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An archive of cases reported from 1969 through 1996 is available as an add-on for CD and/or internet subscribers.

CMS Manuals

  • e purpose of each Manual is to provide direction to the user re-

garding compliance with laws and regulations. Each Manual has a specific audience and the purpose of the manual is explained in the forward. e Internet Research Network (IRN) has the full text of both the previous CMS Paper Based Manuals for historic purposes and the current CMS Internet Only Manuals. Subscribers to the CD and/or internet have the option of subscribing to the full text of all CMS Manuals: Paper Based, Internet Onl , and the archive manuals back to 2000. Transmittals are used to communicate new or changed policies, and/or procedures that are being incorporated into a specific Centers for Medicare & Medicaid Services (CMS) program manual.

  • e transmittal cover page summarizes what is changed.

Administrative Decisions

From a cost and time standpoint, CMS and providers would prefer to resolve issues on an administrative rather than judicial level. e categories of decisions listed below are reproduced in the Guide in all media. ese decisions carry less weight than do the law/regulations/manuals; however, they are binding upon the parties involved and may be valid from a precedent standpoint. Included in the Decisions in the loose-leaf Guide are those in Volume 6. CD and Internet subscribers have access to all those issued from 1997 forward and they have the option to purchase those issued from 1969 through 1996.

ALJ dispositions and may affirm, reverse, or modify such decisions or dismissals. e Medicare Appeals Council (MAC) is a ruling body within the DAB’s Medicare Operations Division (MOD) that provides the final administrative review requested by beneficiaries, suppliers, or providers appealing ALJ decisions related to the denial of payment of claims for items and services under the Medicare pro- gram. e DAB provides impartial independent review of disputed decisions related to the Medicare and Medicaid programs and other programs under HHS. Generall , the DAB issues the final decision for HHS, which may be appealed to the federal court. Medicare and Social Security Administration regulations govern the DAB appeals process, depending upon the type of case being heard.

Provider Reimbursement Review Board Decisions

  • e Provider Reimbursement Review Board (PRRB) is an inde-

pendent body that hears and decides disputes between a provider and an intermediary when at least $10,000 is under dispute. Most PRRB Decisions involve the government’s disallowance of pay- ments that arise based on provider cost reports.

CCH Explanations

For a subscriber to understand how all the primary source docu- ments work together, it is necessary for him/her to begin with the CCH Explanations. e reason for this approach is CCH Editors pull together all relevant primary source documents related to a given topic. e authority is cited within the text of the explanation. At the end of the explanation are the annotations with complete citations to the underlying authority.

CMS Rulings

CMS rulings are decisions of the Administrator that serve as prec- edent final opinions, orders, and statements of policy and interpreta- tion. ey provide clarification and interpretation of complex or ambiguous provisions of the law or regulations relating to Medicare, Medicaid, Utilization and Quality Control Peer Revie , and related matters. CMS rulings are binding on all components: the Provider Reimbursement Review Board, the Medicare Geographic Classifica- tion Review Board, the Appeals Council, and Administrative Law Judges who hear Medicare appeals. ese Rulings promote consis- tency in interpretation of policy and adjudication of disputes.

CMS Administrator Decisions

CMS Administrator decisions arise from appeals of decisions of the Provider Reimbursement Review Board (PRRB), and usually involve issues related to provider cost reports. ese decisions are the highest level of administrative appeal for cost reports; further appeals are brought before the U.S. District Courts. ese decisions also include reviews of decisions made by the Medicare Geographic Classification Review Board (MGBRC).

HHS Departmental Appeals Board Decisions

  • e Departmental Appeals Board (DAB) review is the level of ad-

ministrative review available to parties after the administrative law judge (ALJ) hearing decision or dismissal order has been issued, but before judicial review is available. e DAB is authorized to review

Search Examples

Locate the procedures for obtaining Medicare reimbursement for outpatient ESRD (End Stage Renal Disease).

Print

Internet

Access the Topical Index in Log into the Internet Research Network

Volume 1.

and place a check mark inthe Explanation and Annotations menu line.

Review the entries under Using Boolean as the search method, type

ESRD.

reimbursement w/par outpatient w/par end stage renal disease as the search expression. The search returned 23 documents.

Retrieve Volume 2 and go to Change the display to Table of Contents the ESRD Table of Contents. hits only. Expand the topics and review Paragraph 7598 addresses the documents under Reimbursement

the issue.

for ESRD and Transplant Services.

Save the 2 paragraphs (7598 and 7598B) to a research folder or save to a separate file, or e-mail to another user for review.

Locating changes to regulation 42 CFR §1001.1.

©2007 CCH. ALL RIGHTS RESERVED.

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