Table Of Content

I i< \j OK ft -^t (I . . Revised 03/97 TABLE OF CONTENTS HCFA RULINGS ISSUED IN LOOSE LEAF FORMAT Number Title 82-1 Exclusion from Medicare Coverage of DMSO for Conditions Other Than Interstitial Cystitis (April 20, 1982). 82-2c Constitutionality of Part B Fair Hearing Procedures (April 20, 1982) 82-3 Conditions for Medicare Coverage of Surgery to Relieve Obstructions to Vertebral Artery Blood Flow (Vertebral Artery Surgery) (December 1, 1982). 83-1 Provider Reimbursement Review Board Decision on the Lack of Jurisdiction. (December 2, 1982). 83-2 Criteria for Defining Skilled Nursing Facility Under Section 1861(j)(l) of the Social Security Act (December 3, 1982) 83-3 Revised Criteria for Defining Skilled Nursing Facility When Determining a Beneficiary's Spell of Illness Status (March 22, 1984). 84-1 Provider Reimbursement Review Board Jurisdiction Over Appeals From Estimations of and Modifications to Base Year Costs Under the Prospective Payment System (May 29, 1984). 85-1 Exclusion of Cytotoxic Leukocyte Testing from Medicare Coverage (July 5, 1985). 85-2 Criteria for Medicare Coverage of Inpatient Hospital Rehabilitation Services (July 31, 1985). 86-1 Use of Statistical Sampling to Project Overpayments to Providers and Suppliers (February 20, 1986). 86-2 Provider Reimbursement Review Board Jurisdiction Over Challenges to the Application or the Validity of the Medicare Regulation Governing Apportionment of Malpractice Insurance Costs (42 CFR 405.45) (July 2, 1986) . 87-1 Criteria for Medicare Coverage of Heart Transplants (March 20, 1987) Vf'^\ r ', . TABLE OF CONTENTS HCFA RULINGS ISSUED IN LOOSE LEAF FORiMAT Number Title 87-2 Provider Reimbursement Review Board Jurisdiction Over Challenges to the Application or the Validity of the Medicare Regulation Governing Apportionment of Malpractice Insurance Costs (April 9, 1987). 87-3 Validity of Provider Reimbursement Manual Section 2345 Relating to the Inclusion of Labor/Delivery Room Days in the Calculation of Inpatient Days (April 9, 1987). 87-4 Payments Under Medicare and Awards Under the Federal Tort Claims Act (June 18, 1987). 89-1 Notice of Controlling Adverse Decisions by the Supreme Court and the D.C. Circuit Court of Appeals, and Corresponding Requirement of Remand to the Intermediaries for Payment of Certain Pending Moot Administrative Appeals Challenging the 1981 and 1984 Medicare Wage Index Rules; the 1979 and 1986 Medicare Malpractice Rules; and the Hospital Specific Rate Under PPS (January 26, 1989). 89-2 Notice of Intent to Settle HMO and CMP Cost Reports for Periods Beginning on or After January 1, 1986, Without Application of Absolute Cost Limits (October 31, 1989) . 90-1 Criteria for Medicare Coverage of Seat Lifts (June 11, 1990) 91-1 Notice of Decision to Follow a Consent Order Providing for the Discontinued Application of the 1986 Medicare Malpractice Rule and a Reversion to the Pre-1979 Utilization Method of Paying Certain Hospital Malpractice Insurance Costs (September 30, 1991) . 92-1 Skilled Nursing Facility and Nursing Facility Provider Agreements (August 26, 1992). 93-1 Weight to be Given to a Treating Physician's Opinion in Determining Medicare Coverage of Inpatient Care in a Hospital or Skilled Nursing Facility (May 18, 1993). 94-1 Policy Regarding Medicare Payments in the Event a Primary Payer is Bankrupt or Insolvent (April 18, 1994) . 't ;•* 95-1 Requirements for Determining Limitation on Liability of a Medicare Beneficiary, Provider, Practitioner or Other Supplier for Certain Services and Items for which Medicare Payment is Denied (December 22, 1995). 96-1 Clarification of the terms "Orthotics," "Braces," and "Durable Medical Equipment" under Medicare Part B. (September 18, 1996) 96-2 Requirements for determining limitation on liability of a Medicare beneficiary, supplier, practitioner, or other supplier for PAP smears and mammography services for which Medicare payment is denied. (November 6, 1996) . 96-3 Requirements for determining limitation on liability of a Medicare beneficiary, provider, practitioner, or other supplier for parenteral and enteral nutrition therapy, including intradialytic parenteral nutrition therapy, services and items for which Medicare payment is denied. (December 12, 1996) 97-1 Requirements for determining limitation on liability of a Medicare beneficiary, provider, practitioner, or other supplier for partial hospitalization services for which Medicare payment is denied, (signed February 10, 1997) 97-2 Interpretation of Medicaid Days Included in the Medicare Disproportionate Share Adjustment Calculation (signed February 27, 1997) . HCFA Rulings Department of Health and Human Services Health Care Financing Administration Ruling No. 98-1 Date: December 1998 Health Care Financing Administration (HCFA) Rulings are decisions of the Administrator that serve as precedent final opinions and orders and statements of policy and interpretation. They provide clarification and interpretation of complex or ambiguous provisions of the law or regulations relating to Medicare, Medicaid, Utilization and Quality Control Peer Review, private health insurance, and related matters HCFA Rulings are binding on all HCFA components. Medicare contractors, the Provider Reimbursement Review Board, the Medicare Geographic Classification Review Board, the Departmental Appeals Board, and Administrative Law Judges (ALJs) who hear Medicare HCFAR 98-1-2 appeals. These Rulings promote consistency in interpretation of policy and adjudication of disputes. This Ruling states the policy of the Health Care Financing Administration regarding the appropriate administrative appeals process the Medicare carrier must provide to physicians, non-physician practitioners, and to certain entities that receive reassigned benefits from physicians and non-physician practitioners. This appeals process will be available to a physician or entity that (i) has received reassigned benefits; (ii) has been denied enrollment in the Medicare program or had Medicare billing privileges revoked; and (iii) is not eligible to use the appeals procedures in 42 CFR part 498. MEDICARE PROGRAM Medicare Supplementary Medical Insurance (Part B) THE ADMINISTRATIVE APPEALS PROCESS FOR PHYSICIANS, NON-PHYSICIAN PRACTITIONERS, AND ENTITIES THAT RECEIVE REASSIGNED BENEFITS AND THAT ARE NOT PROVIDED APPEAL RIGHTS UNDER 42 CFR PART 498