[Federal Register: December 23, 2005 (Volume 70, Number 246)]
[Notices]
[Page 76290-76313]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr23de05-81]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-9033-N]
Medicare and Medicaid Programs; Quarterly Listing of Program
Issuances--July Through September 2005
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice lists CMS manual instructions, substantive and
interpretive regulations, and other Federal Register notices that were
published from July 2005 through September 2005, relating to the
Medicare and Medicaid programs. This notice provides information on
national coverage determinations (NCDs) affecting specific medical and
health care services under Medicare. Additionally, this notice
identifies certain devices with investigational device exemption (IDE)
numbers approved by the Food and Drug Administration (FDA) that
potentially may be covered under Medicare. This notice also includes
listings of all approval numbers from the Office of Management and
Budget for collections of information in CMS regulations. Finally, this
notice includes a list of Medicare-approved carotid stent facilities.
Section 1871(c) of the Social Security Act requires that we publish
a list of Medicare issuances in the Federal Register at least every 3
months. Although we are not mandated to do so by statute, for the sake
of completeness of the listing, and to foster more open and transparent
collaboration efforts, we are also including all Medicaid issuances and
Medicare and Medicaid substantive and interpretive regulations
(proposed and final) published during this 3-month time frame.
FOR FURTHER INFORMATION CONTACT: It is possible that an interested
party may have a specific information need and not be able to determine
from the listed information whether the issuance or regulation would
fulfill that need. Consequently, we are providing information contact
persons to answer general questions concerning these items. Copies are
not available through the contact persons. (See Section III of this
notice for how to obtain listed material.)
Questions concerning items in Addendum III may be addressed to
Timothy Jennings, Office of Strategic Operations and Regulatory
Affairs, Centers for Medicare & Medicaid Services, C4-26-05, 7500
Security Boulevard, Baltimore, MD 21244-1850, or you can call (410)
786-2134.
Questions concerning Medicare NCDs in Addendum V may be addressed
to Patricia Brocato-Simons, Office of Clinical Standards and Quality,
Centers for Medicare & Medicaid Services, C1-09-06, 7500 Security
Boulevard, Baltimore, MD 21244-1850, or you can call (410) 786-0261.
Questions concerning FDA-approved Category B IDE numbers listed in
Addendum VI may be addressed to John Manlove, Office of Clinical
Standards and Quality, Centers for Medicare & Medicaid Services, C1-13-
04, 7500 Security Boulevard, Baltimore, MD 21244-1850, or you can call
(410) 786-6877.
Questions concerning approval numbers for collections of
information in Addendum VII may be addressed to Bonnie Harkless, Office
of Strategic Operations and Regulatory Affairs, Regulations Development
and Issuances Group, Centers for Medicare & Medicaid Services, C5-14-
03, 7500 Security Boulevard, Baltimore, MD 21244-1850, or you can call
(410) 786-5666.
Questions concerning Medicare-approved carotid stent facilities may
be addressed to Sarah J. McClain, Office of Clinical Standards and
Quality, Centers for Medicare & Medicaid Services, C1-09-06, 7500
Security Boulevard, Baltimore, MD 21244-1850, or you can call (410)
786-2994.
Questions concerning all other information may be addressed to
Gwendolyn Johnson, Office of Strategic Operations and Regulatory
Affairs, Regulations Development Group, Centers for Medicare & Medicaid
Services, C5-14-03, 7500 Security Boulevard, Baltimore, MD 21244-1850,
or you can call (410) 786-6954.
SUPPLEMENTARY INFORMATION:
I. Program Issuances
The Centers for Medicare & Medicaid Services (CMS) is responsible
for administering the Medicare and Medicaid programs. These programs
pay for health care and related services for 39 million Medicare
beneficiaries and 35 million Medicaid recipients. Administration of the
two programs involves (1) furnishing information to Medicare
beneficiaries and Medicaid recipients, health care providers, and the
public and (2) maintaining effective communications with regional
offices, State governments, State Medicaid agencies, State survey
agencies, various providers of health care, all Medicare contractors
that process claims and pay bills, and others. To implement the various
statutes on which the programs are based, we issue regulations under
the authority granted to the Secretary of the Department of Health and
Human Services under sections 1102, 1871, 1902, and related provisions
of the Social Security Act (the Act). We also issue various manuals,
memoranda, and statements necessary to administer the programs
efficiently.
Section 1871(c)(1) of the Act requires that we publish a list of
all Medicare manual instructions, interpretive rules, statements of
policy, and guidelines of general applicability not issued as
regulations at least every 3 months in the Federal Register. We
published our first notice June 9, 1988 (53 FR 21730). Although we are
not mandated to do so by statute, for the sake of completeness of the
listing of operational and policy statements, and to foster more open
and transparent collaboration, we are continuing our practice of
including Medicare substantive and interpretive regulations (proposed
and final) published during the respective 3-month time frame.
II. How To Use the Addenda
This notice is organized so that a reader may review the subjects
of manual issuances, memoranda, substantive and interpretive
regulations, NCDs, and FDA-approved IDEs published during the subject
quarter to determine whether any are of particular interest. We expect
this notice to be used in concert with previously published notices.
Those unfamiliar with a description of our Medicare manuals may wish to
review Table I of our first three notices (53 FR 21730, 53 FR 36891,
and 53 FR 50577) published in 1988, and the notice published March 31,
1993 (58 FR 16837). Those desiring information on the Medicare NCD
Manual (NCDM, formerly the Medicare
[[Page 76291]]
Coverage Issues Manual (CIM)) may wish to review the August 21, 1989,
publication (54 FR 34555). Those interested in the revised process used
in making NCDs under the Medicare program may review the September 26,
2003, publication (68 FR 55634).
To aid the reader, we have organized and divided this current
listing into eight addenda:
Addendum I lists the publication dates of the most recent
quarterly listings of program issuances.
Addendum II identifies previous Federal Register documents
that contain a description of all previously published CMS Medicare and
Medicaid manuals and memoranda.
Addendum III lists a unique CMS transmittal number for
each instruction in our manuals or Program Memoranda and its subject
matter. A transmittal may consist of a single or multiple
instruction(s). Often, it is necessary to use information in a
transmittal in conjunction with information currently in the manuals.
Addendum IV lists all substantive and interpretive
Medicare and Medicaid regulations and general notices published in the
Federal Register during the quarter covered by this notice. For each
item, we list the--
[cir] Date published;
[cir] Federal Register citation;
[cir] Parts of the Code of Federal Regulations (CFR) that have
changed (if applicable);
[cir] Agency file code number; and
[cir] Title of the regulation.
Addendum V includes completed NCDs, or reconsiderations of
completed NCDs, from the quarter covered by this notice. Completed
decisions are identified by the section of the NCDM in which the
decision appears, the title, the date the publication was issued, and
the effective date of the decision.
Addendum VI includes listings of the FDA-approved IDE
categorizations, using the IDE numbers the FDA assigns. The listings
are organized according to the categories to which the device numbers
are assigned (that is, Category A or Category B), and identified by the
IDE number.
Addendum VII includes listings of all approval numbers
from the Office of Management and Budget (OMB) for collections of
information in CMS regulations in title 42; title 45, subchapter C; and
title 20 of the CFR.
Addendum VIII includes listings of Medicare-approved
carotid stent facilities. All facilities listed meet CMS standards for
performing carotid artery stenting for high risk patients.
III. How To Obtain Listed Material
A. Manuals
Those wishing to subscribe to program manuals should contact either
the Government Printing Office (GPO) or the National Technical
Information Service (NTIS) at the following addresses: Superintendent
of Documents, Government Printing Office, ATTN: New Orders, P.O. Box
371954, Pittsburgh, PA 15250-7954, Telephone (202) 512-1800, Fax number
(202) 512-2250 (for credit card orders); or National Technical
Information Service, Department of Commerce, 5825 Port Royal Road,
Springfield, VA 22161, Telephone (703) 487-4630.
In addition, individual manual transmittals and Program Memoranda
listed in this notice can be purchased from NTIS. Interested parties
should identify the transmittal(s) they want. GPO or NTIS can give
complete details on how to obtain the publications they sell.
Additionally, most manuals are available at the following Internet
address: http://cms.hhs.gov/manuals/default.asp.
B. Regulations and Notices
Regulations and notices are published in the daily Federal
Register. Interested individuals may purchase individual copies or
subscribe to the Federal Register by contacting the GPO at the address
given above. When ordering individual copies, it is necessary to cite
either the date of publication or the volume number and page number.
The Federal Register is also available on 24x microfiche and as an
online database through GPO Access. The online database is updated by 6
a.m. each day the Federal Register is published. The database includes
both text and graphics from Volume 59, Number 1 (January 2, 1994)
forward. Free public access is available on a Wide Area Information
Server (WAIS) through the Internet and via asynchronous dial-in.
Internet users can access the database by using the World Wide Web; the
Superintendent of Documents home page address is http://www.gpoaccess.gov/fr/index.html
, by using local WAIS client software,
or by telnet to swais.gpoaccess.gov, then log in as guest (no password
required). Dial-in users should use communications software and modem
to call (202) 512-1661; type swais, then log in as guest (no password
required).
C. Rulings
We publish rulings on an infrequent basis. Interested individuals
can obtain copies from the nearest CMS Regional Office or review them
at the nearest regional depository library. We have, on occasion,
published rulings in the Federal Register. Rulings, beginning with
those released in 1995, are available online, through the CMS Home
Page. The Internet address is http://cms.hhs.gov/rulings.
D. CMS' Compact Disk-Read Only Memory (CD-ROM)
Our laws, regulations, and manuals are also available on CD-ROM and
may be purchased from GPO or NTIS on a subscription or single copy
basis. The Superintendent of Documents list ID is HCLRM, and the stock
number is 717-139-00000-3. The following material is on the CD-ROM
disk:
Titles XI, XVIII, and XIX of the Act.
CMS-related regulations.
CMS manuals and monthly revisions.
CMS program memoranda.
The titles of the Compilation of the Social Security Laws are
current as of January 1, 2003. (Updated titles of the Social Security
Laws are available on the Internet at http://www.ssa.gov/OP_Home/ssact/comp-toc.htm.
) The remaining portions of CD-ROM are updated on a
monthly basis.
Because of complaints about the unreadability of the Appendices
(Interpretive Guidelines) in the State Operations Manual (SOM), as of
March 1995, we deleted these appendices from CD-ROM. We intend to re-
visit this issue in the near future and, with the aid of newer
technology, we may again be able to include the appendices on CD-ROM.
Any cost report forms incorporated in the manuals are included on
the CD-ROM disk as LOTUS files. LOTUS software is needed to view the
reports once the files have been copied to a personal computer disk.
IV. How To Review Listed Material
Transmittals or Program Memoranda can be reviewed at a local
Federal Depository Library (FDL). Under the FDL program, government
publications are sent to approximately 1,400 designated libraries
throughout the United States. Some FDLs may have arrangements to
transfer material to a local library not designated as an FDL. Contact
any library to locate the nearest FDL.
In addition, individuals may contact regional depository libraries
that receive and retain at least one copy of most Federal Government
publications, either in printed or microfilm form, for use by the
general public. These libraries provide reference services and
interlibrary loans; however, they are not
[[Page 76292]]
sales outlets. Individuals may obtain information about the location of
the nearest regional depository library from any library. For each CMS
publication listed in Addendum III, CMS publication and transmittal
numbers are shown. To help FDLs locate the materials, use the CMS
publication and transmittal numbers. For example, to find the Medicare
NCD publication titled ``Cochlear Implantation,'' use CMS--Pub. 100-03,
Transmittal No. 42.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance, Program No. 93.774, Medicare--
Supplementary Medical Insurance Program, and Program No. 93.714,
Medical Assistance Program)
Dated: December 7, 2005.
Jacquelyn Y. White,
Director, Office of Strategic Operations and Regulatory Affairs.
Addendum I
This addendum lists the publication dates of the most recent
quarterly listings of program issuances.
June 27, 2003 (68 FR 38359)
September 26, 2003 (68 FR 55618)
December 24, 2003 (68 FR 74590)
March 26, 2004 (69 FR 15837)
June 25, 2004 (69 FR 35634)
September 24, 2004 (69 FR 57312)
December 30, 2004 (69 FR 78428)
February 25, 2005 (70 FR 9338)
June 24, 2005 (70 FR 36620)
September 23, 2005 (70 FR 55863)
Addendum II--Description of Manuals, Memoranda, and CMS Rulings
An extensive descriptive listing of Medicare manuals and
memoranda was published on June 9, 1988, at 53 FR 21730 and
supplemented on September 22, 1988, at 53 FR 36891 and December 16,
1988, at 53 FR 50577. Also, a complete description of the former CIM
(now the NCDM) was published on August 21, 1989, at 54 FR 34555. A
brief description of the various Medicaid manuals and memoranda that
we maintain was published on October 16, 1992, at 57 FR 47468.
Addendum III.--Medicare and Medicaid Manual Instructions
[July through September 2005]
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Transmittal No. Manual/Subject/Publication No.
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Medicare General Information
(CMS--Pub. 100-01)
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25 Next Generation Desktop Testing Requirements
Definitions
Next Generation Desktop Maintainer Requirements
26 Implement New Medicare Plan ID and Carrier
Number for the Single Testing Contractor
Shared System Testing Requirements for
Maintainers, Beta Testers, and Contractors
27 Provider Extract File
28 Conforming Changes for Change Request 3648 to
Pub. 100-01
Hospital Insurance (Part A) for Inpatient
Hospital, Hospice, and Skilled Nursing
Facility Services--A Brief Description Home
Health Services
Supplementary Medical Insurance (Part B)--A
Brief Description
Discrimination Prohibited
Role of Part A Intermediaries
Limitation on Physical Therapy, Occupational
Therapy and Speech-Language Pathology Services
Certification for Hospital Services Covered by
the Supplementary Medical Insurance Program
Content of the Physician's Certification
Recertifications for Home Health Services
Physician's Certification and Recertification
for Outpatient Physical Therapy Occupational
Therapy and Speech-Language Pathology
Recertification
Under Arrangements
Term of Agreements
Determining Payment for Services Furnished
After Termination, Expiration, or Cancellation
Home Health Agency Defined
29 2005 Scheduled Release for October Updates to
Software Programs and Pricing/Coding Files
------------------------
Medicare Benefit Policy
(CMS--Pub. 100-02)
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37 Conforming Changes for Change Request 3648 to
Pub. 100-02
Medical and Other Health Services Furnished to
Inpatients of Participating Hospitals
Outpatient Hospital Services
Distinguishing Outpatient Hospital Services
Provided Outside the Hospital Coverage of
Outpatient Therapeutic Services
Medical and Other Health Services Furnished by
Home Health Agencies Skilled Services Defined
Speech-Language Pathology
Physical Therapy, Speech-Language Pathology,
and Occupational Therapy Furnished by the
Skilled Nursing Facility or by Others Under
Arrangements With the Facility and Under Its
Supervision
Inpatient Physical Therapy, Occupational
Therapy, and Speech-Language Pathology
Services
Services Furnished Under Arrangements With
Providers
Supplementary Medical Insurance Provisions
Services Not Provided Within United States
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Medicare National Coverage Determinations
(CMS--Pub. 100-03)
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42 Cochlear Implantation
Cochlear Implantation (Effective April 4, 2005)
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[[Page 76293]]
Medicare Claims Processing
(CMS--Pub. 100-04)
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601 Cochlear Implantation
Billing Requirements for Expanded Coverage of
Cochlear Implantation
Intermediary Billing Procedures
Applicable Bill Types
Special Billing Requirements for Intermediaries
Intermediary Payment Requirements
Carrier Billing Procedures
Healthcare Common Procedure Coding System
602 Expansion of Various Alpha and Numeric Fields
Within the Outpatient Prospective Payment
System Outpatient Code Editor
603 Modification to the Appeals Language on the
Medicare Summary Notice; Full Replacement of
Change Request 3808
Appeals Section
Back of Medicare Summary Notice--Carriers and
Intermediaries Carrier Spanish Medicare
Summary Notices Back Intermediary Spanish
Medicare Summary Notices Back
604 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
605 Frequency Instructions for Smoking and Tobacco-
Use Cessation Counseling Services
Remittance Advice Notices
Medicare Summary Notices
606 Medicare Program-Update to the Hospice Payment
Rates, Hospice Cap, Hospice Wage Index, and
the Hospice Pricer for FY 2005
Payment Rates
607 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
608 New Health Professional Shortage Area Modifier
Zip Code Files
Provider Education
Claims Coding Requirements
Services Eligible for Health Professional
Shortage Area and Physician Scarcity Bonus
Payments
Post-payment Review
Health Professional Shortage Area Incentive
Payments for Physician Services Rendered in a
Critical Access Hospital
609 Remittance Advice Remark Code and Claim
Adjustment Reason Code Update
610 This Transmittal is rescinded and replaced by
Transmittal 634
611 Payment Methodology for Rehabilitation Services
in Indian Health Service/Tribally Owned and/or
Operated Hospitals and Hospital Based
Facilities
Services Paid Under the Physician Fee Schedule
612 Abarelix for Treatment of Prostate Cancer
613 New Healthcare Common Procedure Coding System
Codes and Systems Edits for Supplies and
Accessories for Ventricular Assist Devices--
Full Replacement of CR 3761
614 Medicare Physician Fee Schedule Database 2006
File Layout
615 Revision of Chapter 24, Electronic Data
Interchange Support Requirements
Electronic Data Interchange General Outreach
Activities Carrier, Durable Medical Equipment
Regional Carrier, and Fiscal Intermediary
Analysis of Internal Information
Systems Information
Review of Provider Profiles
Contact with New Providers
Production and Distribution of Material to
Increase Use of Electronic Data Interchange
Electronic Data Interchange Enrollment
New Enrollments and Maintenance of Existing
Enrollments
Submitter Number
Release of Medicare Eligibility Data
Network Service Vendor Agreement
Electronic Data Interchange User Guidelines
Directory of Billing Software Vendors and
Clearinghouses
Technical Requirements--Data, Media, and
Telecommunications System Availability
Media
Telecommunications and Transmission Protocols
Toll-Free Service
Initial Editing
Translators
Required Electronic Data Interchange Formats
General Health Insurance Portability and
Accountability Act Electronic Data Interchange
Requirements
Continued Support of Pre-Health Insurance
Portability and Accountability Act
Electronic Data Interchange Formats
National Council for Prescription Drug Program
Claim Requirements
Crossover Claim Requirements
Direct Data Entry Screens
Use of Imaging, External Key Shop, and In-House
Keying for Entry of Transaction Data Submitted
on Paper
Electronic Funds Transfer
Electronic Data Interchange Testing
Requirements
[[Page 76294]]
Shared System and Common Working File
Maintainers Internal Testing Requirements
Carrier, Durable Medical Equipment Regional
Carrier, and Intermediary Internal Testing
Requirements
Third-Party Certification Systems and Services
Electronic Data Interchange Submitter/Receiver
Testing by Carriers, Durable Medical Equipment
Regional Carriers, and Fiscal Intermediaries
Testing Accuracy
Limitation on Testing of Multiple Providers
That Use the Same Clearinghouse, Billing
Service, or Vendor Software
Carrier, Durable Medical Equipment Regional
Carrier, and Fiscal Intermediary Submitter/
Receiver Testing With Legacy Formats During
the Health Insurance Portability and
Accountability Act Contingency Period
Discontinuation of Use of Claim Legacy Formats
following Successful Health Insurance
Portability and Accountability Act Format
Testing
Electronic Data Interchange Receiver Testing by
Carriers, Durable Medical Equipment Regional
Carriers, and Intermediaries
Changes in Provider's System or Vendor's
Software, and Use of Additional Electronic
Data Interchange Formats
Support of Electronic Data Interchange Trading
Partners
User Guidelines
Technical Assistance to Electronic Data
Interchange Trading Partners
Training Content and Frequency
Prohibition Against Requiring Use of
Proprietary Software or Direct Data Entry
Free Claim Submission Software
Remittance Advice Print Software
Medicare Remit Easy Print Software for Carrier
and Durable Medical Equipment Regional Carrier
Provider Use
Medicare Standard Fiscal Intermediary PC-Print
Software
Newsletters/Bulletin Board/Internet Publication
of Electronic Data Interchange Information
Provider Guidelines for Choosing a Vendor
Determining Goals/Requirements
Vendor Selection
Negotiating With Vendors
Electronic Data Interchange Edit Requirements
Carrier, Durable Medical Equipment Regional
Carrier, and Fiscal Intermediary X12 Edit
Requirements
Supplemental Fiscal Intermediary-Specific
Shared System Edit Requirements
Fiscal Intermediary Health Insurance and
Portability Accountability Act Claim
Level Implementation Guide Edits
Supplemental Carrier/Durable Medical Equipment
Regional Carrier-Specific Shared System
Implementation Guide Edit Requirements
Keyshop and Image Processing
Carrier, Durable Medical Equipment Regional
Carrier, or Fiscal Intermediary Data Security
and Confidentiality Requirements
Carrier, Durable Medical Equipment Regional
Carrier, and Fiscal Intermediary Electronic
Data Interchange Audit Trails
Security-Related Requirements for Carrier,
Durable Medical Equipment
Regional Carrier, or Fiscal Intermediary
Arrangements with Clearinghouses And Billing
Services
Mandatory Electronic Submission of Medicare
Claims
Small Providers and Full-Time Equivalent
Employee Self-Assessments
Exceptions
Unusual Circumstance Waivers
Unusual Circumstance Waivers Subject to
Provider Self-Assessment
Unusual Circumstance Waivers Subject to
Medicare Contractor Approval
Unusual Circumstance Waivers Subject to
Contractor Evaluation and CMS Decision
Electronic and Paper Claims Implications of
Mandatory Electronic Submission Enforcement
Provider Education
616 Certified Registered Nurse Anesthetist Pass-
Through Payments
Anesthesia and Certified Registered Nurse
Anesthetist Services in a Critical Access
Hospitals
Payment for Certified Registered Nurse
Anesthetist Pass-Through Services
Payment for Anesthesia Services by a Certified
Registered Nurse Anesthetist (Method II
Critical Access Hospital Only)
617 Administration of Drugs and Biologicals in a
Method II Critical Access Hospital
Coding for Administering Drugs in a Method II
Critical Access Hospital
Coding for Low Osmolar Contrast Material
618 Coding for the Administration of Other Drugs
and Biologicals
Clarification for Carriers and Durable Medical
Equipment Regional Carriers About Correction
and Recoupment of Previously Processed Claims
619 Late IRF-PAI Data Submission Penalty Protocol
Within the Inpatient Rehabilitation Facility
Prospective Payment System
Payment Adjustment for Late Transmission of
Patient Assessment Data
620 New Fiscal Intermediary (FI) Edit to Identify
Potentially Excessive Medicare Payments
Fiscal Intermediary Edits Affecting Multiple
Bill Types
Threshold Edit for Outpatient and Inpatient
Part B Claims
621 Locality Codes for Purchased Diagnostic Tests
622 This Transmittal is rescinded and replaced by
Transmittal 668
623 Durable Medical Equipment Regional Carrier
Only--Corrections to the Billing Indicator
Field for Adjusted Claims
624 This Transmittal is rescinded and replaced by
Transmittal 686
625 Competitive Acquisition Program for Part B
Drugs--Coding, Testing, and Implementation
626 Common Working File Expansion of Duplicate
Claim Edit for Clinical Diagnostic Services
627 New Low Osmolar Contrast Material (LOCM) HCPCS
Codes/Payment Criteria/Payment Level
[[Page 76295]]
Low Osmolar Contrast Media (HCPCS Codes Q9945-
Q9951)
Payment Criteria/Payment Level
628 Radiopharmaceutical Diagnostic Imaging Agents
Codes Applicable to Positron Emission
Tomography Scan Services Performed on or After
January 28, 2005
Appropriate Common Procedure Terminology Codes
Effective for Positron Emission Tomography
Scan Services Performed on or After January
28, 2005
Tracer Codes Required for Positron Emission
Tomography Scans
629 Certificate of Medical Necessity Claim Edits
Workload Reporting
Durable Medical Equipment Regional Carrier
Systems
630 Medicare Part A Skilled Nursing Facility
Prospective Payment System Pricer
Update and Health Insurance Prospective Payment
System Coding Update Effective January 1, 2006
Health Insurance Prospective Payment System
Rate Code
Skilled Nursing Facility Prospective Payment
System Rate Components
Decision Logic Used by the Pricer on Claims
631 Claim Status Category Code and Claim Status
Code Update
632 Billing and Claims Processing Instructions for
Claims Subject to Expedited Determinations
Limitation of Liability Notification and
Coordination With Quality
Improvement Organizations
Limitation on Liability--Overview
Hospital Claims Subject to Hospital Issued
Notices of Noncoverage
Scope of Issuance of Hospital Issued Notices of
Noncoverage
General Responsibilities of Quality Improvement
Organizations and Fiscal Intermediaries
Related to Hospital Issued Notices of
Noncoverage
Billing and Claims Processing Requirements
Related to Hospital Issued Notices of
Noncoverage
Skilled Nursing Facility, Home Health Agency,
Hospice, and Comprehensive Outpatient
Rehabilitation Facility Claims Subject to
Expedited Determinations
Scope of Issuance of Expedited Determination
Notices
General Responsibilities of Quality Improvement
Organizations and Fiscal Intermediaries
Related to Expedited Determinations
Billing and Claims Processing Requirements
Related to Expedited Determinations
Coordination With the Quality Improvement
Organization
633 Guidelines for Payment of Vaccines
(Pneumococcal Pneumonia Virus, Influenza
Virus, and Hepatitis B Virus) and Their
Administration Provided by Indian Health
Service/Tribally-Owned and/or Operated
Hospitals and Hospital Based Facilities
Billing Requirements
Bills Submitted to Fiscal Intermediaries
Vaccines and Vaccine Administration
634 Guidelines for Payment of Vaccines
(Pneumococcal Pneumonia Virus, Influenza
Virus, and Hepatitis B Virus) and Their
Administration at Renal Dialysis Facilities
Vaccines Furnished to End-Stage Renal Disease
Patients
Fiscal Intermediary Payment for Pneumococcal
Pneumonia, Influenza Virus, and Hepatitis B
Vaccine
Bills Submitted by Hospices and Payment for
Renal Dialysis Facilities
635 Financial Liability for Services Subject to
Home Health Consolidated Billing
Home Health Prospective Payment System
Consolidated Billing and Primary
Home Health Agencies
Home Health Prospective Payment System
Consolidated Billing Beneficiary Notification
and Payment Liability Under Home Health
Consolidated Billing
Responsibilities of Home Health Agencies
Responsibilities of Providers/Suppliers of
Services Subject to Consolidated Billing
Responsibilities of Hospitals Discharging
Medicare Beneficiaries to Home Health Care
Home Health Consolidated Billing Edits in
Medicare Systems
Non-routine Supply Editing
Therapy Editing
Other Editing Related to Home Health
Consolidated Billing
Only Request for Anticipated Payment Received
and Services Fall Within 60 Days After Request
for Anticipated Payment Start Date
No Request for Anticipated Payment Received and
Therapy Services Rendered in the Home
Health Insurance Eligibility Query to Determine
Episode Status
Other Editing and Changes for Home Health
Prospective Payment System Episodes
Coordination of Home Health Prospective Payment
System Claims and Episodes With Inpatient
Claim Types
636 Instructions for Implementation of CMS Ruling
05-01; Presbyopia-Correcting Intraocular Lens
637 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
638 New Medicare Summary Notice Messages
Adjustments
Ajustes
639 Cessation of Additional $50 Payment for New
Technology Intraocular Lenses
Ambulatory Surgical Center Services on
Ambulatory Surgical Center List
Payment for Intraocular Lens
640 Medicare Part A Skilled Nursing Facility
Prospective Payment System Pricer Update FY
2006
641 October 2005 Quarterly Update to Skilled
Nursing Facility Consolidated Billing
642 New Waived Tests
643 Nature and Effect of Assignment on Carrier
Claims
[[Page 76296]]
644 October 2005 Non-Outpatient Prospective Payment
System Code Editor Specifications Version 21
645 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
646 Update to the Inpatient Provider Specific File
and the Outpatient Provider
Specific File to Retain Provider Information
647 The Supplemental Security Income/Medicare
Beneficiary Data for Fiscal Year 2004 for
Inpatient Prospective Payment System Hospitals
648 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
649 Competitive Acquisition Program for Part B
Drugs--Coding, Testing, and Implementation
650 This Transmittal is rescinded and replaced by
Transmittal 673
651 Changes to the Laboratory National Coverage
Determination Edit Software for October 2005
652 This Transmittal is rescinded and replaced by
Transmittal 661
653 October 2005 Quarterly Average Sales Price
Medicare Part B Drug Pricing File, Effective
October 1, 2005 and Revisions to April 2005
and July 2005 Quarterly Average Sale Price
Medicare Part B Drug Pricing File
654 Services Not Provided Within the United States
Services Received by Medicare Beneficiaries
Outside the United States Source of Part B
Claims
Appeals of Denied Charges for Physicians and
Ambulance Services in Connection With Foreign
Hospitalization
Services Rendered in Nonparticipating Providers
Coverage Requirements for Emergency Hospital
Services in Foreign Countries
Services Furnished in a Foreign Hospital
Nearest to Beneficiary's U.S. Residence
Coverage of Physician and Ambulance Services
Furnished Outside U.S.
Payment by the Railroad Retirement
Beneficiaries for Services Furnished in Canada
to Qualified Railroad Retirement Beneficiaries
Foreign Religious Nonmedical Health Care
Facility Claims
Elections to Bill for Services Rendered at
Nonparticipating Hospitals
Processing Claims
Appeals on Claims for Emergency and Foreign
Services
Payment for Services from Foreign Hospitals
Full Denial--Foreign Claim--Beneficiary Filed
655 This Transmittal is rescinded and replaced by
Transmittal 663
656 Full Replacement of Change Request 3607,
Payment Edits in Applicable States For Durable
Medical Equipment Prosthetics, Orthotics &
Supplies
Provider Billing for Prosthetics and Orthotic
Services
657 Quarterly Update to Correct Coding Initiative
Edits, Version V11.3, Effective October 1,
2005
658 Billing for Devices Under the Hospital
Outpatient Prospective Payment System
Billing for Devices Under the Outpatient
Prospective Payment System
Requirements that Hospitals Report Device Codes
on Claims on Which They Report Specified
Procedures
Edits for Claims on Which Specified Procedures
Are To Be Reported With Device Codes
659 Instructions for Downloading the Medicare Zip
Code File
660 This Transmittal is rescinded and replaced by
Transmittal 664
661 This Transmittal is rescinded and replaced by
Transmittal 672
662 This Transmittal is rescinded and replaced by
Transmittal 691
663 Update To The Hospice Payment Rates, Hospice
Cap, Hospice Wage Index, and the Hospice
Pricer for Fiscal Year 2006
664 This Transmittal is rescinded and replaced by
Transmittal 683
665 October Quarterly Update for 2005 Durable
Medical Equipment, Prosthetics, Orthotics, and
Supplies Fees Schedule
666 Updates to the Coordination of Benefits
Contractor Detailed Error
Report File Layout
Consolidation of the Claims Crossover Process
Coordination of Benefits Agreement Detailed
Error Notification Process
667 Home Care and Domiciliary Care Visits (Codes
99321-99350)
668 Enforcement of Hospital Inpatient Bundling:
Carrier Denial of Ambulance Claims During an
Inpatient Stay
Hospital Inpatient Bundling
General Coverage and Payment Policies
Common Working File Editing of Ambulance Claims
for Inpatients
Intermediary Guidelines
Provider/Intermediary Bill Processing
Guidelines Effective April 1, 2002, as a
Result of Fee Schedule Implementation
669 Schedule for Completing the Calendar Year 2006
Fee Updates and the Participating Physician
Enrollment Procedures
670 Realignment of States and Medicare Claims
Processing Workload From Durable Medical
Equipment Regional Carrier Regions A, B, C,
and D to the Durable Medical Equipment Major
Ambulatory Jurisdictions A, B, C and D
671 Updated Manual Instructions for the Medicare
Claims Processing Manual, Regarding Smoking
and Tobacco-Use Cessation Counseling Services
Healthcare Common Procedure Coding System and
Diagnosis Coding
Carrier Billing Requirements
Fiscal Intermediary Billing Requirements
Medicare Summary Notices
672 October Update to the 2005 Medicare Physician
Fee Schedule Database
673 Manual Update on Medical Nutrition Therapy
Services--Manualization
Medicare Nutrition Therapy Services
General Conditions and Limitations on Coverage
Referrals for Medicare Nutrition Therapy
Services
Dietitians and Nutritionists Performing
Medicare Nutrition Therapy Services
[[Page 76297]]
Payment for Medicare Nutrition Therapy Services
General Claims Processing Information
Common Working File Edits
674 This Transmittal is rescinded and replaced by
Transmittal 692
675 Changes to Appeals of Claims Decisions:
Redeterminations and Reconsiderations
(Implementation Date October 1, 2005)
Workload Data Analysis Program
Managing Appeals Workloads
Standard Operating Procedures
Execution of Workload Prioritization
Workload Priorities
676 2006 Healthcare Common Procedure Coding System
Annual Update Reminder
677 This Transmittal is rescinded and replaced by
687
678 This Transmittal is rescinded and replaced by
688
679 Medicare Redetermination Notice and Effect of
the Redetermination Medicare Redetermination
Notice (for partly or fully unfavorable
redeterminations)
Medicare Redetermination Notice (for fully
favorable redeterminations) Effect of the
Redetermination
680 Inpatient Rehabilitation Facility Annual
Update: Prospective Payment System Pricer
Changes for FY 2006
681 Guidelines For Payment of Vaccines
(Pneumococcal Pneumonia Virus, Influenza
Virus, And Hepatitis B Virus) and Their
Administration Provided by Indian Health
Services/Tribally-Owned and/or Operated
Hospitals and Hospital Based Facilities
Billing Requirements
Bills Submitted to Fiscal Intermediaries
Vaccines and Vaccine Administration
682 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
683 October 2005 Outpatient Prospective Payment
System Code Editor Specifications Version
684 Correction to Chapter 17, Section 80.2.3, MSN/
ANSI X12 Denial Messages for Anti-Emetic Drugs
685 Discontinuation of the Skilled Nursing Facility
Healthcare Common Procedure Coding System Help
File and Notification to Fiscal Intermediaries
and Providers of the Redesigned Skilled
Nursing Facility Consolidated Billing Annual
Update File Posted on CMS Web site
Services Included in Part A Prospective Payment
System Payment Not Billable Separately by the
Skilled Nursing Facility
Services Beyond the Scope of the Part A Skilled
Nursing Facility Benefit
Billing for Medical and Other Health Services
General Payment Rules and Application of Part B
Deductible and Coinsurance
686 Common Working File Unsolicited Response
Adjustments for Certain Claims Denied Due to
an Open Medicare Secondary Payer Group Health
Plan Record Where the Group Health Plan Record
Was Subsequently Deleted
687 Appeals of Claims Decisions: Redeterminations
and Reconsiderations (Implementation Dates for
Fiscal Intermediary Initial Determination
Issued On or After May 1, 2005 and Carrier
Initial Determinations Issued on or After
January 1, 2006)
Filing a Request for Redetermination
Appeal Rights for Dismissals
Dismissal Letters
Model Dismissal Notices
Reconsideration--The Second Level of Appeal
Filing a Request for a Reconsideration
Time Limit for Filing a Request for a
Reconsideration
Contractor Responsibilities--General
Qualified Independent Contractor Case File
Development
Qualified Independent Contractor Case File
Preparation
Forwarding Qualified Independent Contractor
Case Files
Qualified Independent Contractor Jurisdictions
Tracking Cases
Effectuation of Reconsiderations
688 Appeals of Claims Decisions: Redeterminations
and Reconsiderations (Implementation Dates for
All Requests for Redetermination Received by
Fiscal Intermediary on or After May 1, 2005,
and All Requests for Redetermination Received
by Carriers on or After January 1, 2006)
Redetermination--The First Level of Appeal
The Redetermination
The Redetermination Decision
Dismissals
Vacating a Dismissal
689 One Time Update to the National Council
Prescription Drug Programs
Companion Document Regarding Crossover Claims
to Medicaid
690 Fiscal Year (FY) 2006 Payment for Services
Furnished in Ambulatory Surgical Centers
691 October 2005 Update of the Hospital Outpatient
Prospective Payment System
692 Fiscal Year 2006 Inpatient Prospective Payment
System and Long Term Care Hospital Changes
693 Updates to the Inpatient Rehabilitation
Facility and Skilled Nursing Facility
Provider Specific File and Changes in Inpatient
Rehabilitation Facility
Prospective Payment System for FY 2006
Provider-Specific File
Case-Mix Groups
Facility Level Adjustments
Area Wage Adjustment
[[Page 76298]]
Rural Adjustment
Outlier
Teaching Status Adjustment
Full Time Equivalent Resident Cap
Inpatient Rehabilitation Facility Prospective
Payment System Pricer Software
694 Update to the Healthcare Provider Taxonomy
Codes Version 5.1
------------------------
Medicare Secondary Payer
(CMS--Pub. 100-05)
------------------------------------------------------------------------
31 Full Replacement of Change Request 3770,
Expanding the Number of Source Identifiers for
Common Working File Medicare Secondary Payer
Records
Change Request 3770 Is Rescinded
Definition of Medicare Secondary Payer/Common
Working File Terms
Medicare Secondary Payer Delete Transaction
Identification of Reimbursement Advisory
Committee Created Group Health Plan Records
32 Exception for Small Employers in Multi-Employer
Group Health Plans Overview and General
Responsibilities
Introduction to the Coordination of Benefits
Contractor
Scope of the Coordination of Benefit Contractor
in Relation to Contractors
Contractors Claim Referrals to the Coordination
of Benefit Contractors IRS/SSA/CMS Data Match
Coordination of Benefit Contractors
Discontinues Dissemination of the Right of
Recovery Letters to Contractors
Exception for Small Employers in Multi-Employer
Group Health Plans
Purpose
Background
Specific Information
33 Working Aged Exception for Small Employers in
Multi-Employer Group Health Plans
34 Manualization: Long-Standing Medicare Secondary
Payer Policy in Chapter 1 of the Medicare
Secondary Payer Internet Only Manual
General Provisions
Working Aged
End-Stage Renal Disease
Workers' Compensation
No-Fault Insurance
Liability Insurance
Conditional Primary Medicare Benefits
When Conditional Primary Medicare Benefits May
Be Paid When a Group Health Plan Is a Primary
Payer to Medicare
When Conditional Primary Medicare Benefits May
Not Be Paid When a Group Health Plan Is a
Primary Payer to Medicare
When Medicare Secondary Payer Benefits Are
Payable and Not Payable
Multiple Insurers
Definitions
Crediting Deductible for Non-Inpatient
Psychiatric Services
Clarification of Current Employment Status for
Specific Groups
Actions Resulting From Group Health Plan or
Large Group Health Plan
Nonconformance
Federal Government's Right to Sue and Collect
Double Damages
35 Updates to the Group Health Plan Identification
and Recovery Processes
General
IRS/SSA/CMS Data Match (Data Match) Group
Health Plan Identified Cases
Non-Data Match Group Health Plan Identified
Cases
Other Sources of Recovery Actions
Group Health Plan Acknowledges Specific Debt
(42 CFR 411.25)
Recovery When a State Medicaid Agency Has Also
Requested a Refund From the Group Health Plan
Identification of Group Health Plan Mistaken
Primary Payments Via the Recovery Management
and Accounting System
Progression of Recovery Management Accounting
System Group Health Plan
Lead Identification
Progression of Recovery Management Accounting
System History Search
Contractor Recovery Case Files (Audit Trails)
Group Health Plan Letters (Used for Recovery
Management Accounting
System/Healthcare Integrated General Ledger
Accounting System (ReMAS/HIGLAS) When the Only
Debtor Interfaced to Healthcare Integrated
General Ledger Accounting System Is the
Employer)
Employer Group Health Plan Letter
Important Information for Employers
Insurer Group Health Plan Letter (Used for
Recovery Management Accounting System/
Healthcare Integrated General Ledger
Accounting System When the Only Debtor
Interfaced to Healthcare Integrated General
Ledger Accounting System Is the Employer)
Accountability Worksheet (Not Applicable to
Recovery Management Accounting System/
Healthcare Integrated General Ledger
Accounting System Users)
Summary Data Sheet (Not Applicable to ReMAS/
HIGLAS Users)
Field Description on the Medicare Secondary
Payer Summary Data Sheet Payment Record
Summary (Used with ReMAS/HIGLAS Users but in a
Modified Format)
[[Page 76299]]
Courtesy Copy of All Medicare Secondary Payer
Group Health Plan-Based Recovery Demand
Packages to the Employer's Insurer/Third Party
Administrator
Insurer/Third Party Administrator Courtesy Copy
Letter
Recovery Management Accounting System Error
Reports
Mistaken Group Health Plan Primary Payments
Mistaken Primary Payment Activities and Record
Layouts
Contractor Actions Upon Receipt of the Data
Match Cycle Tape or Other Notice of Non-Data
Match Group Health Plan Mistaken Payments (for
Contractor Not on ReMAS/HIGLAS for GHP
Recovery) and Actions to Take for Those
Contractors Using Recovery Management
Accounting System/Health Integrated General
Ledger Accounting System Group Health Plan
Functions
Coordination of Benefits Contractor
Responsibility to Obtain Missing Medicare
Secondary Payer Information
Time Limitations for Group Health Plan
Recoveries
Actual Notice
Contractor History Search
Aggregate Claims for Recovery
Documentation of Debt
Recovery Attempt Audit Trails
Summary of Medicare Reimbursement
Claim Facsimiles for Each Claim Mistakenly Paid
IRS/SSA/CMS Mistaken Payment Recovery Tracking
System
Inpatient, Skilled Nursing Facility, and
Religious Non-Medicare Health Care
Outpatient Mistaken Payment Report Record
Layout
Home Health Agency Mistaken Payment Record
Layout
Communication Receive in Response to Recovery
Actions
36 Update to the Healthcare Provider Taxonomy
Codes Version 5.1
------------------------
Medicare Financial Management
(CMS--Pub. 100-06)
------------------------------------------------------------------------
71 Notice of New Interest Rate for Medicare
Overpayments and Underpayments
72 Claims Accounts Receivable Update
Intermediary Claims Accounts Receivable
Financial Reporting for Intermediary Claims
Accounts Receivable
73 This Transmittal is rescinded and replaced by
Transmittal 75
74 Discovery Code Indication for Recovery Audit
Contractor (RAC) Non-MSP Identified
Overpayments
75 New Thresholds for 2nd Demand Letter for
Physicians/Suppliers
Part B Overpayment Demand Letters to Physicians/
Suppliers
76 Development of New Report to Capture Benefits,
Improvement and Protection Act and Medicare
Prescription Drug, Improvement, and
Modernization Act Appeals Data
Monthly Statistical Report on Intermediary and
Carrier Part A and Part B
Appeals Activity Form
Redeterminations
Qualified Independent Contractor
Reconsiderations
Administrative Law Judge Results
Department Appeals Board Effectuations
Clerical Error Reopenings
Validation of Reports
77 Non-Medicare Secondary Payer Debt Referral and
Debt Collection Improvement Act of 1996
Activities
Background
Cross Servicing
Treasury Offset Program
Definition of Delinquent Debt
Referral Requirements
Exemptions to Referral
Debt to be Referred
Delinquent Non-Medicare Secondary Payer Fiscal
Intermediary Debt, Including Debt on the
Provider Overpayment Reporting System
Delinquent Non-Medicare Secondary Payer
Medicare Carrier Debt, Including Debt on the
Physician/Supplier Overpayment Reporting
System
Delinquent Non-Medicare Secondary Payer Debt
Previously Ineligible for Referral
Debt Collection Improvement Act Language/Intent
to Refer Letter
Response to ``Intent to Refer'' Letter
Provider Overpayment Reporting System Updates
Physician/Supplier Overpayment Reporting System
Updates
Cross Servicing Collection Efforts
Actions Subsequent to Debt Collection System
Input
Transmission of Debt
Update to Debt Collection System After
Transmission
Financial Reporting for Debt Referred
Financial Reporting for Non-Medicare Secondary
Payer Debt
[[Page 76300]]
78 Coordination of Benefits Agreement Process for
Contractor Financial Staff Notification
------------------------
Medicare State Operations Manual
(CMS--Pub. 100-07)
------------------------------------------------------------------------
09 Revision of Appendix P and Certain Exhibits of
the State Operations Manual
10 Revisions--Appendix J--Interpretive Guidelines
Intermediate Care Facilities With Mental
Retardation
11 Revised Chapter 2--``The Certification
Process,'' Sections 2180E thru 2200F, and
Appendix B--``Interpretive Guidelines: Home
Health Agencies''
------------------------
Medicare Program Integrity
(CMS--Pub. 100-08)
------------------------------------------------------------------------
115 Program Integrity Manual Revision
Affiliated Contractor/Full Program Safeguard
Contractor Communication With the
Comprehensive Error Rate Testing Contractor
Overview of the Comprehensive Error Rate
Testing Process
Providing Sample Information to the
Comprehensive Error Rate Testing Contractor
Providing Review Information to the
Comprehensive Error Rate Testing Contractor
Providing Feedback Information to the
Comprehensive Error Rate Testing Contractor
Disputing/Disagreeing With a Comprehensive
Error Rate Testing Decision Handling
Overpayments and Underpayments Resulting From
the Comprehensive Error Rate Testing Findings
Handling Appeals Resulting From Comprehensive
Error Rate Testing Initiated Denials
Tracking Overpayments
Tracking Appeals
Potential Fraud
Full Program Safeguard Contractor Requirements
Involving Comprehensive Error Rate Testing
Information Dissemination
Full Program Safeguard Contractor Error Rate
Reduction Plan
Contacting Non-Responders
Late Documentation Received by the
Comprehensive Error Rate Testing Contractor
Voluntary Refunds
Local Coverage Determination/National Coverage
Determination
Comprehensive Error Rate Testing Review
Contractor Review Guidelines
116 Revise the Fiscal Intermediary Shared System to
Allow Reporting of Data for the Comprehensive
Error Rate Testing Program Resolution File at
a Line Level
117 Revise the Medicare Contractor System and the
VIPS Medicare System To Allow Update of the
Comprehensive Error Rate Testing Program
Resolution File Within Five Business Days of a
Comprehensive Error Rate Testing Request
118 Various Benefit Integrity Clarifications
Goal of Medical Review Program
Overpayment Procedures
Disposition of the Suspension
The Medicare Fraud Program
Program Safeguard Contractor and Medicare
Contractor Benefit Integrity Unit
Organizational Requirements
Training for Law Enforcement Organizations
Procedural Requirements
Requests for Information From Outside
Organizations
Sharing Fraud Referrals Between the Office of
Inspector General and the Department of
Justice
Complaint Screening
Investigations
Conducting Investigations
Disposition of Cases
Reversed Denials by Administrative Law Judges
on Open Cases
Types of Fraud Alerts
Coordination
Investigation, Case, and Suspension Entries
Update Requirements for Cases
Closing Investigations
Deleting Investigations, Cases, or Suspensions
Access
Harkin Grantees or Senior Medicare Patrol--
Complaint Tracking System
Harkin Grantees or Senior Medicare Patrol
Project Description
Harkin Grantees Tracking System Instructions
System Access to Metaframe and Data Collection
Data Dissemination/Aggregate Report
Referral of Cases to the Office of the
Inspector General/Office of Investigations
Immediate Advisements to the Office of
Inspector General/Office of Investigations
Denial of Payments for Cases Referred to and
Accepted by Office of Inspector General/Office
of Investigations
Take Administrative Action on Cases Referred to
and Refused by Office of Inspector General /
Office of Investigations
Referral to State Agencies or Other
Organizations
Referral to Quality Improvement Organizations
[[Page 76301]]
Referral Process to CMS
Referrals to Office of Inspector General
Breaches of Assignment Agreement by Physician
or Other Supplier
Annual Deceased-Beneficiary Postpayment Review
Vulnerability Report
119 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
120 Correction to Change Request (CR) 3222: Local
Medical Review Policy/Local Coverage
Determination Medicare Summary Notice Message
Revision Denials Notices
121 This Transmittal is rescinded and replaced by
Transmittal 124
122 Medical Review Collection Number Requirements
Overview of Prepayment and Postpayment Review
for Medical Review Purposes
123 Chapter 3, Medicare Modernization Act Section
935
Verifying Potential Errors and Setting
Priorities
Determining Whether the Problem Is Widespread
or Provider Specific
Overpayment Procedures
``Probe'' Reviews
124 Evidence of Medical Necessity: Wheelchair and
Power Operated Vehicle Claims
125 Medical Review Additional Documentation
Requests
Additional Documentation Requests During
Prepayment or Postpayment
Medical Review
------------------------
Medicare Contractor Beneficiary and Provider Communications
(CMS--Pub. 100-09)
------------------------------------------------------------------------
12 Next Generation Desktop Testing Requirements
13 Provider Contact Centers Training Program
Guidelines for Telephone Service
Staff Development and Training
------------------------
Medicare Managed Care
(CMS--Pub. 100-16)
------------------------------------------------------------------------
66 Beneficiary Enrollment and Disenrollment
Requirements for Medicare Advantage Plans
Changes in Requirements for Periodic Surveys of
Current and Former Enrollees, and in the CMS
Method for Calculating Interest on Overpayment
and Underpayments to Health Maintenance
Organizations, Comprehensive Medical Plans and
Health Care Prepayment Plans
67 Initial Publication of Chapter 1--General
Provisions
Introduction
Definitions
Types of Medical Assistance Plans
Cost Sharing in Enrollment--Related Costs
68 Revisions to Chapter 12, ``Effect of Change of
Ownership,'' and Chapter 14, ``Contract
Determination and Appeals''
Effect of Change of Ownership
What Constitutes a Change of Ownership
Address for Sending Notifications to CMS
When a Novation Agreement Is Required
Acceptable Novation Agreements
Contract Determination Notice
Postponement of the Contract Determination's
Effective Date
Reconsiderations
Time Frames for Filing a Reconsideration
Request
Parties to the Hearing
Conduct and Record of a Hearing
Reopening of Contract Reconsidered
Determination or Decision of a Hearing Officer
or the Administrator
69 Beneficiary Enrollment and Disenrollment
Requirements for Medicare Advantage Plans
70 Deletion of MCM Chapter 19--The Enrollment and
Payment User's Guide, and Chapter 20--Managed
Care and Medical Assistance Business
Requirements
71 Changes in Manual Instructions for Benefits and
Beneficiary Protections
Basic Rules
Types of Benefits
Availability and Structure of Plans
CMS Review and Approval of M+C Benefit--
rewritten and relocated to Sec. 20
Requirements Relating to Medicare Conditions of
Participation--renumbered as Sec. 4.10.7
Provider Networks--renumbered as new Sec.
10.8 and parts of the old Sec. 20,
``Original Medicare Covered Benefits''
CMS Approval of Proposed Plan MA Benefits--old
10.7 revised and located here
General Guidelines on Benefit Approval
Screening Mammography, Influenza Vaccine, and
Pneumococcal Vaccine
Inpatient Hospital Rehabilitation Service
Value-Added Items and Services
Prescription Drug Discount Programs
[[Page 76302]]
Waiting Periods and Exclusions That Are Not
Present in Original Medicare
Annual Beneficiary Out-of-Pocket Cap
Drug Benefits
Drugs That Are Covered Under Original Medicare
Mid-Year Benefit Enhancements
Multi-Year Benefits
Return to Home Skilled Nursing Facility
Guidance on Acceptable Cost-Sharing and
Deductibles
Homemaker Services
Caregiver Resource Services
Electronic Monitoring
Dentures
Chiropractic Services
Cash
Beauty Parlor
Transportation
Safety Items
Travel for Transplants
Meals
Basic Benefits
Cost-sharing Rules for Medical Assistance
Regional Plans
Supplemental Benefits and Mandatory
Supplemental and Optional Supplemental
Basic Versus Supplemental Benefits
The Annual Deductible
General Rule
Accessing Plan Contracting Providers
Enrollee Information and Disclosure
Definitions
Factors That Influence Service Area Approval
The ``County Integrity Rule''
General Rule
Employer Plans
Basic Rule
Medicare Benefits Secondary to Group Health
Plans and Large Group Health Plans
Medicare Secondary Payer Rules and State Laws
Discrimination Against Beneficiaries Prohibited
Disclosure Requirements at Enrollment (and
Annually Thereafter)
Information Pertaining to a Medical Assistance
Organization Changing Their Rules or Provider
Network
Other Information That Is Disclosable Upon
Request
Access and Availability Rules for Coordinated
Care Plans
Emergency and Urgently Needed Services
Post-Stabilization Care Services
General Description
Private Fee-for-Service Plan Terms and
Conditions of Participation
Provider Types--Direct Contracting, Deemed
Contracting, Non-Contracting Access to
Services
Payments and Balance Billing
Advance Notice of Coverage
Prompt Payment Requirements
Original Medicare vs. Estimated Payment Amounts
Table Summarizing Private Fee-for-Service Plan
Provider Types and Rules
72 Changes in Manual Instructions for Intermediate
Sanctions
Types of Intermediate Sanctions
General Basis for Imposing Intermediate
Sanctions on Medical Assistance Organizations
Imposing Sanctions for Specific Medical
Assistance Contract Violations
Civil Monetary Penalties for Medical Assistance
Organizations That Improperly Terminate the
Medical Assistance Contract
CMS Process for Suspending Marketing,
Enrollment, and Payment
Contract Termination by CMS
------------------------
Medicare Business Partners Systems Security
(CMS--Pub. 100-17)
------------------------------------------------------------------------
00 None
------------------------
Demonstrations
(CMS--Pub. 100-19)
------------------------------------------------------------------------
26 This Transmittal is rescinded and replaced by
Transmittal 27
27 The Medicare Chronic Care Improvement,
``Medicare Health Support,'' Program
28 The Medicare Care Management for High Cost
Beneficiaries Demonstration
------------------------
[[Page 76303]]
One-Time Notification
(CMS--Pub. 100-20)
------------------------------------------------------------------------
161 Kansas Blue Cross Blue Shield Carrier Numbering
Issue
162 Instructions for Fiscal Intermediary Standard
System and Multi-Carrier System
Healthcare Integrated General Ledger Accounting
System Changes
163 Qualified Independent Contractor Jurisdictions
164 Medicare HIPAA Electronic Claims Report--Third
Reporting Timeframe Extension
165 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
166 This Transmittal is rescinded and replaced by
Transmittal 173
167 Issued to a specific audience, not posted to
Internet/Intranet due to Sensitivity of
Instruction
168 Shared System Maintainer Hours for Resolution
of Problems Detected During Health Insurance
Portability and Accountability Act Transaction
January 2006 Release Testing
169 Analysis of Systems Improvements to Streamline
POS Code Set Updates
170 Updates to the Coordination of Benefits
Agreement Insurance File for Use in the
National Claims Crossover Program
171 Preliminary system updates in preparation for
ending the Medicare contingency plan in
October 2005
172 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
173 Overnight Oximetry Testing
174 Fiscal Intermediary Shared System Modification
175 Common Working File Calculation of Next
Eligible Date for Preventive Services
176 Change of the CareFirst Part A Plan to Highmark
in the State of Maryland and Washington, DC
177 Termination of Existing Crossover Agreements as
Trading Partners
Transition to the National Coordination of
Benefits Agreement Program
178 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
179 Calculation of the Interim Payment of Indirect
Medical Education Through the Inpatient
Prospective Payment Pricer for Hospitals That
Received an Increase to Their Full-Time
Equivalent Resident Cap Under Section 422 of
the Medicare Modernization Act, P.L. 108-173
180 Issued to a specific audience, not posted to
Internet/Intranet due to Confidentiality of
Instruction
181 National Modifier and Condition Code To Be Used
To Identify Disaster Disaster Related Claims
------------------------------------------------------------------------
Addendum IV.--Regulation Documents Published in the Federal Register
[July through September 2005]
----------------------------------------------------------------------------------------------------------------
FR Vol.
Publication date 70 page CFR parts affected File code Title of regulation
number
----------------------------------------------------------------------------------------------------------------
July 6, 2005..................... 39022 414................. CMS-3125-IFC Medicare Program;
Competitive Acquisition
of Outpatient Drugs and
Biologicals Under Part
B.
July 8, 2005..................... 39514 .................... CMS-1288-N Medicare Program;
Meeting of the Advisory
Panel on Ambulatory
Payment Classification
(APC) Groups--August
17, 18, and 19, 2005.
July 12, 2005.................... 40039 .................... CMS-2212-N Medicaid Program;
Meeting of the Medicaid
Commission--July 27,
2005.
July 14, 2005.................... 40788 484................. CMS-1301-P Medicare Program; Home
Health Prospective
Payment System Rate
Update for Calendar
Year 2006.
July 14, 2005.................... 40709 .................... CMS-1288-CN Medicare Program;
Meeting of the Advisory
Panel on Ambulatory
Payment Classification
(APC) Groups--August
17, 18, and 19, 2005;
Correction.
July 22, 2005.................... 42331 .................... CMS-3142-FN Medicare Program;
Evaluation Criteria and
Standards for Quality
Improvement Program
Contracts.
July 22, 2005.................... 42330 .................... CMS-1315-N Medicare Program; August
22, 2005, Meeting of
Practicing Physicians
Advisory Council and
Request for
Nominations.
July 22, 2005.................... 42329 .................... CMS-3153-N Medicare Program;
Meeting of the Medicare
Coverage Advisory
Committee--October 6,
2005.
July 22, 2005.................... 42328 .................... CMS-4093-N Medicare Program;
Request for Nominations
for the Advisory Panel
on Medicare Education.
July 22, 2005.................... 42327 .................... CMS-3158-N Medicare Program;
Request for Nominations
for Members for the
Medicare Coverage
Advisory Committee.
July 22, 2005.................... 42276 146................. CMS-4094-F3 Amendment to the Interim
Final Regulation for
Mental Health Parity.
July 25, 2005.................... 42674 419 and 485......... CMS-1501-P Medicare Program;
Proposed Changes to the
Hospital Outpatient
Prospective Payment
System and Calendar
Year 2006 Payment
Rates.
August 4, 2005................... 45130 418................. CMS-1286-F Medicare Program;
Hospice Wage Index for
Fiscal Year 2006.
[[Page 76304]]
August 4, 2005................... 45026 409, 411, 424, and CMS-1282-F Medicare Program;
489. Prospective Payment
System and Consolidated
Billing for Skilled
Nursing Facilities for
FY 2006.
August 4, 2005................... 44930 .................... CMS-2220-N Medicare Program;
Meeting of the Medicaid
Commission--August 17-
18, 2005.
August 4, 2005................... 44879 402................. CMS-6019-P Medicare Program;
Revised Civil Money
Penalties, Assessments,
Exclusions, and Related
Appeals Procedures.
August 8, 2005................... 45764 405, 410, 411, 413, CMS-1502-P Medicare Program;
414, and 426. Revisions to Payment
Policies Under the
Physician Fee Schedule
for Calendar Year 2006.
August 12, 2005.................. 47278 405, 412, 413, 415, CMS-1500-F Medicare Program;
419, 422, and 485. Changes to the Hospital
Inpatient Prospective
Payment Systems and
Fiscal Year 2006 Rates.
August 15, 2005.................. 47880 412................. CMS-1290-F Medicare Program;
Inpatient
Rehabilitation Facility
Prospective Payment
System for FY 2006.
August 15, 2005.................. 47759 483................. CMS-3198-P Medicare and Medicaid
Programs; Condition of
Participation:
Immunization Standard
for Long Term Care
Facilities.
August 26, 2005.................. 50940 410................. CMS-3017-IFC Medicare Program;
Conditions for Payment
of Power Mobility
Devices, including
Power Wheelchairs and
Power-Operated
Vehicles.
August 26, 2005.................. 50680 419 and 485......... CMS-1501-CN Medicare Program;
Proposed Changes to the
Hospital Outpatient
Prospective Payment
System and Calendar
Year 2006 Payment
Rates; Correction.
August 26, 2005.................. 50375 .................... CMS-4111-N Medicare Program;
Meeting of the Advisory
Panel on Medicare
Education, September
27, 2005.
August 26, 2005.................. 50374 .................... CMS-1330-N Medicare Program; Town
Hall Meeting on the
Medicare Provider
Feedback Group (MPFG)--
September 12, 2005.
August 26, 2005.................. 50373 .................... CMS-4106-PN Medicare Program;
Changes in Medicare
Advantage Deeming
Authority.
August 26, 2005.................. 50372 .................... CMS-1309-NC Medicare and Medicaid
Programs; Announcement
of an Application From
a Hospital Requesting
Waiver for Organ
Procurement Service
Area.
August 26, 2005.................. 50358 .................... CMS-2209-N Medicaid Program; Fiscal
Disproportionate Share
Hospital Allotments and
Disproportionate Share
Hospital Institutions
for Mental Disease
Limits.
August 26, 2005.................. 50358 .................... CMS-1486-N Medicare Program;
Announcement of New
Members of the Advisory
Panel on Ambulatory
Payment Classification
(APC) Groups.
August 26, 2005.................. 50262 447 and 455......... CMS-2198-P Medicaid Program;
Disproportionate Share
Hospital Payments.
August 26, 2005.................. 50214 433................. CMS-2210-IFC Medicaid Program; State
Allotments for Payment
of Medicare Part B
Premiums for Qualifying
Individuals: Federal
Fiscal Year 2005.
August 26, 2005.................. 50214 405................. CMS-4064-IFC3 Medicare Program;
Changes to the Medicare
Claims Appeal
Procedures: Correcting
Amendment to a
Correcting Amendment.
August 30, 2005.................. 51321 410................. CMS-6024-P Medicare Program; Prior
Determination for
Certain Items and
Services.
September 1, 2005................ 52105 .................... CMS-1308-NC Medicare Program;
Withdrawal of Ambulance
Fee Schedule Issued in
Accordance With Federal
District Court Order in
Lifestar Ambulance v.
United States, No. 4:02-
CV-127-1 (M.D. Ga.,
Jan. 16, 2003)--
Medicare Covered
Ambulance Services.
September 1, 2005................ 52056 405, 410, 411, 413, CMS-1502-CN Medicare Program;
414, and 426. Revisions to Payment
Policies Under the
Physician Fee Schedule
for Calendar Year 2006;
Correction.
September 1, 2005................ 52023 422................. CMS-4069-F3 Medicare Program;
Establishment of the
Medicare Advantage
Program; Correcting
Amendment; Partial Stay
of Effectiveness.
September 1, 2005................ 52019 403................. CMS-4063-F Medicare Program;
Medicare Prescription
Drug Discount Card;
Revision of Marketing
Rules for Endorsed Drug
Card Sponsors.
September 6, 2005................ 52930 414................. CMS-1325-IFC2 Medicare Program;
Competitive Acquisition
of Outpatient Drugs and
Biologicals Under Part
B: Interpretation and
Correction.
[[Page 76305]]
September 16, 2005............... 54751 .................... CMS-5017-N Medicare Program;
Medicare Health Care
Quality (MHCQ)
Demonstration Programs.
September 23, 2005............... 55905 .................... CMS-3159-N Medicare Program;
Meeting of the Medicare
Coverage Advisory
Committee--November 29,
2005.
September 23, 2005............... 55903 .................... CMS-1269-N5 Medicare Program;
Emergency Medical
Treatment and Labor Act
(EMTALA) Technical
Advisory Group (TAG)
Meeting--October 26,
2005 Through October
28, 2005.
September 23, 2005............... 55897 .................... CMS-8027-N Medicare Program;
Medicare Part B Monthly
Actuarial Rates,
Premium Rate, and
Annual Deductible for
Calendar Year 2006.
September 23, 2005............... 55896 .................... CMS-8025-N Medicare Program; Part A
Premium for Calendar
Year 2006 for the
Uninsured Aged and for
Certain Disabled
Individuals Who Have
Exhausted Other
Entitlement.
September 23, 2005............... 55887 .................... CMS-1307-GNC Medicare Program;
Criteria and Standards
for Evaluating
Intermediary, Carrier,
and Durable Medical
Equipment, Prosthetics,
Orthotics, and Supplies
(DMEPOS) Regional
Carrier Performance
During Fiscal Year
2006.
September 23, 2005............... 55885 .................... CMS-8026-N Medicare Program;
Inpatient Hospital
Deductible and Hospital
and Extended Care
Services Coinsurance
Amounts for Calendar
Year 2006.
September 23, 2005............... 55863 .................... CMS-9032-N Medicare and Medicaid
Programs; Quarterly
Listing of Program
Issuances-April Through
June 2005.
September 23, 2005............... 55862 .................... CMS-2227-PN Medicare and Medicaid
Programs; Application
by the Accreditation
Commission of
Healthcare for Deeming
Authority for Home
Health Agencies.
September 23, 2005............... 55812 447 and 455......... CMS-2198-CN Medicaid Program;
Disproportionate Share
Hospital Payments.
September 29, 2005............... 56901 .................... CMS-2230-FN State Children's Health
Insurance Program
(SCHIP); Redistribution
of Unexpended SCHIP
Funds From the
Appropriation for
Fiscal Year 2002.
September 30, 2005............... 57376 505................. CMS-1320-P Medicare Program; Health
care Infrastructure
Improvement Program;
Forgiveness of
Indebtness.
September 30, 2005............... 57368 505................. CMS-1287-IFC Medicare Program; Health
Care Infrastructure
Improvement Program;
Selection Criteria of
Loan Program for
Qualifying Hospitals
Engaged in Cancer-
Related Health Care.
September 30, 2005............... 57300 .................... CMS-1307-CN Medicare Program;
Criteria and Standards
for Evaluating
Intermediary, Carrier,
and Durable Medical
Equipment, Prosthetics,
Orthotics, and Supplies
(DMEPOS) Regional
Carrier Performance
During Fiscal Year
2006; Correction
Notice.
September 30, 2005............... 57297 .................... CMS-3144-NC Medicare Program;
Calendar Year 2005
Review of
Appropriateness of
Payment Amounts for New
Technology Intraocular
Lenses (NTIOLs)
Furnished by Ambulatory
Surgical Centers
(ASCs).
September 30, 2005............... 57296 .................... CMS-1269-N6 Medicare Program;
Emergency Medical
Treatment and Labor Act
(EMTALA) Technical
Advisory Group (TAG):
Announcement of a New
Member.
September 30, 2005............... 57174 418................. CMS-1286-CN Medicare Program;
Hospice Wage Index for
Fiscal Year 2006.
September 30, 2005............... 57166 412................. CMS-1290-CN Medicare Program;
Inpatient
Rehabilitation Facility