be in a position to: 1.
8. Define racism and its operative levels (e.g., institutional, social, internal) as they ran into with psychological state access and outcomes for African yank patients.
9. 2.
10. Describe 5 ways in which racial bias impacts diagnosing and treatment of mental disorders in African yankee patients.
11. 3.
12. Suggest 2 methods for addressing racial bias in mental state care.
13. Introduction Health inequities have been are among people with minority racial standing for whom discrimination may be a common experience.1–4 inside medicine, it has been shown that racial minorities are less doubtless to attain symptom remission and are a lot of doubtless to be indeterminately impaired given a mental state diagnosing.5,6 Bias and racism have been are as key factors tributary to those inequities.7,8 The gift of slavery and racism, still because the current realities of racial oppression and violence, has unambiguously compact the mental state of African Americans.
14. For African Americans, mental state inequities began throughout the time of exploitation and slavery, once myths of racism were being integrated into the developing field of medicine.
15. By the tip of the nineteenth century, several psychologists accepted an inspiration that African Americans were biologically inferior, with smaller brains and a natural instinct for labor.9 African Americans who participated in the meliorist and Civil Rights movements were met with prejudice by psychological state practitioners, who tagged them schizophrenic World Health Organization their supposed pathologic need for equality.9 This distinctive history warrants specific focus throughout residency coaching.
16. The overdiagnosis of dementia praecox among African Americans persists nowadays,7,10–12 and that they are additional doubtless to be treated with atarac medications that may have lasting, negative facet effects.13–15 to boot, African Americans have higher rates of severe depression nonetheless lower rates of treatment compared to white populations.16 African Americans are less doubtless to receive office-based substance for psychological stressors17 and are a lot of doubtless to be seen in emergency rooms.18 Among whites, there's a persistence of negative racial stereotypes of African Americans as headless, lazy, preferring to measure off welfare, and liable to violence.19 Health care disparities are tutored at the grad school level primarily through the lens of cultural ability.20–22 Limitations to the present approach, however, embrace assertions that we must go “beyond notions of ‘cultural competency’ to think about problems with power and privilege, difference, and identity in fostering knowledgeable self committed to fairness and justice.”23,24 in addition, issues that cultural ability washes out the particular effects of race are supported by Flores, Gee, and Kastner.25 when racism is directly self-addressed in medical coaching, positive amendment in implicit racial attitudes has been shown.26,27 240.2 - Conditions and Examples That May Establish Good Cause for Late Filing by Beneficiaries (Rev.
17. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) A.
18. Conditions Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following: • Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties; • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline); NOTE: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request; • When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster); • Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely; • Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person; • A death or serious illness in his or her immediate family; • A request was sent to a Government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired; or • Delay due to additional time required to produce the beneficiary’s Medicare documents (such as an MSN) in an accessible format (e.g., large print, Braille, etc.); • Delay as the result of an individual having sought and received help from an auxiliary resource (such as a SHIP or senior center), due to his or her disability, in order to be able to file the appeal.
19. B.
20. Examples Following are examples of cases where good cause for late filing is found.
21. This list is illustrative only and not all-inclusive: • Beneficiary was hospitalized and extremely ill, causing a delay in filing; • Beneficiary is deceased.
22. Her husband, as representative of the beneficiary’s estate, died during the appeals filing period.
23. Request was then filed late by the deceased husband’s executor; • The denial notice sent to the beneficiary did not specify the time limit for filing for the redetermination; and • The request was received after, but close to, the last day to file, and the beneficiary claims that the request was submitted timely.
24. 240.3 - Conditions and Examples That May Establish Good Cause for Late Filing by Providers, Physicians, or Other Suppliers (Rev.
25. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) In general, A/B MACs (A), (B), (HHH), and DME MACs should not routinely find good cause when a provider, physician or other supplier submits an untimely appeal request.
26. However, good cause may be found when the record clearly shows, or the provider, physician or other supplier alleges and the record does not negate, that the delay in filing was due to one of the following: • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the MACs, or the Social Security Administration) to the provider, physician, or other supplier; or • Unavoidable circumstances that prevented the provider, physician, or other supplier from timely filing a request for redetermination.
27. Unavoidable circumstances encompass situations that arebeyond the provider, physician or supplier’s control, such as major floods, fires, tornados, and other natural catastrophes.
28. NOTE: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is NOT grounds for finding good cause for late filing.
29. The MAC does not find good cause where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.
30. 240.4 – Good Cause - Administrative Relief Following a Disaster (Rev.
31. 4380, Issued: 08-30-19, Effective: 07-08-19, Implementation: 10- 01-19) When a disaster occurs, whether natural or man-made, MACs shall anticipate both an increased demand for emergency and other health care services, and a corresponding disruption to normal health care delivery systems and networks.
32. For appeals purposes, as defined in this IOM, a ‘disaster area’ is declared by the Federal Emergency Management Agency (FEMA).
33. In disaster situations, MACs that process appeals for beneficiaries, providers, and suppliers affected by a disaster shall exercise good cause in accordance with regulations and follow the guidance below regarding how to process Fee-for-Service appeal requests in an area(s) declared by FEMA as a disaster area.
34. When a Presidential declaration occurs, the HHS Secretary may, under section 319 of the Public Health Service Act, declare that a Public Health Emergency (PHE) exists in the affected State.
35. Once a PHE is declared, section 1135 of the Social Security Act authorizes the Secretary, among other things, to temporarily modify or waive certain Medicare, Medicaid, CHIP, and HIPAA requirements as determined necessary by CMS.
36. A.
37. Definition of Disaster A disaster is defined as any natural or man-made catastrophe (such as hurricane, tornado, earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing, fire, flood, or explosion) which causes damage of sufficient severity and magnitude to partially or completely destroy medical records and associated documentation that could be needed and/or requested by the MACs in the course of the adjudication process, interrupts normal mail service (including US Postal delivery, overnight parcel delivery services, etc.), impacts ability to file appeals in a timely manner, and/or otherwise significantly limit the provider’s/supplier's daily operations.
38. A disaster may be widespread and impact multiple structures (e.g., a regional flood) or isolated and impact a single site only (e.g., water main failure).
39. The fact that a provider/supplier is located in a presidentially declared disaster area under the power of the Stafford Act is not sufficient in itself to justify administrative relief, as not all structures in the disaster area may have been subject to the same amount of damage.
40. Damage must be of sufficient severity and extent to compromise retrieval of medical records.
41. The provider/supplier needs to state that they were impacted by the disaster.
42. B.
43. Basis for Providing Administrative Relief In the event of a disaster, MACs shall grant temporary administrative relief to any affected providers and suppliers for up to 6 months (or longer with good cause).
44. Administrative relief is to be granted to providers/suppliers/beneficiaries on a case-by-case basis in accordance with the following guidelines: 1.
45. Situation: A provider/supplier/beneficiary in the affected area needs an extension to file a request for an appeal.
46. Action: The MAC shall grant an extension to request an appeal under the good cause exception.
47. Please see 42 CFR § 405.942. If the request is related to an overpayment, the MAC shall accept the request and stop recoupment immediately.
48. 2.
49. Situation: The MAC has requested or needs to request additional documentation for a pending appeal, but the provider/supplier/beneficiary has been impacted by a disaster.Action: The MAC shall hold the request until the documentation can be obtained or submitted.
50. However, to the extent that the contractor can use other data sources that are available to substantiate payment for the claim, it should do so.
51. The CMS will waive the timeliness requirements for processing these appeals.
52. 3.
53. Situation: A request for an appeal filed by an appointed representative on behalf of a party contains a missing or defective appointment instrument and the party is in the affected area.
54. Action: The contractor shall process the request and attempt to obtain the corrected appointment instrument.
55. If the corrected appointment instrument is not received by the end of the appeals adjudication period, contractors shall send the redetermination decision letter to the appellant party and any other party to the appeal, but not to the individual attempting to act as the representative.
56. 4.
57. Situation: A MAC receives a request for redetermination from a provider/supplier/beneficiary in the affected area and the request is missing some of the required elements to make it a valid request.
58. However, the MAC has information in the shared systems that would allow it to identify the missing element(s).
59. Action: The MAC shall accept and process the request, using information already available to it via the shared system.
60. C.
61. Verification In the case of complete destruction of medical records where no backup records exist, MAC Appeal Units and QICs shall accept an attestation that no medical records exist and consider the services covered and correctly coded.
62. 240.5 - Procedures to Follow When a Party Fails to Establish Good Cause (Rev.
63. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) If a party files an untimely request for redetermination and there is insufficient or no explanation for the delay or no other evidence that establishes the reason for late filing, the MAC dismisses the redetermination request.
64. The MAC explains in the dismissal letter that the party can: 1) request that the MAC vacate the dismissal by providing an explanation for the late filing to the MAC within 6 months of the dismissal of the redetermination request; and 2) request that the QIC review the MAC’s dismissal action by filing a request with the QIC within 60 days of the date of receipt of the dismissal notice 280 - Fraud and Abuse (Rev.
65. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) 280.1 - Fraud and Abuse - Authority (Rev.
66. 2926, Issued: 04-11-14, Effective: 07-14-14, Implementation: 07-14-14) To protect the Medicare program from fraud and abuse, civil and criminal violation provisions have been included in §§1107, 1128A, 1128B, 1872, and 1877 of the Act.
67. 280.2 - Inclusion and Consideration of Evidence of Fraud and/or Abuse (Rev.
68. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) The MAC shall inquire fully into the matters at issue by receiving, in evidence, the testimony of witnesses and any documents that are relevant to the claims at issue.
69. If the MAC believes that evidence has been tampered with, it shall refer this documentation to either the medical review or the UPIC’s units for their follow-up.
70. The MAC may receive evidence obtained and provided by the UPIC concerning fraud or potential fraud with respect to the claim(s) at issue.
71. If the UPIC provides such evidence, it becomes part of the case file and must be made available for inspection by the appellant prior to the reconsideration.
72. Evidence of this nature is to be evaluated to determine issues such as whether, in conjunction with other credible evidence, the services in question were actually provided or were provided as billed.
73. NOTE: See §300.3 for additional information regarding fraud and abuse investigations.
74. 280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed (Rev.
75. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) Where there is a substantial basis for determining that an item or service either was not furnished or was not furnished as billed, the MAC may deny or down-code payment, as appropriate.
76. The reviewer must ensure that the case file clearly documents the evidence that formed the basis for the determination.
77. Appeal rights after such a determination remain the same as they would for any other unfavorable decision.
78. If the MAC has reason to believe or evidence to support that items or services were not furnished or were not furnished as billed, it shall send a copy of the decision to its UPIC.
79. 280.4 - Responsibilities of Adjudicators (Rev.
80. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) If, during the course of the redetermination, the reviewer suspects a civil or criminal law violation, the reviewer shall render a decision only on the coverage or payment issues raised by the redetermination request.
81. Although the reviewer cannot make a determination of civil or criminal fraud, he/she may still deny or reduce payment if he/she believes that the items or services at issue were not rendered, or were not rendered as billed (as discussed above).
82. In making this determination, the reviewer may consider all available evidence that is included in the case file, including witness testimony, medical records, and evidence compiled through a fraud investigation, as discussed above.
83. (See §310.4.B below.) In addition to denying the claims because the services were not rendered as billed, if the reviewer suspects fraud, he/she shall forward information regarding the potential civil or criminal violation to the UPIC.
84. For further discussion on Medicare fraud issues, refer to the Medicare Program Integrity Manual, IOM 100-08, Chapter 4.
85. 280.5 - Requests to Suspend the Appeals Process (Rev.
86. 2729, Issued: 06-21-13, Effective: 07-23-13, Implementation: 07-23-13) The MAC does not have the authority to suspend redeterminations at the request of the Office of the Inspector General (OIG) or the Department of Justice (DOJ) without approval and direction from CMS central office (CO).
87. If the OIG or DOJ submits a request to suspend a redetermination, the MAC shall first bring that request to the attention of CO through the RO.
88. 280.6 - Continuing Appeals of Providers, Physicians, or Other Suppliers Who are Under Fraud or Abuse Investigations (Rev.
89. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) Reviewers shall continue adjudicating the appeals of Medicare claims submitted by a provider, physician, or other supplier who is being or has been investigated, indicted, or convicted for fraud or abuse on other Medicare claims, or who is on Medicare payment suspension, unless the MAC has been informed that the provider, physician, or other supplier has agreed, as part of a settlement with the Government, or as the result of a prosecution, to withdraw the appealed claims or to waive the right to appeal the subject claim(s).
90. If it has received notice of such a settlement, the MAC shall dismiss the appeal based on the fact that the appellant has waived his/her/its right to an appeal, and/or agreed to withdraw appeal of these claims as part of a settlement agreement with the Government.
91. The MAC places a copy of the settlement document or other evidence of a settlement in the file.
92. A reviewer shall remain neutral in the adjudication of claims that involve a provider, physician, or other supplier who is being or has been investigated, indicted or convicted of fraud or abuse.
93. 280.7 - Appeals of Claims Involving Excluded Providers, Physicians, or Other Suppliers (Rev.
94. 3549, Issued: 06-24-16, Effective: 07-26-16, Implementation: 07-26-16) The appeals process remains in effect for all claims with service dates prior to the effective date of exclusion.
95. An excluded provider, physician, or supplier, or the beneficiary may appeal such claims.
96. In addition, if the billing privileges of a provider, physician, or supplier are revoked retroactively, and the contractor reopens previously paid claims to assess an overpayment against the excluded party, the excluded party (or the beneficiary) may appeal the revised initial determination and overpayment under the claims appeal process (42 CFR part 405 subpart I).
97. NOTE: A provider or supplier's appeal of a revocation or denial of billing privileges is processed in accordance with the procedures set forth in 42 CFR part 405 subpart H and 42 CFR part 498 (see also, IOM 100-08, Chapter 15, §15.25). The contractor is bound by the terms of the revocation action unless billing privileges are reinstated under the enrollment appeals process.
98. 290 - Guidelines for Writing Appeals Correspondence (Rev.
99. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) The guidelines in this section are to be used when preparing appeals correspondence, which includes redeterminations decisions and inquiries about the status of appeals.
100. These shall be handled as expeditiously as possible without lowering the quality of the response.
101. General instructions on responding to beneficiary and provider/supplier communications are found in CMS Medicare Pub.
102. 100-09.
103. All other CMS-issued instructions on correspondence guidelines apply as well, including instructions on correspondence letterhead requirements.
104. 290.1 - General Guidelines (Rev.
105. 2729, Issued: 06-21-13, Effective: 07-23-13, Implementation: 07-23-13) MACs shall prepare appeals correspondence so the appellant can easily understand both the reason why any of the services were not covered or could not be fully reimbursed, and what action the appellant can take if the appellant disagrees with that decision.
106. In addition, the guidelines listed here should be followed to the extent possible: • Keep the language as simple as possible; • Do not use abbreviations or jargon; • Choose a positive rather than a negative tone, whenever possible.
107. Avoid words or phrases that emphasize what cannot be done by the MAC or the appellant; • If possible, avoid one sentence paragraphs, uneven spacing between paragraphs, etc.; • Apologize when appropriate, e.g., if the response is late.
108. However, do not apologize for enforcing Medicare guidelines that may be adverse to the appellant’s claim; • Summarize the question before providing a response; and, • Use correct spelling, grammar, and punctuation.
109. 290.2 - Letter Format (Rev.
110. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) Appeals correspondence shall follow the instructions issued by CMS for MAC written correspondence letterhead requirements unless otherwise instructed and/or agreed to by CMS.
111. In addition, observe the following information: • Numerical dates must not be used (i.e., instead of 6/16/13, use June 16, 2013), except when included in a table; • Type/font size must be 12 point or larger (all responses are to be processed using a font size of 12 and a font style of Universal or Times New Roman or similar style for the ease of reading by the beneficiary and the provider); • When the subject matter is lengthy or complicated, bullet points should be used to clarify, if possible; • For long letters, headings should be used to break it up (e.g., DECISION, BACKGROUND, RATIONALE);• If procedure codes are cited, the actual name of the procedure must be associated with the code; • Span dates may not be used for 1 day of service; and • The MAC should not use all capital letters.
112. Letters that contain all capital letters appear impersonal and computer generated.
113. Refer to §300.5 for instructions on how to handle cases involving multiple beneficiaries, including overpayment cases involving multiple beneficiaries.
114. 290.3 - How to Establish Reading Level (Rev.
115. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) The MMA requires that appeals correspondence be written in a manner calculated to be understood by beneficiaries.
116. MACs shall write appeals correspondence that is understandable to beneficiaries.
117. The purpose of this section is to provide some guidance to MACs on writing letters that are easy for beneficiaries to understand.
118. To achieve this goal, MACs shall: (1) Write in plain English/plain language with a clear, simple, conversational writing style with good communication of key points.
119. (2) Get reading levels of letters as low as you can without losing important content or distorting the meaning and without sounding condescending to the reader.
120. NOTE: This requirement does not apply to providers.
121. MACs can use a cover sheet for the beneficiary, when sending a copy of the decision.
122. 290.3.1 - Writing in Plain Language (Rev.
123. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) The following are some tips to help MACs to write letters in plain language: • Include definitions or explain terms you must use that are not familiar with your intended audience.
124. • Use heading, subheadings, or other devices to signal what's coming next.
125. Labels for sections, headings, and subheading should be clear and informative to the intended audience.
126. • Write in an active voice and in a conversational style.
127. For example, conversational style uses contractions (I'd instead of I would) and informal vocabulary (find out instead of determine).
128. • Use a friendly and positive tone.
129. • Use words that are familiar to your intended audience.
130. Shorter words tend to be more common, and they are generally preferable.
131. For example, use doctor instead of physician.
132. Pay back instead of reimburse.
133. Can get instead of eligible.
134. There are exceptions.
135. For example, access is a short word, but it is health care jargon that is hard for many consumers to understand.
136. Organization is a five-syllable word, but is probably familiar to most readers.
137. • When a term is best known to your intended audience by its acronym, use the acronym and spell out the word that it represents in parenthesis with the letters that form the acronym in bold.
138. For example: PCP (Primary Care Provider).
139. • Be on alert for words that are abstract or vague, or that may mean different things to different people.
140. Replace these words with more specific words to be sure your readers understand the key messages.• Keep your sentences simple and direct.
141. Most should be reasonably short; about eight to ten words per sentence for most sentences.
142. When sentences are long, the main point gets lost in all the words.
143. Active voice makes the style more direct.
144. • Vary the length of your sentences.
145. Somewhat longer, natural-sounding sentences of about 12 to 15 words can effectively break up the choppy effect of using many short sentences.
146. • Paragraphs should be relatively short.
147. Short paragraphs are more inviting to your reader and give the visual appearance of being easier to read.
148. • Use simpler words rather than technical terms whenever you can without losing the content or distorting the meaning.
149. Sometimes it's important to use a technical term, such as the words mammogram, or cholesterol.
150. • Appearance should be appealing at first glance.
151. Pages should be uncluttered with generous margins and plenty of white space.
152. • The graphic design should use contrast, indentation, bullets, and other devices to signal the main points and make the text easier to skim.

153. • Use a large type and spacing between lines.

154. 290.4 - Required Elements in Appeals Correspondence (Rev.

155. 2926, Issued: 04-11-14, Effective: 07-14-14, Implementation: 07-14-14) The following should be used in all appeals correspondence: • The name of the beneficiary/provider/physician/supplier to whom the letter is addressed rather than “Dear Sir/Madam;" • Correspondence is identified by either the date on written correspondence or the date the written correspondence was received; • The name of the provider, physician or supplier as well as the date(s) of service; • When appropriate, an explanation in letters to beneficiaries, explaining why he/she is being sent a letter if the appeal came from the provider, physician or other supplier; • The appeal determination/decision is placed in the beginning of the letter; • Explicit rationale that describes why the items or services at issue do not meet Medicare guidelines.

156. Merely stating that an item or service is “not medically reasonable and necessary under §1862(a)(1)” or “not medically reasonable and necessary under Medicare guidelines” does not provide any rationale.
157. The rationale should include a description of the logic that led to the decision, references used to support the decision, and other information that is relevant to support the decision in the case; • When the appeals correspondence includes Medicare statutory citations, they must be related to the decision in layman’s terms.
158. The statutory cite is listed as a parenthetical at the end of the sentence.

159. For example, instead of beginning a sentence with, “§1879 of the Social Security Act states that...,” the sentence should start with “Under Medicare law, suppliers must...(§1879 of the Social Security Act)”;• Whenever the person is to receive some further response, such as an MSN (if available), an estimated time frame as to when he/she will receive it is provided; • Telephone number on all correspondence for additional questions; • What, if anything, must be done next, and by whom; • As appropriate, the results of any consultations with professional medical staff; • When applicable, a statement advising the appellant that upon written request the MAC will provide them copies of regulations, statutes, and guidelines used in making the determination; • For appeals, if the redetermination is partially or wholly favorable, an explanation about why the new determination is different from the previous determination; and • The correspondence must be written in a clear manner and with a customer- friendly tone.

160. 300 - Disclosure of Information (Rev.
161. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) 300.1 - General Information (Rev.
162. 3549, Issued: 06-24-16, Effective: 07-26-16, Implementation: 07-26-16) The basis for policy governing the disclosure and confidentiality of information collected by the contractor is §1106 of the Act, the Department’s Public Information regulations, as well as the Privacy Act, and the Freedom of Information Act.
163. In general, all information relating to an individual is confidential except as provided by regulation.
164. In the interest of an appellant’s right to due process, there are situations where information may be disclosed.
165. The CMS regulations implementing §1106 of the Act can be found at 42 CFR Part 401, Subpart B.
166. (See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 6.) In addition, §1106 in title XI of the Act provides penalties for violation of the provisions concerning confidentiality of information.
167. Activities prohibited under the provisions of the Act include, but are not limited to, making false and fraudulent statements, fraudulent concealment of evidence affecting payment benefits, false impersonation of another individual, misuse or conversion of payments for use of another, and improper disclosure of confidential information.
168. (See the Medicare Program Integrity Manual 100-08.) 300.2 - Disclosure of Information to Third Parties (Rev.
169. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07) If a beneficiary wishes to have his/her information disclosed to a third party without appointing that individual as a representative, this can be accomplished by the beneficiary or third party providing written authorization to the MAC for the release of the information.
170. The written authorization must contain a signature of the beneficiary and an explanation of the type of information the beneficiary agrees to release to the individual.
171. An example of this type of situation is where a beneficiary has asked a Member of Congress for assistance with his/her appeal.
172. In this case, it may be necessary for the Member of Congress to receive the decision; however the Member of Congress does not wish to accept the responsibility associated with being the beneficiary's appointed representative or the beneficiary does not wish to appoint the Member of Congress as his/her representative.
173. See §310.1 for more information on requests for redetermination submitted by Members of Congress.
174. If the beneficiary wishes to appoint a representative, MACs should refer to §270.
175. 300.3 - Fraud and Abuse Investigations (Rev.
176. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19)

     Any and all evidence used by the A/B MAC (A), (B), (HHH), or DME MAC to arrive at a determination or decision shall be placed in the appeals case file (copies are acceptable).

177. Information in the case file shall be made available to an appellant upon request.
178. Therefore, the MAC shall be aware that information placed in the case file is accessible to an appellant.
179. The UPIC shall also understand that the MAC may not consider any evidence that has not been made a part of the case file.

180. The UPIC and the MAC shall therefore exercise discretion when deciding whether to place any of the following information into the appeals case file: • The impetus behind a fraud and abuse investigation; • The name of the beneficiary or any other person lodging the complaint that triggers the fraud and abuse investigation; • Notes or transcripts of beneficiary interviews resulting from a fraud and abuse investigation; • Records or information compiled for law enforcement purposes during a fraud and abuse investigation; or • The name of a confidential source(s) when confidentiality has been promised by CMS in return for cooperation in a fraud and abuse investigation.

181. Where the MAC relies upon any of the above information in order to deny a claim or to render a less than fully favorable determination or decision, then an appellant has a due process right to review this information.
182. If information is kept out of an appeals case file for confidentiality reasons, it may not be relied upon to make a coverage decision or deny or reduce payment.
183. 300.4 - Medical Consultants Used (Rev.
184. 1274, Issued: 06-29-07, Effective: 07-01-07, Implementation: 10-01-07)

     The parties are entitled to know the identity and qualifications of any consultant whose evidence the MAC used to support the initial claim determination or the redetermination.

185. If the MAC uses a consultant, it shall include the identity and qualifications of the consultant in the file for possible use by the ALJ, and for the appellant’s use upon request.
186. This applies to both external medical consultants and internal staff used to review the claim.
187. An example of this would be the name and title of the medical consultant.
188. 300.5 - Appeal Decision Involving Multiple Beneficiaries (Rev.
189. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) A.
190. Appeals of Overpayments Involving Multiple Beneficiaries with a Single Account Receivable If an appellant submits a request for redetermination that involves an overpayment with a single account receivable for claims involving multiple beneficiaries, the MAC shall issue one decision letter to the appellant that includes information specific to the claims for each beneficiary.
191. The summary of facts, coverage, payment and liability decisions for each beneficiary’s claim(s) may be included as a separate attachment to the decision letter.
192. Since each beneficiary is a party to the appeal, subject to the exception in §300.5.C below, the MAC shall send each beneficiary a copy of their own determination without compromising the privacy of other beneficiaries in the appeal.
193. (Refer to IOM, 100-06, Medicare Financial Management Manual, Chapter 6, section 460.1, for instructions on how to count requests that involve multiple beneficiaries).
194. 
     

B.

Appeals Involving Claims of Multiple Beneficiaries, Other than Overpayments with a Single Account Receivable If a party files a request for redetermination that involves claims of multiple beneficiaries that do not comprise an overpayment with a single account receivable, the MAC may process the appeal by issuing aseparate decision letter for each beneficiary's claim(s) (i.e., as a split appeal), or the MAC may issue a single letter with attachments for each separate claim, whichever is more efficient.

195. 
     

196. Example: If a supplier submits a single appeal request involving unrelated claims for various beneficiaries that were denied on prepayment review or through prepayment edits, the MAC may process the appeal as a split and issue separate letters to the supplier-appellant, or the MAC may issue a single letter with attachments for each claim.

197. In either case, the beneficiary, as a party to the appeal, must receive a copy of the decision letter that pertains to his or her claims.

198. Example: If a supplier submits a single appeal request involving claims reviewed by a recovery auditor on a postpayment basis, resulting in overpayments (not extrapolated) processed as separate accounts receivable, the MAC may issue either a single decision letter to the appellant with attachments for each claim, or separate decision letters, whichever is more efficient.

199. The beneficiary, as a party to the appeal, must receive a copy of the decision letter that pertains to his or her claims, subject to the exception noted in §300.5.C below.
200. C.
201. Exception to Sending Decision Letters to Beneficiaries in Overpayment Cases In an overpayment case involving multiple beneficiaries who have no financial liability prior to, and following the redetermination, the MAC mails the decision letter to the appellant or their appointed representative.
202. In this situation, MACs are not required to send the decision letters to beneficiaries who are parties to the redetermination (see 42 CFR 405.956(a)(2)). However, if financial liability shifts from the provider or supplier to the beneficiary, the MAC issues a separate decision letter to the beneficiary that explains why he/she is liable, and explains the subsequent appeal rights available.
203. Example: During a postpayment review, claims for multiple beneficiaries are initially denied as being not medically reasonable and necessary, and the determination of liability under section 1879 of the Act finds the physician financially responsible for the denied services.
204. If during the appeal, the physician demonstrates that a valid ABN was issued for some of the services provided to certain beneficiaries and financial responsibility shifts from the physician to those beneficiaries, the MAC must issue separate decision letters to the affected beneficiaries, but is not required to issue separate decision letters to those beneficiaries whose liability has not changed (i.e., liability remains with the physician).
205. 310 - Redetermination - The First Level of Appeal (Rev.
206. 2729, Issued: 06-21-13, Effective: 07-23-13, Implementation: 07-23-13) A party dissatisfied with an initial determination may request that the MAC review its determination.
207. A redetermination is the first level of appeal after the initial determination on Part A and Part B claims.
208. It is a second look at the claim and supporting documentation and is made by an employee that did not take part in the initial determination.
209. If an initial determination is not made, there are no appeal rights on that claim (see §200.C for a list of actions that are not initial determinations and therefore do not have appeal rights).
210. The reviewer must comply with, and is bound by, all applicable statutory and regulatory provisions.
211. The reviewer may not overrule the provisions of the law or interpret them in a way different than CMS; nor may the reviewer comment upon the legality, constitutional or otherwise, of any provision of the Act, regulations, or CMS policy in the review determination.
212. The reviewer is also bound by all CMS-issued policies and procedures, including CMS rulings, Medicare manual instructions, change requests, national coverage determinations, and local coverage determinations.
213. The reviewer must consider the applicability of all CMS-issued policies and procedures to the facts of a given claim.

214. The reviewer may not change the amount required to be paid under the Physician Fee Schedule The term "Cotard's syndrome" is used to describe a number of clinical features, mostly hypochondriac and nihilistic delusions, the most characteristic of which are the ideas "I am dead" and "my internal organs do not exist".

215. Besides, anxious and depressed mood, delusions of damnation, possession and immortality, suicidal and self-mutilating behavior are included.
216. The first description of the syndrome was made in 1880 by Cotard, who presented the case of a female patient in a lecture.
217. He originally named it "hypochondriac delusion", and some years later "delusion of negations", while it was named "Cotard delusion" after his death.
218. In international literature, the terms "nihilistic delusion" and "Cotard's syndrome" prevailed over "delusion of negations" and "Cotard delusion".
219. In the present study we report the case of a 59 year-old woman, who was admitted to our department after a suicide attempt, and who showed symptoms of Cotard's syndrome for about two years, namely depressed mood, hypochondriac and nihilistic delusions, delusions of immortality and damnation, suicidal ideation, severe psychomotor retardation, diminished motivation and tendency to stay in bed.
220. She never took the medication she was prescribed, and at times she refused to eat.
221. During her hospitalization, there was performed a full blood panel and medical imaging, that showed chronic ischemic infarctions, periventricular leukoencephalopathy and diffuse cerebral atrophy in MRI.
222. All the other test results were normal.
223. She was administered treatment with haloperidol, mirtazapine and venlafaxine.
224. Gradually, her psychomotor ability, motivation and mood improved, she didn't express suicidal ideation, her delusions were less intense and she was able to question them, but they weren't eliminated.
225. She was discharged in improved condition, after 44 days.
226. Cotard's syndrome isn't mentioned in the current classification systems (ICD-10, DSM-5).
227. In literature though, it has been divided into three types, according to the clinical symptoms: psychotic depression, Cotard type I, and Cotard type II, and three stages have been proposed: germination stage, blooming stage and chronic stage.
228. It has been associated with various medical conditions, such as cerebral infractions, fronto-temporal atrophy, epilepsy, encephalitis, brain tumors, traumatic brain injury.
229. Furthermore, it has been associated with psychiatric conditions, such as mental retardation, postpartum depression, depersonalization disorder, catatonia, Capgras syndrome, Fregoli syndrome, Odysseus syndrome, koro syndrome.

230. Several reports about successful pharmacological treatments have been published, both monotherapies with antidepressants, antipsychotics or lithium, and by antidepressant and antipsychotic combination treatments.

231. The most reported successful treatment strategy for Cotard's syndrome is electroconvulsive therapy (ECT), administration of which should follow current treatment guidelines of the underlying conditions.
232. Hypochondriacal delusions are not bound to a specific mental disorder, but occur in the whole spectrum of psychoses.
233. In spite of the implicitly wrong conception of reality, the significance of these delusions as an attempt to express, interpret and cope with mental illness should not be neglected if an approach to the patient's own experience is sought.
234. On the one hand, hypochondriacal delusions are based on altered body perceptions in mental illness, characterized by primary local or general dysaesthesias to the point of depersonalisation, or caused secondarily by the patient's increased attention to his own body.
235. This alienated bodily experience is named in (lay) medical terms by the delusional hypochondriac.
236. On the other hand, "illness" with its manifold cultural and psychological meanings stands as a polyvalent metaphor for the incomprehensible alteration of the patient's self-experience in general: thus, the feeling of exposure to external attacks, of guilt, sinfulness, shame, loss of self-esteem or even the experience of a disruption of personality may find their expression in the hypochondriacal delusion.

237. What Is somatic Symptom Disorder? Somatic symptom disorder is diagnosed when someone features a vital target physical symptoms, like pain, weakness or shortness of breath, to A level that ends up in major distress and/or issues functioning.

238. The individual has excessive thoughts, feelings and behaviors about the physical symptoms.
239. The physical symptoms could or might not be related to a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness).
240. A person isn't diagnosed with corporeal symptom disorder only because a medical cause can’t be known for a physical symptom.
241. the stress is on the extent to which the thoughts, feelings and behaviors associated with the malady are excessive or out of proportion.
242. Diagnosis 1 One or a lot of physical symptoms that are distressing or cause disruption in existence Excessive thoughts, feelings or behaviors associated with the physical symptoms or health issues with a minimum of one among the following: in progress thoughts that ar out of proportion with the seriousness of symptoms in progress high level of tension concerning health or symptoms Excessive time and energy spent on the symptoms or health considerations a minimum of one symptom is consistently present, although there could also be totally different symptoms and symptoms could return and go People with somatic symptom disorder usually visit a medical aid medico instead of a head-shrinker or alternative mental state skilled.
243. people with corporeal symptom disorder could experience issue acceptive that their issues concerning their symptoms are excessive.
244. they will still be fearful and disquieted even once they are shown proof that they are doing not have a heavy condition.
245. Some folks have solely pain as their dominant symtom.
246. somatic symptom disorder sometimes begins by age thirty.
247. Treatment Treatment for somatic symptom disorder is meant to assist control symptoms and to permit the person to operate as unremarkably as attainable.
248. Treatment for corporeal symptom disorder usually involves the person having regular visits with a trusty health care skilled.
249. The doc offers support and support, monitor heath and symptoms and avoid supernumerary tests and coverings.
250. Psychotherapy (talk therapy) will facilitate the individual modification their thinking and behavior, and learn ways in which to address pain or alternative symptoms, trot out stress and improve functioning.
251. Antidepressant or anti-anxiety medications will be helpful if the person is additionally experiencing vital depression or anxiety.
252. Related Disorders Illness folie was antecedently remarked as "hypochondriasis." The person is preoccupied with having an ill health or obtaining an unwellness – perpetually worrying regarding their health.
253. they'll ofttimes check themselves for signs of malady and take extreme precautions to avoid health risks.
254. not like bodily symptom disorder, an individual with sickness disturbance typically does not experience symptoms.
255. Conversion disorder (functional medical specialty symptom disorer) may be a condition during which the symptoms in which a person’s perception, sensation or movement with no proof of a physical cause.
256. someone could have symptom, cecity or hassle walking.
257. The symptoms tend to come back on suddenly.
258. The symptoms might last for a protracted time or might escape quickly.
259. folks with conversion disorder also ofttimes experience depression or anxiety disorders.
260. Factitious disorder involves folks manufacturing or faking physical or psychopathy once they don't seem to be very sick, or deliberately creating a minor malady worse.
261. a person with artificial disorder may create associate degree unwellness or injury in another person (factitious disorder obligatory on another), such as faking the symptoms of a toddler in their care.
262. The person could or may not appear to profit (such as obtaining out of college or work) from matters they produce.
263. Reference Diagnostic and applied mathematics Manual of Mental Disorders, Fifth Edition (DSM-5).
264. yankee medical specialty Association.
265. (2013).
266. Severity Measure for Generalized Anxiety Disorder—Adult Name:____________________________________ Age: ______ Sex: Male Female Date:_________________ Instructions: The following questions ask about thoughts, feelings, and behaviors, often tied to concerns about family, health, finances, school, and work.
267. Please respond to each item by marking ( or x) one box per row.
268. Clinician Use During the PAST 7 DAYS, I have... Never Occasionally Half of the time Most of the time All of the time Item score 1.
269. felt moments of sudden terror, fear, or fright 0 1 2 3 4 2.
270. felt anxious, worried, or nervous 0 1 2 3 4 3.
271. had thoughts of bad things happening, such as family tragedy, ill health, loss of a job, or accidents 0 1 2 3 4 4.
272. felt a racing heart, sweaty, trouble breathing, faint, or shaky 0 1 2 3 4 5.
273. felt tense muscles, felt on edge or restless, or had trouble relaxing or trouble sleeping 0 1 2 3 4 6.
274. avoided, or did not approach or enter, situations about which I worry 0 1 2 3 4 7.
275. left situations early or participated only minimally due to worries 0 1 2 3 4 8.
276. spent lots of time making decisions, putting off making decisions, or preparing for situations, due to worries 0 1 2 3 4 9.
277. sought reassurance from others due to worries 0 1 2 3 4 10.
278. needed help to cope with anxiety (e.g., alcohol or medication, superstitious objects, or other people) 0 1 2 3 4 Total/Partial Raw Score: Prorated Total Raw Score: (if 1-2 items left unanswered) Average Total Score: Craske M, Wittchen U, Bogels S, Stein M, Andrews G, Lebeu R.
279. Copyright © 2013 American Psychiatric Association.
280. All rights reserved.
281. This material can be reproduced without permission by researchers and by clinicians for use with their patients.
282. Copyright © 2013 American Psychiatric Association.
283. All Rights Reserved.
284. This material can be reproduced without permission by researchers and by clinicians for use with their patients.
285. Instructions to Clinicians The Severity Measure for Generalized Anxiety Disorder—Adult is a 10-item measure that assesses the severity of generalized anxiety disorder in individuals age 18 and older.
286. The measure was designed to be completed by an individual upon receiving a diagnosis of generalized anxiety disorder (or clinically significant generalized anxiety symptoms) and thereafter, prior to follow-up visits with the clinician.
287. Each item asks the individual to rate the severity of his or her generalized anxiety disorder during the past 7 days.
288. Scoring and Interpretation Each item on the measure is rated on a 5-point scale (0=Never; 1=Occasionally; 2=Half of the time; 3=Most of the time, and 4=All of the time).
289. The total score can range from 0 to 40, with higher scores indicating greater severity of generalized anxiety disorder.
290. The clinician is asked to review the score of each item on the measure during the clinical interview and indicate the raw score for each item in the section provided for “Clinician Use.” The raw scores on the 10 items should be summed to obtain a total raw score.
291. In addition, the clinician is asked to calculate and use the average total score.
292. The average total score reduces the overall score to a 5-point scale, which allows the clinician to think of the severity of the individual’s generalized anxiety disorder in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4).
293. The use of the average total score was found to be reliable, easy to use, and clinically useful to the clinicians in the DSM-5 Field Trials.
294. The average total score is calculated by dividing the raw total score by number of items in the measure (i.e., 10).
295. Note: If 3 or more items are left unanswered, the total score on the measure should not be calculated.
296. Therefore, the individual receiving care should be encouraged to complete all of the items on the measure.
297. If 1 or 2 items are left unanswered, you are asked to calculate a prorated score.
298. The prorated score is calculated by summing the scores of items that were answered to get a partial raw score.
299. Multiply the partial raw score by the total number of items on the Severity Measure for Generalized Anxiety Disorder (i.e., 10) and divide the value by the number of items that were actually answered (i.e., 8 or 9).
300. The formula to prorate the partial raw score to Total Raw Score is: ____________(Raw sum x 10)_____________ Number of items that were actually answered If the result is a fraction, round to the nearest whole number.
301. Frequency of Use To track changes in the severity of the individual’s generalized anxiety disorder over time, the measure may be completed at regular intervals as clinically indicated, depending on the stability of the individual’s symptoms and treatment status.
302. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant further assessment, treatment, and follow-up.
303. Your clinical judgment should guide your decisio Physician Review By: Philip R.
304. Muskin, M.D., M.A. August 2021 Chapter one.
305. Compulsive Sexual Behavior Disorder: From Myths to Reality Chapter 2.
306. Sexual Addiction vs.
307. CSBD Chapter 3.
308. Compulsive Sexual Behavior and Substance Use Disorders Chapter 4.
309. the net and CSBD Chapter 5.
310. Diagnostic Aspects of CSBD: DSM and on the far side Chapter 6.
311. Clinical analysis of CSBD Chapter 7.
312. Pharmacotherapy for Patients With CSBD Chapter 8.
313. Psychotherapies within the Treatment of CSBD Chapter 9.
314. Compulsive Sexual Behavior Disorder in ladies Chapter 10.
315. rhetorical Aspects of Hypersexuality Chapter 11.
316. Hypersexuality and Sexual Compulsivity: Behavioral/Sexual Risks and Risks of Sexually Transmitted Diseases Chapter 12.
317. non secular and Cultural Influences of CSBD Medicare Beneficiary Identifier (MBI) and Name to Number Converter The Interactive Voice Response (IVR) and Computer Telephone Integration (CTI) systems require entry of your patient's name and Medicare number during the beneficiary validation process.
318. Use the following converter tools to convert letters to numbers for easy entry using your telephone keypad.
319. Claim Submissions and Denials 5010 277CA Reject Code Lookup Tool The Reject Code Lookup Tool provides explanations for the edit codes returned on the Status Information segment (STC) of the version 5010 277CA – Claim Acknowledgement for an electronically submitted claim.
320. Advanced Modifier Engine (AME) The AME helps suppliers bill proper HCPCS codes and modifier combinations.
321. Select a DMEPOS category, HCPCS code, scenario, and sub-scenario, and the AME will recommend suggested modifiers for claim submission.
322. CGS Wizard The CGS Wizard contains detailed processed claim information for all claims submitted, including ADR status, medical review decisions, education, and resources.
323. All you need to enter is a 14-digit Claim Control Number (CCN).
324. Claim Denial Resolution Tool Español This tool provides the remittance message for the claim denial and lists possible causes and resolutions.
325. Please note that this tool is available for claim denial assistance with the common denials and may not address every scenario.
326. Claim Documentation Divider Sheets Claim Documentation Divider Sheets standardize the process, so you no longer need to create your own cover sheets for documentation.
327. Claims Timely Filing Calculator This tool helps determine the claim timely filing limit for billed service(s).
328. CMS 1500 Claim Form Instructions Tool The CMS 1500 Claim Form Instructions Tool gives suppliers an easy way to view instructions for each item on the claim form.
329. Simply hover your cursor over a specific field, and instructions will pop up.
330. Consolidated Billing Tool This tool helps suppliers determine if a specific DMEPOS item is payable for beneficiaries in a skilled nursing facility (SNF), during a home health episode, or while enrolled in hospice.
331. HCPCS Lookup The HCPCS Lookup Tool shows the description of individual HCPCS codes.
332. KE & KY Modifier Tool This tool helps suppliers correctly use of the KE and/or KY modifiers, which indicate options/accessories used with a non-competitive bid base.
333. Medicare Secondary Payer Lookup Unsure if Medicare should pay as the primary or secondary insurer for your patient? Answer a few simple questions and find our suggestion.
334. Modifier Finder Tool This tools helps suppliers use modifiers correctly.
335. Search the database by modifier or keyword, and review the corresponding records.
336. You can also view the entire list of modifiers, definitions, and additional billing information.
337. Remittance Advice Instructions Tool On the Remittance Advice Instructions Tool, suppliers can hover over fields on the form and read descriptions and instructions, making it easy to understand.
338. Many of the descriptions will also apply to the Electronic Remittance Advice, though they may not appear in the same order.
339. Same/Similar Tool The Same/Similar Tool helps suppliers determine if an item may be considered the same as, or similar to, equipment already in possession of the beneficiary when billing base items.
340. Just enter the HCPCS code in the search field to view the results! Disclaimer: This tool is a guide only.
341. Lower Limb Prosthetics HCPCS codes, some HCPCS codes that are not part of an LCD policy, and HCPCS codes associated with accessories and supplies have been excluded from this tool.
342. Although every reasonable effort has been made to ensure the accuracy of this tool, there may be situations in the claim history that will still cause a claim to allow or deny in a same/similar situation.
343. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided.
344. The tool is not claim or beneficiary specific.
345. Please utilize the myCGS web portal for beneficiary specific utilization information.
346. Medicare Beneficiary Identifier (MBI) Converter Louisiana DME MAC - JC A/B MAC - JH HH + H MAC - JM CGS Administrators, LLC Novitas Solutions, Inc.