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LIST OF EXHIBITSExhibit 1 - RUG III Urban Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Exhibit 2 - RUG III Rural Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Exhibit 3 - Sample MDS Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-37Exhibit 4 - Sample UB-92 Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38-39Exhibit 5 - DMEPOS Claims Jurisdiction <strong>by</strong> Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Exhibit 6 - Sample HCFA-1500 Claim Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45-46Exhibit 7 - HCPCS Codes for Enteral Supplies and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Exhibit 8 - Medicare Approved Medical <strong>Nutrition</strong> Products Provided <strong>by</strong> <strong>Mead</strong> <strong>Johnson</strong> . . . . . . . . . . . . . . . 49Exhibit 9 - Enteral Therapy Diagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Exhibit 10 - Sample CMN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-55Exhibit 11 - Medicare Timely Filing Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Exhibit 12 - Medical Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58-59Exhibit 13 - Diagnoses Generally Accepted Indications for Enteral Therapy with ICD-9-CM Codes. . . . . . . 61Exhibit 14 - Clinical Conditions for Swallowing Disorders with ICD-9-CM Code . . . . . . . . . . . . . . . . . . . . . 62Exhibit 15 - Indications for Use and Required Justification for Reimbursement of a Category IV Formula . . 63-66Exhibit 16 - Enteral Products Reference Guide: 1998 – 2002 Medicare IIC Rates . . . . . . . . . . . . . . . . . . . 67-68Exhibit 17 - Methods of Establishing Capitation Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714
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