License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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Limitation on Recoupment (935)

Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments. This means that when an overpayment is subject to the limitation on recoupment protections, Medicare will not begin overpayment collection (or will cease collections that have started) when it receives a valid request for a redetermination (first level of appeal), or a reconsideration (second level of appeal). The following provides additional information about this process.

Immediate Recoupment for 935 Overpayments

Providers have the opportunity to request immediate recoupment to avoid making payment by check and/or avoid the assessment of interest if the immediate recoupment pays the debt in full before day 31. An immediate recoupment is considered a voluntary repayment. The request for immediate recoupment should be received in writing at least 16 days from the date of initial demand letter to avoid the assessment of interest; however, when the request is received after 16 days from the date of the demand letter, the debt shall be placed in an immediate recoupment status and interest will continue to accrue if the debt is not fully collected by day 31. Please note the following two options for immediate recoupment:

A one-time request on the total overpayment amount (All accounts receivables) in a single demand letter and any future demanded overpayments; Or
A request on the demanded overpayment (All accounts receivables) addressed in a single demand letter only.

For overpayments that receive a demand letter:

Complete the J15 Part A and HH&H Services Immediate Offset Request Form
Fax request to: 1.615.664.5932

Results Letters

Overpayments may be the result of a post-pay review or a Medicare Secondary Payer (MSP) recovery. Post-pay reviews may be done by any of the Medicare Contractors.

Based on the overpayment determined by the post-pay review or MSP recovery, CGS will adjust the claim and apply the limitation on recoupment. A demand letter explaining the reason for the overpayment decision is generated and sent to the provider.

Interest begins to accrue on the 31st day from the date of the demand letter, and recoupment will proceed on day 41 from the demand letter.

Rebuttal Process

An opportunity for you to rebut the recoupment action is available by submitting a statement within 15 days of the notice. The rebuttal process is not considered an appeal and does not stop recoupment activities. Rebuttal statements should explain or provide evidence about why the recoupment should not take place. Rebuttal statements can be mailed to:

CGS Administrators, LLC
Attn: HHH OPR
P.O. Box 20014
Nashville, TN 37202

Please send rebuttal statement separately from redetermination requests.

Redetermination (First Level of Appeal)

Recoupment will proceed on day 41 from the demand letter unless you submit a valid redetermination that stops the recoupment process. A valid redetermination request:

Must be received by the 30th day from the date of the demand letter to stop recoupment of the 935 overpayment
May be received within 120 days from the date of the demand letter, recoupment will stop once the redetermination request is received, but any recoupment already taken will not be refunded.
Includes a completed Redetermination Form and supporting medical record documentation.

If you DO NOT request a redetermination or make payment in full by the 39th day:

A withholding is initiated on the Remittance Advice (RA) to begin recoupment on the 41st day from the initial demand letter.
Interest accrues on the money owed from the date of the initial demand letter.
The withholding amount will appear in the 935 withholding section of the RA.

If you DO request a redetermination:

The recoupment stops, but not the accrual of interest.
A letter will be sent to inform you that the appeal request has been received and the recoupment stopped.

There are three outcomes that may result from the redetermination:

Full reversal – The claim will be adjusted and shown on the Medicare remittance advice but will not impact reimbursement. An adjustment will be made to reduce the overpayment balance and accrued interest to $0.00. A refund will be issued for any collections on the debt. The refund may be withheld and applied to other debt that you might owe, and any excess will be released to you.

Partial reversal – The claim will be adjusted and shown on the Medicare remittance advice but will not impact reimbursement. The overpayment will be reduced and interest will be recalculated based on the revised overpayment amount. A refund will be issued for any amounts collected in excess of the revised overpayment amount and recalculated interest charges. A letter will be issued to inform the provider of the recalculated overpayment amount and balance due. This letter will indicate that recoupment will begin no earlier than 60 days from the date of the revised overpayment determination.
Full affirmation – A letter will be issued to inform the provider of the balance due. The letter will state that recoupment will begin no earlier than 60 calendar days after the Medicare redetermination notice.

Reconsideration (Second Level of Appeal)

If you are not satisfied with the outcome of the redetermination, you may file a reconsideration with the Qualified Independent Contractor (QIC) within 60 days of the redetermination notice. When CGS is notified by the QIC of your valid and timely request for reconsideration, recoupment of the overpayment will stop, or not initiated if it has not yet begun. In addition:

The amount already recouped will be applied first to interest and then to principal.
Other debts you might owe will continue to be collected; but any monies related to this debt will not be withheld or placed in suspense while it is in the appeal status.

There are three outcomes that may result from the QIC reconsideration:

Full reversal – The claim will be adjusted and shown on the Medicare remittance advice but will not impact reimbursement. An adjustment will be made to reduce the overpayment balance and accrued interest to $0.00. A refund will be issued for any collections on the debt that you might owe, and any excess will be released to you.
Partial reversal – The claim will be adjusted and shown on the Medicare remittance advice but will not impact reimbursement. The overpayment will be reduced and interest will be recalculated based on the revised overpayment amount. A refund will be issued for any amounts collected in excess of the revised overpayment amount and recalculated interest charge. A letter will be issued to inform the provider of the recalculated overpayment amount and balance due. This letter will indicate that recoupment will begin no earlier than 30 days after the date of the revised overpayment determination.
Full affirmation – Recoupment activity may be resumed 30 days after the date of the notice of the reconsideration.

If you subsequently appeal the overpayment to the Administrative Law Judge (third level), Appeals Council (fourth level), or the Judicial (fifth level), CGS will continue to recoup payment until the debt is satisfied in full.

Resources:

Updated: 12.21.21