CMS Rulings
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Centers for Medicare & Medicaid Services (CMS) 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.
CMS Rulings are binding on all CMS components, Medicare contractors, the Provider Reimbursement Review Board, the Medicare Geographic Classification Review Board, and Administrative Law Judges (ALJs) of the Social Security Administration (SSA) who hear Medicare appeals. These Rulings promote consistency in interpretation of policy and adjudication of disputes.
(PDF-131 kb) dated October 2002
This CMS Ruling sets forth our policy regarding implementation of the new appeals provisions in section 1869 of the Social Security Act, as amended by section 521 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554. The Ruling identifies changes that take effect on October 1, 2002 and provides notice of the administrative procedures that CMS contractors, administrative law judges, and the Departmental Appeals Board are to follow in processing Medicare claims appeals.
dated September 2001
This Ruling states the CMS policy regarding the appropriate actions upon receipt of a complaint seeking review of a national or local coverage determination under section 522 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554.
dated December 1998
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.
dated February 1997
This Ruling states the policy of the Health Care Financing
Administration concerning the determination to change its
interpretation of section 1886(d)(5)(F)(vi)(II) of the
Social Security Act (the Act) and 42 CFR 412.106(B)(4) to
follow the holdings of the United States Courts of Appeals
for the Fourth, Sixth, Eighth, and Ninth Circuits. Under
the new interpretation, the Medicare disproportionate share
adjustment under the hospital inpatient prospective payment
system will be calculated to include all inpatient hospital
days of service for patients who were eligible on that day
for medical assistance under a State Medicaid plan in the Medicaid fraction, whether or not the hospital received
payment for those inpatient hospital services.
dated February 1997
This Ruling states the policy of the Health Care Financing
Administration concerning the requirements for determining if
Medicare payment will be made under the limitation on
liability provision, section 1879 of the Social Security Act,
to a provider, practitioner, or other supplier for partial
hospitalization services for which Medicare payment is denied.
dated December 1996
This Ruling states the existing policy of the Health Care Financing Administration concerning the requirements for determining if Medicare payment will be made under the limitation on liability provision, section 1879 of the Social Security Act, to a 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. This Ruling supplements HCFAR 95-1 with respect to section 1879(g) of the Act.
dated November 1996
This Ruling states the policy of the Health Care Financing Administration concerning the requirements for determining if Medicare payment will be made under the limitation on
liability provision, section 1879 of the Social Security Act, to a supplier, practitioner, or other supplier for pap smears and mammography services for which Medicare payment is denied.
dated September 1996
This Ruling states the policy of the Health Care Financing Administration regarding the distinction between the statutory benefits of "orthotics" and "durable medical equipment" under Medicare Part B. The distinction may have an effect on the Medicare approved amount of payment and is necessary in those instances where items are furnished in skilled nursing facilities that meet the definition in section 1819(a)(1) of the Social Security Act (the Act) or hospitals due to the express exclusion from Part B coverage of durable medical equipment when used in a hospital or skilled nursing facility.
The Ruling clarifies that the "orthotics" benefit in section 1861(s)(9) of the Act, insofar as braces are concerned, is limited to leg, arm, back, and neck braces that are used independently rather than in conjunction with, or as components of, other medical or non-medical equipment. It also clarifies that accessories used in conjunction with, and necessary for the full functioning of, durable medical
equipment fall under the durable medical equipment benefits category. Finally, the Ruling provides several examples that illustrate the application and scope of these two terms.
dated December 1995
This Ruling states the policy of the Health Care Financing Administration concerning the requirements for determining if Medicare payment will be made under the limitation on liability provisions, section 1879 of the Social Security Act, to a provider, practitioner, or other supplier for certain services and items for which Medicare payment is denied.
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Last Modified on Thursday, September 16, 2004
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