Region B DMERC Supplier Bulletin, June 2006, Volume

Transcription

To Serve the Medicare Community
Region B DMERC Supplier
Bulletin June 2006, Volume 06–Issue 02
Jurisdiction B Durable Medical Equipment
Medicare Administrative Contractor
Transition Updates
Attention All Medicare Suppliers:
DME MAC News #1: DME MAC Implementation—Information
for Suppliers
MLN Matters Number: SE0628
Provider Types Affected
Suppliers that bill Medicare durable medical equipment regional carriers (DMERCs) for their services, especially
suppliers in the states of Kentucky, Maryland, Virginia, West Virginia and the District of Columbia
Key Points
The Centers for Medicare & Medicaid Services (CMS), in consultation with the current DMERCs, has begun a process
to transition work from DMERCs to the new durable medical equipment Medicare administrative contractors (DME
MACs) in a way that presents the least disruption to the durable medical equipment (DME) supplier community.
This process will be especially helpful to the suppliers in Kentucky, Maryland and the District of Columbia, which soon
will be serviced by a different Medicare contractor. (See the Background section of this article for a brief explanation of
why CMS is transitioning to DME MACs.)
The decisions regarding the transition to the DME MACs include the following:
•
Two DME MACs (National Heritage Insurance Company, Inc. [NHIC] and AdminaStar Federal) will each assume
full responsibility for the work of their respective geographic jurisdiction on July 1, 2006.
•
These two new DME MACs have established Web pages that will be updated regularly with implementation
information, contact numbers, and e-mail addresses. The contractors’ Web pages are:
−
−
National Heritage Insurance Company (NHIC): www.medicarenhic.com/dme/index.shtml
AdminaStar Federal: www.adminastar.com/Providers/DMERC/ContractorReform/ContractorReform.html
This bulletin should be shared with all health care practitioners and managerial members of the
provider/supplier staff. Bulletins are available at no cost from our Web site at: www.adminastar.com
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•
There will be no need for DME suppliers currently enrolled in the Medicare fee-for-service program to re-enroll or
obtain a new supplier number. Enrollment information will transfer to the new DME MACs.
•
Current electronic data interchange (EDI) support for each DME region/jurisdiction has been extended until at least
September 30, 2006.
•
DME MACs will continue to support all DME free billing software packages.
•
Although suppliers in Kentucky, Maryland and the District of Columbia may continue to submit electronic claim
transactions to the DME contractor that currently services them and have the claims redirected to the appropriate
DME MAC, CMS encourages suppliers to connect to the DME MAC that will service them effective July 1st.
•
Connection to the servicing DME MAC will be required to receive all electronic output, including electronic
remittance advices (ERAs).
•
Suppliers in Kentucky or those in the states that will be serviced by NHIC must complete a new copy of the
Authorization Agreement for Electronic Funds Transfer and submit it to your new DME MAC if you wish to
continue to receive Medicare payments via electronic funds transfer (EFT) effective July 1. Please see your DME
MAC’s Web page for specifics.
•
Suppliers connected to multiple regions will need to understand regional specific file retrieval options, including
how to retrieve remittance advice files.
•
Please refer to Medicare Learning Network Matters article SE0540 for more information regarding remittance
advice, and to Medicare Learning Network Matters article SE0611 for information regarding Medicare Remit Easy
Print (MREP) software you may use to print Medicare’s electronic remittances. These articles are available at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0540.pdf and
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0611.pdf on the CMS Web site.
•
New suppliers who want to conduct EDI transactions with Medicare should enroll with the appropriate DME
contractor using standard enrollment forms and processes. (Please refer to links below.)
•
The implementation of DME MACs for Jurisdictions C and D has been delayed pending resolution by CMS of a
formal protest of those awards. Because of this delay, suppliers providing services to Medicare beneficiaries in
Virginia and West Virginia will continue to be serviced by AdminaStar Federal until further notice. Once the protest
is resolved and the new DME MAC for Jurisdiction C can be implemented, it will take over the work for Virginia
and West Virginia.
Background
The Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003 (P.L. 108-173) allows CMS to
take appropriate steps to transition from contracts under section 1842(a) of the Social Security Act to contracts with
MACs under section 1874A.
The changes to Medicare’s administration of the fee-for-service program (Medicare Contracting Reform) are designed to
increase the efficiency of Medicare’s claim processing and related functions. They will benefit Medicare providers and
Medicare’s enrollee population.
For more information on Medicare Contracting Reform and plans for the acquisition and implementation of MACs,
please see Medicare Learning Network Matters article SE0624 at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0624.pdf on the CMS Web site or visit the Medicare Contracting
Reform Web page at www.cms.hhs.gov/MedicareContractingReform/ on the CMS Web site.
On January 6, 2006, CMS announced the following:
Region B DMERC Supplier Bulletin
June 2006, Volume 06–Issue 02
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AdminaStar Federal
•
The DME MAC contract for Jurisdiction A (Connecticut, Delaware, District of Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) was awarded to
NHIC.
•
The DME MAC contract for Jurisdiction B (Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin)
was awarded to AdminaStar Federal, Inc.
•
The DME MAC contract for Jurisdiction C (Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana,
Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin
Islands, Virginia and West Virginia) was awarded to Palmetto GBA, LLC.
•
The DME MAC contract for Jurisdiction D (Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho,
Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South
Dakota, Utah, Washington and Wyoming) was awarded to Noridian Administrative Services.
•
A protest of the DME MAC awards for Jurisdictions C and D was filed with the Government Accountability Office
(GAO) in January 2006. Until GAO issues a decision (due May 4, 2006) on the protest, any activity associated with
the contract awards for administration of MAC Jurisdictions C and D is on hold.
Additional Information
For additional information about Medicare Contracting Reform, and specifically the DME MAC transition process,
please refer to www.cms.hhs.gov/MedicareContractingReform/ on the CMS Web site.
For information about Medicare provider/supplier enrollment, please refer to
www.cms.hhs.gov/MedicareProviderSupEnroll/ on the CMS Web site.
Form CMS-855S, Medicare Federal Health Care Provider/Supplier Enrollment Application, can be found at
www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/cms855s.pdf on the CMS Web site.
SE0540, CMS Releases New Educational Guide on Remittance Advice (RA) Notices, is located at
SE0611, Medicare Remit Easy Print (MREP) Software, is available at
SE0624, Assignment of Physicians and Providers to the Medicare Administrative Contractors (MACs), can be viewed at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0624.pdf on the CMS Web site. This last article provides an
overview of the Medicare Contracting Reform process as it applies to providers and suppliers.
MMA—Assignment of Physicians, Providers, and Suppliers to
the Medicare Administrative Contractors*
Providers, physicians and suppliers who bill Medicare contractors (fiscal intermediaries, including RHHIs, and carriers,
including DMERCs) for their services
Key Points
The CMS is implementing significant changes to the Medicare fee-for-service program’s administrative structure. This
Medicare Contracting Reform (MCR) will:
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AdminaStar Federal
•
•
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integrate and simplify the administration of Medicare Parts A and B with primary A/B Medicare administrative
contractors (MACs) which will process both Part A and Part B claims for the fee-for-service benefit;
make contracting dynamic, competitive and performance-based, resulting in more accurate claims payments and
greater consistency in payment decisions; and
centralize information, creating a platform for advances in the delivery of comprehensive care.
Under MCR, there will be 23 MACs with no national MAC. These new MACs will include:
•
•
•
Fifteen primary A/B MACs to serve the majority of all types of providers for Part A and Part B
Four specialty MACs to serve home health and hospice providers, and
Four specialty MACs to serve durable medical equipment (DME) suppliers
MACs will serve as the primary point of contact for provider enrollment, Medicare coverage and billing requirements
training for providers, and the receipt, processing and payment of Medicare fee-for-service claims for Medicare
providers’ respective jurisdictions.
Medicare providers will be assigned to the local designated MAC based on their geographic location to the MAC which
has jurisdiction for that benefit category and location.
Note: Please be aware that in the event that your current fiscal Intermediary does not win the contract to serve the area
where you are located, you will be required to be reassigned to the MAC that has won the jurisdiction for your area.
The new MAC jurisdictions will be more similar to each other in size than the existing fiscal intermediary and carrier
jurisdictions. The workload allocation and the number of fee-for-service beneficiaries and providers in each MAC
jurisdiction will be reasonably balanced. The jurisdictions of the eight specialty MACs will overlay the boundaries of the
fifteen primary A/B MAC jurisdictions.
Background
The MMA of 2003 (Public Law 108-173) allows the CMS to take appropriate steps to transition from agreements under
section 1816 of the Social Security Act to contracts with MACs under section 1874A. The changes to Medicare’s
administration are designed to increase the efficiency of Medicare’s claims processing and related functions; they will
benefit Medicare providers and Medicare’s enrollee population.
During the initial implementation phase (2005–2011) of the Medicare fee-for-service administrative contracting reform,
CMS intends to issue Requests for Proposals (RFPs) to compete and award contracts for 23 MACs (four DME and four
home health/hospice MACs, and 15 primary A/B MACs).
The transition to the MAC administrative structure will be implemented through a series of acquisition cycles (9–12
months from solicitation to award). The subsequent workload transition to the new MAC system is projected to take 6–
13 months after contract award.
Medicare’s MAC Jurisdictions
Jurisdiction
A
B
C
States Included in Jurisdiction
Specialty MAC Jurisdictions (DME and
Home Health/Hospice)
Connecticut, Delaware, District of Columbia,
Maine, Maryland, Massachusetts, New
Hampshire, New Jersey, New York,
Pennsylvania, Rhode Island and Vermont
Illinois, Indiana, Kentucky, Michigan,
Minnesota, Ohio and Wisconsin
Alabama, Arkansas, Colorado, Florida,
Georgia, Louisiana, Mississippi, New
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Procurement Schedule
RFP Issuance
Award Date
DME March 2005
DME January 2006
Home Health/ Hospice
September 2007
Home Health/Hospice
September 2008
AdminaStar Federal
Jurisdiction
D
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
States Included in Jurisdiction
Mexico, North Carolina, Oklahoma, Puerto
Rico, South Carolina, Tennessee, Texas, U.S.
Virgin Islands, Virginia and West Virginia
Alaska, American Samoa, Arizona,
California, Guam, Hawaii, Idaho, Iowa,
Kansas, Missouri, Montana, Nebraska,
Nevada, North Dakota, Northern Mariana
Islands, Oregon, South Dakota, Utah,
Washington, and Wyoming
Primary A/B MAC Jurisdictions
American Samoa, California, Guam, Hawaii,
Nevada, and Northern Mariana Islands
Alaska, Idaho, Oregon, and Washington
Arizona, Montana, North Dakota, South
Dakota, Utah and Wyoming
Colorado, New Mexico, Oklahoma, and
Texas
Iowa, Kansas, Missouri, and Nebraska
Illinois, Minnesota, and Wisconsin
Arkansas, Louisiana, and Mississippi
Indiana and Michigan
Florida, Puerto Rico, and U.S. Virgin Islands
Alabama, Georgia, and Tennessee
North Carolina, South Carolina, Virginia and
West Virginia
Delaware, District of Columbia, Maryland,
New Jersey, and Pennsylvania
Connecticut and New York
Maine, Massachusetts, New Hampshire,
Rhode Island, and Vermont
Kentucky and Ohio
Procurement Schedule
RFP Issuance
September 2006
Award Date
September 2007
September 2006
September 2005
September 2007
June 2006
September 2006
September 2007
September 2006
September 2007
September 2006
September 2007
September 2007
September 2007
September 2007
September 2007
September 2008
September 2007
September 2008
September 2008
September 2008
September 2008
September 2006
September 2007
September 2006
September 2007
September 2007
September 2008
September 2007
September 2008
For additional information about the MCR process, please refer to www.cms.hhs.gov/MedicareContractingReform/ on
the CMS Web site.
Change Request 4002, transmittal 670, Realignment of States and Medicare Claims Processing Workload from DMERC
Regions A, B, C and D to the DME MAC Jurisdictions A, B, C, and D, discusses phase 1 of the MAC acquisition and
transition schedule. It can be found at www.cms.hhs.gov/transmittals/downloads/R670CP.pdf on the CMS Web site.
Jurisdiction B Transition Frequently Asked Questions Now
Available on the AdminaStar Federal Web Site
AdminaStar Federal has developed a DME MAC transition Frequently Asked Questions (FAQ) to help educate suppliers
in the current Region B DMERC environment and Kentucky suppliers in the current Region C DMERC environment.
The FAQ identifies the roles and responsibilities of these suppliers once they have transitioned to the new DME MAC
environment. AdminaStar Federal will continue to update the FAQ as new transition information is made available.
To view the transition FAQ, go to the following links on the AdminaStar Federal DME MAC transition page:
www.adminastar.com/Providers/DMERC/ContractorReform/files/ DMEMACFAQ1_0406Rev2.pdf
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AdminaStar Federal
New! Jurisdiction B DME MAC Transition Option Now
Available on the Interactive Voice Response Unit
To help increase awareness of transition impacts for Region B/Jurisdiction B suppliers, AdminaStar Federal has added a
general information option about the upcoming DME MAC transition to the Region B DMERC Interactive Voice
Response (IVR) unit. There will be a new Main Menu option with general transition information for suppliers who serve
beneficiaries residing in Kentucky, Maryland, Washington D.C., Virginia and West Virginia.
The transition submenu can be accessed by selecting option 5 from the Main Menu. The transition submenu contains the
following options:
•
•
•
Option 1 contains transition information specific to suppliers submitting claims for Kentucky beneficiaries
Option 2 contains transition information specific to suppliers submitting claims for Maryland and Washington D.C
beneficiaries, and
Option 3 contains transition information specific to suppliers submitting claims for Virginia and West Virginia
beneficiaries
Additionally, the AdminaStar Federal Web site also hosts a DME MAC transition page dedicated to transition
information for all Region B/Jurisdiction B suppliers. Suppliers can access the transition page at the following links on
the AdminaStar Federal Web site:
www.adminastar.com/Providers/DMERC/ContractorReform/ContractorReform.html
The IVR User Guide and one-page IVR Flow Chart have been updated with the new transition menu option information,
and are available on the AdminaStar Federal Web site at the following links:
www.adminastar.com/AboutUs/ContactUs/Telephone/IVR/DMERCProvider.html
Important Information Regarding Dark Days—June 28–30, 2006
In preparing for the transition to the DME MAC environment, AdminaStar Federal would like for all suppliers to be
aware of the “dark days” for the transition. During these “dark days,” the IVR Unit and the customer service
representatives (CSRs) will be unavailable. The “dark days” are June 28–30, 2006. Suppliers will be able to access
both the IVR and CSRs on July 3, 2006.
Note: AdminaStar Federal is anticipating a high call volume on July 3, 2006. Therefore, suppliers who do not have a
significant issue are being asked to wait and call after July 3, 2006.
Attention All Maryland and District of Columbia
Suppliers:
Jurisdiction A DME MAC Transition 07/01/06
The CMS has announced that it has awarded contracts to four specialty contractors who will be responsible for handling
the administration of Medicare claims from durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
effective July 1, 2006.
National Heritage Insurance Company (NHIC) is pleased to serve as the DME MAC for Jurisdiction A effective July 1,
2006. NHIC will provide its services for Medicare beneficiaries and DMEPOS suppliers in DME MAC Region A, which
includes: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey,
New York, Pennsylvania, Rhode Island and Vermont.
Note: There is no change in the toll-free telephone number beneficiaries use for Medicare questions. Beneficiaries
should continue to call the 1-800-MEDICARE number as they do today!
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AdminaStar Federal
1-800-MEDICARE (1-800-633-4227)—24 hours a day, say the word “AGENT” to speak to a live person.
Medicare beneficiaries located in one of the above Jurisdiction A DME MAC states that need to submit a DME claim or
correspondence should use the following addresses:
DME—Specialty Claims
P.O. Box 9165
Hingham, Massachusetts 02043-9165
DME—Written Inquiries
P.O. Box 9146
DME—Redeterminations
P.O. Box 9150
Payment Floor for Maryland and District of Columbia Claims
AdminaStar Federal will release the payment floor for Maryland and District of Columbia claims on June 19, 2006, and
will continue to immediately pay claims as they are released for payment when the Maryland and District of Columbia
files and records are transferred to NHIC—the Jurisdiction A DME MAC. All pending and new Maryland and District of
Columbia claims that are held during the cutover timeframe will be transferred to NHIC at cutover.
Electronic Funds Transfer Re-enrollment Required!
Suppliers who currently receive EFT from the Region B DMERC must re-enroll with NHIC, the Jurisdiction A DME
MAC, to receive electronic Medicare payments for DMEPOS claims submitted on or after the July 1, 2006 for
beneficiaries in the DME MAC Jurisdiction A.
The DME MAC Jurisdiction A includes the states of Connecticut, Delaware, District of Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.
NHIC EFT Re-enrollment Instructions
1.
Suppliers who wish to continue to receive Medicare payments via EFT from NHIC must complete a new copy of
the CMS-588 form (Authorization Agreement for Electronic Funds Transfer) before July 1, 2006. Suppliers can
download a copy of the CMS-588 form from the CMS Web site at:
http://new.cms.hhs.gov/cmsforms/downloads/CMS588.pdf
2.
Provide a voided check that reflects the supplier business name, bank account number and the name and address of
the bank in which the Medicare funds will be deposited.
3.
Mail the signed authorization agreement, along with the voided check to:
National Heritage Insurance Company
75 Sgt. William Terry Drive
Hingham, Massachusetts 02044
Attention: DME EFT
Suppliers are encouraged to enroll in the NHIC transition Web site mailing list at
www.medicarenhic.com/dme/index.shtml to ensure they receive all July 1, 2006 transition updates as they are
finalized.
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AdminaStar Federal
Attention All Suppliers Submitting Kentucky Claims:
Electronic Data Interchange Registration Forms for Suppliers
Submitting Kentucky Claims Due June 1, 2006
AdminaStar Federal will be processing all claims for Kentucky beneficiaries beginning July 1, 2006 as the Jurisdiction B
DME MAC. Due to the delay in implementation of the DME MAC Medicare Electronic Data Interchange System
(MEDIS) option, AdminaStar Federal will provide electronic support for Jurisdiction B until at least September 30, 2006.
Beginning July 1, 2006, there are two options for submitting electronic claims for beneficiaries in Kentucky.
1.
Suppliers can submit electronic claims directly to AdminaStar Federal (the Jurisdiction B DME MAC).
- Or 2.
Suppliers can continue to submit electronic claims to the DMERC contractor they currently use, Palmetto GBA (the
current Region C DMERC). If suppliers choose to submit their electronic claims to Palmetto GBA, the misdirected
claims logic will apply and claims will be forwarded to AdminaStar Federal for adjudication and payment.
With either option listed above, suppliers must complete an AdminaStar Federal DME Electronic Data Interchange
(EDI) registration package by June 1, 2006 when the following applies:
•
•
•
Supplier sends claims for beneficiaries in Kentucky and is not currently enrolled with AdminaStar Federal for
electronic submission.
Supplier currently receives ERA from Palmetto for Kentucky claims and is not enrolled with AdminaStar Federal
for ERAs.
Supplier currently receives EFT from Palmetto for Kentucky claims and is not enrolled with AdminaStar Federal
for EFTs.
The EDI registration package will enroll suppliers submitting Kentucky claims for electronic submission, ERA and EFT.
Further details and instructions are available in the DME EDI registration package. Go to the following link to view the
DME EDI registration package for suppliers submitting Kentucky claims:
www.adminastar.com/Providers/EDI/DMERC/Agreements/files/EXTEC030_DMEEDIRegistrationPackage_
KYsuppliers.pdf
For suppliers submitting Kentucky claims that need access to the AdminaStar Federal online Claim Status Inquiry
System (CSI) beginning July 1, 2006, please complete the CSI agreement form found at the following link:
www.adminastar.com/Providers/EDI/DMERC/Agreements/files/EXTEC019_DMECSIRequest030806.pdf
Note: Registrations must be completed by June 1, 2006.
Payment Floor for Kentucky Claims
Palmetto GBA will release the claim payment floor for Kentucky claims on June 19, 2006, and it will remain off
throughout the cutover period. All pending and new Kentucky claims held during the cutover timeframe will be
transferred to AdminaStar Federal at cutover, and paid after July 1, 2006 according to the standard payment floor
requirements.
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AdminaStar Federal
Stay Up-To-Date—Join CMS Listserv Today!
The Centers for Medicare & Medicaid Services (CMS) electronic mailing lists (Listservs) can help your business! For
more details, download the Fact Sheet describing all available CMS Listservs on the CMS Web site at the following
links: www.cms.hhs.gov/MLNProducts/downloads/MailingLists_FactSheet.pdf
Source: CMS Joint Signature Memorandum 06-403 dated April 17, 2006
Sign Up For Region B DMERC Listserv
To receive the most up-to-date information relating to Medicare and/or changes within the Region B Durable Medical
Equipment Regional Carrier (DMERC), AdminaStar Federal encourages suppliers to sign up for the Region B DMERC
Listserv. To subscribe, enter the following into your Internet browser:
www.adminastar.com/Providers/DMERC/Listserv/Secure/dmerc_mailermailer.html
Electronic Data Interchange Listserv
To receive the latest information regarding electronic claims, electronic data interchange (EDI) advantages, new
products and upgrades, enrollment forms, the Health Insurance Portability and Accountability Act, and the E-Commerce
Connection newsletter, AdminaStar Federal encourages suppliers to sign up for the Region B DMERC EDI Listserv.
To subscribe, enter the following into your Internet browser:
www.adminastar.com/Providers/EDI/secure/listserv/edi_mailermailer.html
AdminaStar Federal’s EDI Listserv applies to software vendors, billing services, and clearinghouses, as well as suppliers.
CMS Quarterly Provider Update
The Centers for Medicare & Medicaid Services (CMS) publishes the Quarterly Provider Update at the beginning of each
quarter to inform the providers and suppliers about the following:
•
•
•
Regulations and major policies currently under development during the quarter
Regulations and major policies completed or cancelled
New or revised manual instructions
To access the CMS Quarterly Provider Update, enter the following link into your Internet browser:
www.cms.hhs.gov/QuarterlyProviderUpdates/
CMS Medicare Learning Network Articles
Many of the articles included in this publication are derived from CMS Medicare Learning Network (MLN) Matters
articles (previously referred to as Medlearn Matters...Information for Medicare Providers articles). MLN Matters articles
are prepared as a service to the public and are not intended to grant rights or impose obligations. The articles may contain
references or links to statutes, regulations, or other policy materials. MLN Matters articles are designed to help
providers/suppliers understand new or changed Medicare policy, and the information provided is only intended to be a
general summary. The articles are not intended to take the place of either the written law or regulations. Readers should
review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Medicare contractors are required to publish the MLN Matters articles verbatim in their regularly scheduled newsletters
to promote national consistency in the information originating from CMS. As such, articles published in the Region B
DMERC Supplier Bulletin tha originate from CMS MLN Matters articles will be identified with the asterisk symbol (*)
appearing at the conclusion of the article’s title.
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AdminaStar Federal
In This Issue
Medical Policy
12
Medical Policy Information Available on the TriCenturion Web Site....................................................................... 12
June 2006 Local Coverage Determination Revision Summary.................................................................................. 12
Attention All Miscellaneous DMEPOS Suppliers:
Subcutaneous Immune Globulin Added to External Infusion Pumps Local Coverage Determination...................... 14
Negative Pressure Wound Therapy Length of Need.................................................................................................. 15
Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing*.................................................. 15
Attention All Respiratory Suppliers:
Oximetry Testing—Supplier Involvement................................................................................................................. 17
Medicare System Edits for Respiratory Assist Devices with Bi-Level Capability and a Back-Up Rate* ................. 18
General Provider Education for Changes in the Payment for Oxygen Equipment and Capped Rentals for
Durable Medical Equipment Due to the Deficit Reduction Act of 2005*.................................................................. 18
Attention All Mobility Suppliers:
Advanced Determination of Medicare Coverage ....................................................................................................... 20
Power Wheelchairs and Power Operated Vehicles—Documentation Requirements................................................. 21
Wheelchair Seating—New Codes.............................................................................................................................. 21
New Temporary Codes for Adjustable Wheelchair Cushions*.................................................................................. 22
Payment for Power Mobility Device Claims* ........................................................................................................... 22
Attention All Drug Suppliers:
Oral Antiemetic Drug Claims Paid In Error............................................................................................................... 24
Dexamethasone (J8540) Documentation Requirement for the Oral Antiemetic Drugs Local
Coverage Determination ........................................................................................................................................... 25
Benefit Integrity
26
TriCenturion Program Safeguard Contractor Contact Information............................................................................ 26
Coverage and Billing
26
CMS-1500 Claim Form Instructions—Box 11 .......................................................................................................... 26
Change Payment Floor Date for Paper Claims*......................................................................................................... 26
Change in the Long Descriptor for HCPCS Code Q4080* ........................................................................................ 27
Eliminate the Use of Surrogate Unique Physician Identification Numbers on Medicare Claims* ............................ 28
Rescind Change Request 4177—Eliminate the Use of Surrogate UPINs (OTH000) on Medicare Claims* ............. 28
Durable Medical Equipment Regional Carrier Information Form* ........................................................................... 30
Denial of Claims Not Timely Filed*.......................................................................................................................... 31
Full Replacement of Change Request 4349—Hold on Medicare Payments—Change Request 4349
Is Rescinded* ............................................................................................................................................................. 32
Revised CMS-1500 Claim Form*.............................................................................................................................. 33
New Durable Medical Equipment Prosthetic, Orthotics & Supplies Certificates of Medical Necessity and Durable
Medical Equipment Medicare Administrative Contractor Information Forms for Claims Processing* .................... 34
Remittance Advice Remark Code and Claim Adjustment Reason Code Update*..................................................... 36
Remittance Advice Remark Code and Claim Adjustment Reason Code Update*..................................................... 40
Quarterly Medicare Summary Notice Printing Cycle* .............................................................................................. 41
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AdminaStar Federal
Appeals
42
MMA—Changes to Chapter 29—Appeals of Claims Decisions: Administrative Law Judge; Departmental
Appeals Board; U.S. District Court Review*............................................................................................................. 42
Department Updates
44
New Hours of Operation for the Region B DMERC Customer Service Unit Effective March 6, 2006 .................... 44
Reminder: Immediate Offset Requests....................................................................................................................... 44
Reminder: Voluntary Refund Checks Submitted to Incorrect DMERC Regions ...................................................... 45
Voluntary Refund Clarification.................................................................................................................................. 45
Electronic Data Interchange
45
E-Commerce Connection ........................................................................................................................................... 45
Stage 1 Use and Editing of National Provider Identifier Numbers Received in Electronic Data Interchange
Transactions, via Direct Data Entry Screens, or Paper Claim Forms*....................................................................... 46
National Provider Identifier Tip................................................................................................................................. 48
National Council for Prescription Drug Program Coordination of Benefits Workaround Instructions* ................... 49
2005 Revised American National Standards Institute X12N 837 Professional Health Care Claim Companion
Document* ................................................................................................................................................................. 50
Medicare to Stop Mailing Standard Paper Remittance for Those Providers/Suppliers Also Receiving the
Electronic Remittance Advice.................................................................................................................................... 51
Suppression of Standard Paper Remittance Advice to Providers and Suppliers Also Receiving Electronic
Remittance Advice for 45 Days or More* ................................................................................................................. 51
Options for Providers/Suppliers Affected by Change Request 4376: Suppression of Standard Paper Remittance
Advice to Providers and Suppliers Also Receiving Electronic Remittance Advice for 45 Days or More* ............... 54
Medicare Remit Easy Print Software* ....................................................................................................................... 55
Medicare Remit Easy Print Enhancements and Clarification of Check Issue/Electronic Funds Transfer
Effective Date* .......................................................................................................................................................... 58
Medicare Remit Easy Print Update*.......................................................................................................................... 60
Electronic Remittance Advice and Medicare Remittance Easy Print Testimonials ................................................... 61
Update to Chapter 24 (EDI Support Requirements) of the Medicare Claims Processing Manual to Show New
CMS Web Site URL References*.............................................................................................................................. 62
Shared Systems Medicare Secondary Payer Balancing Edit and Administrative Simplification Compliance Act
Enforcement Update*................................................................................................................................................. 63
Fee Schedule
64
April 2006 Quarterly Average Sales Price Medicare Part B Drug Pricing File and Revisions to January 2005,
April 2005, July 2005, October 2005 and January 2006 Quarterly Average Sales Price Medicare Part B Drug
Pricing Files* ............................................................................................................................................................. 64
April Quarterly Update for 2006 Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule* .......... 67
July Quarterly Update for 2006 Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule*............ 68
Medicare Part B Drug Pricing Update—Payment Limit for J7620 (Albuterol and Ipratropium Bromide,
Noncompounded)*..................................................................................................................................................... 70
Miscellaneous
71
Top Ten Region B DMERC Supplier Telephone Inquiries ....................................................................................... 71
Top Ten Region B DMERC Supplier Written Inquiries ............................................................................................ 72
Top Ten Claim Submission Errors for Fiscal Year 2006 Second Quarter ................................................................. 74
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Announcing a New Name for Medicare’s Provider Education Articles—Medicare Learning Network Matters*........ 76
Revisions to Instructions for Contractors Other Than the Religious Nonmedical Health Care Institutions
Specialty Contractor Regarding Claims for Beneficiaries with Religious Nonmedical Health Care
Institutions Elections*................................................................................................................................................ 77
2006 Jurisdiction List*............................................................................................................................................... 79
New! Drug Coverage Materials for Health Care Professionals ................................................................................. 80
Instructions for Provider Notification Regarding Streamlined Drug Coverage Materials for Health Care
Professionals, a New Fact Sheet and Script for Recent Audio Conference* ............................................................. 81
An Important Message for Providers Regarding Medicare Part D from the Centers for Medicare & Medicaid
Services Administrator, Dr. Mark McClellan ............................................................................................................ 82
Centers for Medicare & Medicaid Services Seeks Provider Input on Satisfaction with Medicare Fee-for-Service
Contractor Services* .................................................................................................................................................. 82
Facilitating Your Medicare Enrollment* ................................................................................................................... 83
MMA—The Centers for Medicare & Medicaid Services Recovery Audit Contractor Initiative*............................. 85
Cultural Competency: A National Health Concern*.................................................................................................. 86
CMS Regional Offices’ Online Quarterly Publication—The Pulse of CMS, Spring 2006—Now Available
for Viewing ................................................................................................................................................................ 88
AdminaStar Federal Contact Information
88
Attachments
90
•
•
TriCenturion ADMC Request Form
The Pulse of CMS, Spring 2006 Edition
Medical Policy
Medical Policy Information Available on the TriCenturion
Web Site
TriCenturion is the Program Safeguard Contractor (PSC) responsible for all medical policy functions for Region B
DMERC suppliers. Suppliers should refer to the TriCenturion Web site (www.tricenturion.com) for all medical policy
information and to view each individual medical policy. Please Note: The medical policies will no longer be included in
chapter 17 of the Region B DMERC Supplier Manual.
June 2006 Local Coverage Determination Revision Summary
Listed below is a summary of the principal changes to the Local Coverage Determinations (LCDs) and Policy Articles
that have been revised this quarter. Please review the entire LCD and related Policy Article for complete information.
Cervical Traction Devices
Revision Effective Date: 07/01/2006
Indications and Limitations of Coverage:
• Coverage of E0855 if both Cervical Traction criteria and the noted additional criteria A and B are met
Documentation Requirements:
• Added requirements for use of KX with E0855
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External Infusion Pumps
• Added subcutaneous immune globulin (J7799) criteria
ICD-9 Codes That Support Medical Necessity:
• Added subcutaneous immune globulin and related diagnosis codes
Motorized/Power Wheelchair Bases
• Revised the time frame for the supplier to obtain the dispensing order and report of the face-to-face exam from the
physician from 30 days to 45 days
• Added requirement for the supplier to date stamp the order and the report of the face-to-face examination
Negative Pressure Wound Therapy Pumps
Indications and Limitations of Coverage and/or Medical Necessity:
• Removed individual consideration language from “When Coverage Ends” section
• Corrected reference to “Indications” section
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
• Added J8540 to KX requirement
Power Operated Vehicles
• Deleted criteria for dates of service prior to 10/25/05
• Revised the time frame for the supplier to obtain the dispensing order and report of the face-to-face exam from the
physician from 30 days to 45 days
• Added requirement for the supplier to date stamp the order and the report of the face-to-face examination
Respiratory Assist Devices
CMS National Coverage Policy:
• Deleted reference to National Coverage Determinations manual
• Revised least costly medically appropriate language for E0471 to reflect new payment category
• Moved statement concerning separate payment for accessories to the Policy Article
Appendices:
• Moved definitions of NPPRA and FIO2 from the Policy Article
• Moved definition of respiratory cycle to the Policy Article
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Wheelchair Options/Accessories
• Added new battery code, K0733
• Deleted criteria for reclining backs for dates of service prior to 05/01/06
HCPCS Codes:
Added: K0733
Advisory Committee Notes:
• Deleted statement which applied to changes made in a previous version
Wheelchair Seating
• Substituted new codes for adjustable seat cushions
HCPCS Codes:
• Added: K0734, K0735, K0736, K0737
• Discontinued: K0108
ICD-9 Codes That Support Medical Necessity:
• Corrected by deleting A9900 in last group
• Removed claim submission requirements for K0108
Source: This article was provided by TriCenturion, the PSC for the Region B DMERC.
Attention All Miscellaneous DMEPOS Suppliers:
Subcutaneous Immune Globulin Added to External Infusion
Pumps Local Coverage Determination
Subcutaneous immune globulin (SCIG) has been added to the External Infusion Pumps LCD.
SCIG that is administered using a durable medical equipment (DME) infusion pump is covered only if criteria 1 and 2
are met:
1.
2.
The subcutaneous immune globulin preparation is a pooled plasma derivative which is approved for the treatment of
primary immune deficiency disease; and
The patient has a diagnosis of primary immune deficiency disease (ICD-9 codes 279.04, 279.05, 279.06, 279.12,
279.2).
The coverage is effective for claims with dates of service on or after January 9, 2006.
The DME pump and related supplies are also covered; this typically involves a nonelectric syringe pump (E0779).
Healthcare Common Procedure Code System (HCPCS) code K0552 is used for the syringe and HCPCS code A4221 is
billed for the infusion sets and all other needed supplies. Only one (1) unit of service of A4221 may be billed per week.
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Use HCPCS code J7799 (Not otherwise classified drugs, other than inhalation drugs, administered through DME) for
SCIG. HCPCS codes J1566 and J1567 (Intravenous immune globulin) must not be used.
Intravenous immune globulin (IVIG) is covered for the same conditions but under a separate benefit category. An
infusion pump and related supplies are not covered for administration of IVIG.
Other uses of SCIG or IVIG are not covered. Refer to the External Infusion Pumps LCD for additional information
about SCIG.
Negative Pressure Wound Therapy Length of Need
Negative pressure wound therapy (NPWT) is eligible for reimbursement for up to four months on the most recent
covered wound. After four months, the LCD states that coverage ends. Recently questions have arisen about how to
obtain coverage for more than four months of therapy.
Claims that exceed the fourth month of therapy will be denied. Suppliers have the opportunity, using the established
appeals process, to submit information explaining any special circumstances that might justify payment for additional
months on a month-by-month basis.
Refer to the NPWT LCD for additional information on coverage criteria and documentation.
Coverage and Billing for Ultrasound Stimulation for Nonunion
Fracture Healing*
Medlearn Matters Number: MM4085
Related Change Request #: 4085
Related Change Request Release Date: January 20, 2006
Effective Date: April 27, 2005
Related Change Request Transmittal #: R816CP
Implementation Date: April 3, 2006
Physicians, suppliers and providers billing Medicare fiscal intermediaries, including regional home health intermediaries
(RHHIs), for ultrasound stimulation for nonunion fracture healing
Provider Action Needed
STOP—Impact to You
This article is based on Change Request 4085, which supplements Change Request 3836, “Coverage and Billing
Requirements for Ultrasound Stimulation for Nonunion Fracture Healing.”
CAUTION—What You Need to Know
Effective for services performed on or after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically
reasonable and necessary for the treatment of nonunion bone fractures prior to surgery. Please note that there have been
changes made to Change Request 3836 business requirements. These changes are discussed in the Additional
Information section of this article. All other material and information remain the same as in the original Change
Request 3836.
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GO—What You Need to Do
See the Background section of this article for further details regarding this change.
Background
The Centers for Medicare & Medicaid Services (CMS) determined that evidence is adequate to conclude that it is
reasonable and necessary to use noninvasive ultrasound stimulation for the treatment of nonunion bone fractures prior to
surgical intervention.
Therefore, effective for services performed on or after April 27, 2005, ultrasonic osteogenic stimulators are covered as
medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgery.
Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing
An ultrasonic osteogenic stimulator is a non-invasive device that emits low-intensity, pulsed ultrasound. This device is
applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to
stimulate fracture healing.
Note: Ultrasonic osteogenetic stimulators are not to be used concurrently with other noninvasive osteogenetic devices.
Coverage Requirements
Effective for dates of service on and after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically
reasonable and necessary for the treatment of nonunion bone fractures prior to surgical intervention. In demonstrating
nonunion fractures, CMS expects a minimum of two sets of radiographs, obtained prior to starting treatment with the
osteogenic stimulator, separated by a minimum of 90 days.
Each radiograph set must include multiple views of the fracture site, accompanied with a written interpretation by a
physician stating that there has been no clinically significant evidence of fracture healing between the two sets of
radiographs.
Note: For further coverage information, please refer to the CMS Internet-Only Manual (IOM) Publication 100-03,
Medicare National Coverage Determinations manual, chapter 1, section 150.2, which can be found at
www.cms.hhs.gov/manuals/downloads/ncd103c1_Part2.pdf on the CMS Web site.
Note: Hospitals should note that there are no covered services for ultrasonic osteogenic stimulation for which hospitals
can be paid by the fiscal intermediary. Thus, hospitals cannot bill for ultrasonic osteogenic stimulators.
Bill Types When Billing Regional Home Health Intermediaries
When billed to RHHIs, ultrasonic osteogenic stimulators must be billed on type of bill 32X, 33X, 34X, and is payable
under the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule.
Note: Ultrasonic osteogenic stimulators must be in the patient’s home health plan of care if billed on either type of bill
32X or 33X.
Billing Instructions When Billing Medicare Carriers
Effective for dates of service on or after April 27, 2005, carriers will allow payment for ultrasonic osteogenic stimulators
with the following Current Procedural Terminology (CPT) code:
20979
Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative).
Billing Instructions for Durable Medical Equipment Regional Carriers and Regional Home Health
Intermediaries Effective for Dates of Service On or After April 27, 2005
Durable medical equipment regional carriers (DMERCs) and RHHIs will allow payment for ultrasonic osteogenic
stimulators with the following HCPCS codes:
•
E0760 for low-intensity ultrasound (include modifier “KF”), or
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•
E1399 for other ultrasound stimulation (include modifier “KF”)
RHHIs will:
•
•
Pay for ultrasonic osteogenic stimulators only when services are submitted on type of bills 32X, 33X or 34X
Pay HHAs on bill types 32X, 33X and 34X for ultrasonic osteogenic stimulators on the DMEPOS fee schedule
Note: Medicare carriers, fiscal intermediary and RHHIs will adjust claims with dates of service on and after April 27,
2005, if brought to their attention.
Implementation
The implementation date for the instruction is April 3, 2006.
Some of the differences between Change Request 3836 and the new Change Request 4085 include the following:
•
•
A modifier is not needed when billing code 20979 to a carrier as a result of Change Request 4085.
Modifier “KF” is now to be used when billing code E0760 or code E1399 to a DMERC or RHHI.
For complete details, please see the official instruction issued to your carrier/DMERC/fiscal intermediary/RHHI
regarding this change. That instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R816CP.pdf on the
CMS Web site.
Attention All Respiratory Suppliers:
Oximetry Testing—Supplier Involvement
In Change Request 3751, Transmittal 173, published on August 16, 2005, CMS provided guidance on when a DME
supplier may deliver test equipment used in overnight oximetry testing. Suppliers have asked a number of questions
concerning this issue. This article repeats the main criteria from that document and provides additional information to
address those questions.
Beneficiaries may self-administer home based overnight oximetry tests under the direction of a Medicare-enrolled
independent diagnostic testing facility (IDTF). Further, a DME supplier or another shipping entity may deliver a pulse
oximetry test unit and related technology used to collect and transmit test results to the IDTF to a beneficiary’s home
under the following circumstances:
1.
The beneficiary’s treating physician has contacted the IDTF to order an overnight pulse oximetry test before the test
is performed.
2.
The test is performed under the direction and/or instruction of a Medicare-approved IDTF. Because the beneficiary
self-administers this test, the IDTF must provide clear written instructions to the beneficiary on proper operation of
the test equipment and must include access to the IDTF in order to address other concerns that may arise. The DME
supplier may not create this written instruction, provide verbal instructions, answer questions from the beneficiary,
apply or demonstrate the application of the testing equipment to the beneficiary, or otherwise participate in the
conduct of the test.
3.
The test unit is sealed and tamper-proof such that test results cannot be accessed by anyone other than the IDTF who
is responsible for transmitting a test report to the treating physician. The DME supplier may use related technology
to download test results from the testing unit and transmit those results to the IDTF. In no cases may the DME
supplier access or manipulate the test results in any form.
The IDTF may send the test results only to the physician. It must not send them to the supplier.
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It is important to note that supplier involvement in the delivery of oximetry devices to perform tests used to determine
Medicare coverage for home oxygen is limited to sleep oximetry tests. Oximetry test results obtained through a similar
process while the beneficiary is awake, either at rest or with exercise, may not be used for purposes of qualifying the
beneficiary for home oxygen therapy.
Suppliers are also cautioned that sleep oximetry testing must be based on a request that is initiated by the treating
physician. It is inappropriate for a supplier or IDTF to initiate a contact with the physician either directly or through the
beneficiary to request, suggest, or otherwise seek an order for home oximetry testing.
Medicare System Edits for Respiratory Assist Devices with
Bi-Level Capability and a Back-Up Rate*
Related Change Request Release Date: February 1, 2006
Providers and suppliers who bill Medicare RHHIs or DMERCs for respiratory assist devices (RADs)
Please be aware of this payment change for RADs with bi-level capability and a back-up rate.
Key Points
•
•
•
The Final Rule, CMS-1167-F, Payment for Respiratory Assist Devices with Bi-Level Capability and a Back-Up
Rate, states that RADs with bi-level capability and a back-up rate must be paid as capped rental items or durable
medical equipment (DME) under the Medicare program.
RADs should not be paid as items requiring frequent and substantial servicing, as defined in section 1834(a)(3) of
the Social Security Act.
Effective April 1, 2006, Medicare will move the Healthcare Common Procedure Coding System (HCPCS) codes
E0471 and E0472 from the frequent and substantial servicing category to the capped rental category.
The first claim received for each beneficiary for these codes with a date of service on or after April 1, 2006, will be
counted as the first rental month in the cap rental period. Suppliers should begin submitting cap rental modifiers KH, KI
or KJ, as appropriate, with all rental claims for these codes with dates of service on or after April 1, 2006.
The official instruction issued to your RHHI or DMERC regarding this change may be found by going to
www.cms.hhs.gov/Transmittals/downloads/R825CP.pdf on the CMS Web site.
General Provider Education for Changes in the Payment for
Oxygen Equipment and Capped Rentals for Durable Medical
Equipment Due to the Deficit Reduction Act of 2005*
MLN Matters Number: MM5010
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Related Change Request Release Date: April 28, 2006
Effective Date: May 30, 2006
Implementation Date: May 30, 2006
Suppliers and providers billing Medicare DMERCs for oxygen equipment/services or other rentals of capped DME.
Physicians treating Medicare patients using oxygen equipment or other rentals of capped DME may also want to be
aware of this issue.
Background
Recent legislative changes mandated by section 5101(a) and 5101(b) of the Deficit Reduction Act (DRA) of 2005
require changes to the DME claims processing systems.
The purpose of this article and related Change Request 5010 are to provide DME suppliers with an explanation of how
these changes will impact them.
Important Points to Remember
Changes in Capped Rentals for Durable Medical Eqipment
Section 5101(a) of the DRA is effective for capped rental items for which the first rental month occurs on or after
January 1, 2006.
•
For claims with dates of service (DOS) on and after January 1, 2006, the DMERCs, and eventually their
replacements, the durable medical equipment Medicare administrative contractors (DME MACs), will limit the total
number of months for which they make payment for capped rental DME to 13 months.
•
After the DME MAC (or DMERC) has paid for 13 months for capped rental DME, title for the equipment will be
transferred to the beneficiary.
•
This policy applies only to beneficiaries who began a new DME capped rental period for dates of service on or after
January 1, 2006.
•
For claims with dates of services prior to January 1, 2006, current rules apply.
Changes Related to Payment for Oxygen Equipment:
•
Section 5101(b) of he DRA establishes a 36 month (three year) limit or cap on monthly payments for stationary and
portable oxygen equipment. This cap applies to oxygen equipment furnished on or after January 1, 2006, and applies
to all claims for the following list of HCPCS codes.
E0424 – Stationary gaseous oxygen system
E0434 – Portable liquid oxygen system
E1390 – Oxygen concentrator, single delivery port
E1392 – Portable oxygen concentrator
E0431 – Portable gaseous oxygen system
E0439 – Stationary liquid oxygen system
E1391 – Oxygen concentrator, dual delivery port
E1405 – Oxygen and water vapor enriching system with
heated delivery
E1406 – Oxygen and water vapor enriching system
without heated delivery
•
Payments for any of the above described items terminate after a period of continuous use of 36 months beginning on
or after January 1, 2006. On the first day after the month for which the 36th monthly payment amount is made, the
supplier must transfer title for the stationary and/or portable oxygen equipment to the beneficiary.
•
On the same day that title for the equipment is transferred to the patient, monthly payments can begin to be made for
oxygen contents used with patient-owned gaseous and liquid oxygen equipment.
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The HCPCS codes for oxygen contents include the following:
E0441 – Stationary gaseous contents used with patient
owned gaseous stationary system
E0443 – Portable gaseous contents used with patient
owned gaseous portable system
E0442 – Stationary liquid contents used with patient
owned liquid stationary system
E0444 – Portable liquid contents used with patient owned
liquid portable system
Note: Medicare DMERCs will begin the 36-month count for beneficiaries that were already receiving oxygen therapy on
January 1, 2006. Months prior to January 2006 will not be included in the 36-month count.
DMERCs will pay for reasonable and necessary maintenance and servicing (i.e., parts and labor not covered by a
supplier’s or manufacturer’s warranty) of beneficiary-owned equipment (including oxygen concentrators).
Updates to the CMS IOM Publication 100-04, Medicare Claims Processing manual and the CMS IOM Publication 100-02,
Medicare Benefits Policy manual related to Change Request 5010 will be made at a later date to reflect these changes.
Use of HCPCS Modifiers
Additional program billing and claims processing instructions will be issued later this year. For now, suppliers should
continue to use the KH, KI, and KJ modifiers in the manner as previously instructed for capped rental DME. These
modifiers do not need to be submitted for oxygen or oxygen equipment claims. Suppliers should continue to use the BP,
BR, and BU modifiers with respect to capped rental periods that began prior to January 1, 2006.
Implementation
The implementation date for this instruction is May 30, 2006.
The official instructions issued to your DMERC regarding this change can be found at
Attention All Mobility Suppliers:
Advanced Determination of Medicare Coverage
Advanced Determination of Medicare Coverage (ADMC) is a process by which the PSC will provide the requestor with
a coverage decision prior to delivery of an item.
Items Eligible for Advanced Determination of Medicare Coverage
ADMC is available only for the following wheelchair base HCPCS Codes and related options and accessories:
•
•
Manual wheelchairs described by codes E1161, E1231–E1234, K0005 and K0009
Power wheelchairs described by codes K0011 and K0014, only when a power tilt and/or power recline seating
system or a non-joystick control device (e.g., head control, sip and puff, switch control) is ordered
Submitting Advanced Determination of Medicare Coverage Requests
Requests may either be mailed or sent by fax. When submitting an ADMC via fax, please use the cover sheet included in
the Attachments section of this bulletin for each request, and indicate whether the request is an ADMC for Region A or
for Region B. Note: ADMC requests cannot be submitted electronically.
The mailing address for ADMC requests is:
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Tricenturion, LLC
Attention: ADMC
7909 Parklane Road
Suite 190
Columbia, South Carolina 29223
The fax number for ADMC requests is: 803-419-6080
Refer to the TriCenturion Web site at www.tricenturion.com for additional information about ADMC requests.
Power Wheelchairs and Power Operated Vehicles—
Documentation Requirements
The Final Rule relating to documentation for power wheelchairs and power operated vehicles was published in the
Federal Register on April 5, 2006 and became effective for claims with dates of service on or after June 5, 2006. The
Final Rule is similar to the Interim Final Rule, which became effective for claims with dates of services on or after
October 25, 2005, with one significant change. The Final Rule states that the physician’s order for a power mobility
device and a copy of the report of the face-to-face evaluation of a patient’s mobility needs must be received by the
supplier within 45 days following the completion of the face-to-face evaluation. The previous requirement was that these
documents be received by the supplier within 30 days following the face-to-face examination.
In order to document that the order and report of the exam were received by the supplier within 45 days after the date of
the face-to-face examination, the supplier must use a date stamp or equivalent when the documents received. This
requirement will be enforced on orders and exam reports that are received by the supplier on or after July 1, 2006.
Revisions of the Power Wheelchair and Power Operated Vehicles medical policies incorporating these changes are
published in the TriCenturion June 2006 Supplier Manual update.
Wheelchair Seating—New Codes
Effective for claims with dates of service on or after July 1, 2006, four new HCPCS codes have been established for
adjustable wheelchair cushions:
K0734
K0735
K0736
K0737
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth
Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
Currently, suppliers have been instructed to use HCPCS code K0108 for these cushions. For dates of service on or after
July 1, 2008, HCPCS code K0108 must not be used for a wheelchair cushion.
The only products which may be billed using these codes are those products for which a written coding verification has
been made by the Statistical Analysis DME Regional Carrier (SADMERC). Information concerning the documentation
that must be submitted to the SADMERC for a coding verification request can be found on the SADMERC Web site, or
by contacting the SADMERC. A Product Classification List showing all products that have received a coding
verification can also be found on the SADMERC Web site.
A revision of the Wheelchair Seating LCD, which incorporates these changes, is included in the TriCenturion June 2006
Supplier Manual update.
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New Temporary Codes for Adjustable Wheelchair Cushions*
Effective Date: July 1, 2006
Implementation Date: July 3, 2006
Durable medical equipment suppliers and providers who order wheelchair services for Medicare beneficiaries
Medicare may not reimburse you correctly for ordering or supplying wheelchair cushions for your Medicare patients if
you don’t use the correct codes on your claim.
The CMS has established four new “K” codes for adjustable wheelchair cushions, effective July 1, 2006.
Make sure that your billing staffs are aware of these new “K” codes for wheelchair cushions.
Background
CMS has established four new “K” codes for adjustable wheelchair cushions, effective for services provided on or after
July 1, 2006.
These new codes are displayed in the following table:
“K” Codes for Adjustable Wheelchair Cushions, Effective July 1, 2006
Code
K0734
K0735
K0736
K0737
Description
Skin protection wheelchair seat cushion, adjustable, width
less than 22 inches, any depth
Skin protection wheelchair seat cushion, adjustable, width
22 inches or greater, any depth
Skin protection and positioning wheelchair seat cushion,
adjustable, width less than 22 inches, any depth
Skin protection and positioning wheelchair seat cushion,
adjustable, width 22 inches or greater, any depth
You can find more information about the four new “K” codes for adjustable wheelchair cushions at
Payment for Power Mobility Device Claims*
MLN Matters Number: MM4372 Revised
Related Change Request Release Date: March 10, 2006
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Effective Date: January 1, 2006
Related Change Request Transmittal #: R215OTN
Implementation Date: No later than March 24, 2006
Note: This article was revised on March 24, 2006, to emphasize that providers submitting claims on or after April 1,
2006, must bill the evaluation and management (E&M) and the G0372 code on the same claim.
Physicians, providers, and nonphysician practitioners billing Medicare carriers, DMERCs, RHHIs and/or fiscal
intermediaries for power mobility devices (PMDs) and services related to prescribing PMDs
Options for Submitting G0372 and E&M Codes
Providers billing a Medicare carrier have the following options for submitting the G0372 code and the E&M code during
January 1, 2006, through March 31, 2006:
•
•
•
Submit the G0372 code and E&M now on the same claim. Payment for these claims will be held through March 31,
2006.
Hold all claims containing the G0372 code until after March 31, 2006.
Submit the E&M service now and bill the G0372 code after March 31, 2006. The E&M service will be paid now.
Note that this is not intended to require that Medicare fiscal intermediaries or carriers split claims submitted with
both the E&M and G0372 code. Rather, the physician/provider may choose to submit two separate claims for the
individual services.
Providers submitting claims on or after April 1, 2006, must bill the E&M and the G0372 code on the same claim.
Critical access hospitals (CAHs) billing the fiscal intermediary under Method II have the following options from January
1, 2006, through July 2, 2006, for submitting the G0372 code and the E&M code:
•
•
•
Submit the G0372 and E&M now on the same claim. Payment for these claims will be held by the fiscal
intermediary through July 2, 2006.
Hold all claims containing the G0372 code until after July 2, 2006.
Submit the E&M service now and bill the G0372 code after July 2, 2006. The E&M service will be paid now. Note
that this is not intended to require the fiscal intermediaries or carriers to split claims submitted with both the E&M
and G0372 code. Rather, the physician or treating practitioner may choose to submit two separate claims for the
individual services.
Method II CAHs submitting claims on or after July 2, 2006, must bill the E&M and the G0372 code on the same claim.
Background
The CMS published an Interim Final Rule on power mobility devices to conform its regulations to section
302(a)(2)(E)(iv) of the Medicare Modernization Act (MMA) of 2003, which is codified at section 1834(a)(1)(E)(iv) of
the Social Security Act (SSA). The effective date of the rule was October 25, 2005. For PMDs, the MMA mandated that:
•
•
A face-to-face examination of the individual be conducted by a physician, a physician assistant, a nurse practitioner,
or a clinical nurse specialist; and
That payment may not be made for a motorized or power wheelchair unless the physician or treating practitioner has
written a prescription for the item.
By defining the practitioners allowed to conduct the face-to-face examination, it also effectively removed the current
requirement that a beneficiary must be seen by a specialist in physical medicine, orthopedic surgery, neurology, or
rheumatology in order to get a power-operated vehicle.
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Submission of Medical Record and Prescription
Apart from the MMA requirements, the other key change made by this regulation is a requirement that the physician or
treating practitioner must submit pertinent parts of the medical record (in lieu of the CMN), along with the prescription,
to the DME supplier within 30 days of the face-to-face examination.
A separate add-on payment (an add-on payment to the office visit billed with the code of G0372) was established by the
rule to recognize the additional physician work and resources required for submitting pertinent parts of the medical
record. Payment for the history and physical examination is made through the appropriate E&M code along with the
add-on payment (G0372) which goes to the local Medicare fiscal intermediary or carrier. The PMD claim will go to the
local DMERC.
Appropriations Act
Title II, section 222, of the Departments of Labor, Health and Human Services, and Education and Related Agencies
Appropriations Act of 2006 (H.R. 3010) (the Appropriations Act) was signed into law on December 30, 2005. It states,
in part:
SEC. 222. None of the funds made available under this Act may be used to implement or enforce the interim final rule
published in the Federal Register by the Centers for Medicare & Medicaid Services on August 26, 2005, (70 Fed. Reg.
50940) prior to April 1, 2006.
Although this section of the Appropriations Act does not allow federal funds to implement or enforce the rule, CMS
believes that this section does not affect the validity of the rule. Therefore, CMS is instructing DMERCs and/or DME
Program Safeguard Contractors that, between January 1, 2006 to April 1, 2006, contractors will only pay PMD claims
that satisfy the requirements of section 1834(a)(1)(E)(iv) of the SSA. Based on the Appropriations Act, CMS is
instructing fiscal intermediaries and carriers to hold claims that contain G0372. These claims must be held through
March 31, 2006. Carriers will begin to release physician claims for processing on April 3, 2006.
Implementation
The implementation date for this instruction is no later than two weeks after release of Change Request 4372 or March
24, 2006.
For additional information regarding PMDs, you may want to review the following Medlearn Matters articles:
•
•
MM4121: MMA—New G Code for Power Mobility Devices (PMDs);
www.cms.hhs.gov/MLNMattersArticles/downloads/MM4121.pdf
MM3952: MMA—Evidence of Medical Necessity: Power Wheelchair and Power Operated Vehicle (POV)/Power
Mobility Device (PMD) Claims; www.cms.hhs.gov/MLNMattersArticles/downloads/MM3952.pdf
The official instructions issued to your carrier, DMERC, fiscal intermediary or RHHI regarding this change can be found
at www.cms.hhs.gov/Transmittals/downloads/R215OTN.pdf on the CMS Web site.
Attention All Drug Suppliers:
Oral Antiemetic Drug Claims Paid In Error
AdminaStar Federal, the Region B DMERC has identified approximately 202 Aprepitant (J8501) and Dexamethasone
(J8540) claims that were submitted with dates of service 01/01/06 through 04/07/06. These claims have been paid in
error. Claims for HPCCS codes J8540 and J8501 will be adjusted and the Region B DMERC will initiate overpayment
requests.
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AdminaStar Federal
Aprepitant (J8501) and Dexamethasone (J8540) are covered if the statutory coverage criteria specified in the medical
policy is met and they are administered to patients who are receiving one or more of the following anticancer
chemotherapeutic agents:
•
•
•
•
•
•
•
•
•
Carmustine
Cisplatin
Cyclophosphamide
Dacarbazine
Mechlorethamine
Streptozocin
Doxorubicin
Epirubicin
Lomustine
If Aprepitant and Dexamethasone meet the statutory coverage criteria, but are not used with one of the preceding
chemotherapeutic agents listed above, they will be denied as not medically necessary.
Please refer to the Oral Antiemetic drug LCD on the TriCenturion Web site at www.tricenturion.com for additional
information.
Dexamethasone (J8540) Documentation Requirement for the
Oral Antiemetic Drugs Local Coverage Determination
Dexamethasone (J8540) was recently added to the Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
Local Coverage Determination (LCD). Dexamethasone is used as part of a three-drug regimen along with aprepitant
(J8501) and one of the listed anticancer drugs. All three drugs are reimbursable when used in this manner.
The Documentation section of the LCD requires the use of the KX modifier with aprepitant when it is used as part an
approved three-drug regimen. Dexamethasone also requires the KX modifier when it is used as part of an approved
three-drug regimen—but was inadvertently omitted from the Documentation section. The LCD Documentation
paragraph should have read,
“If aprepitant (J8501) and dexamethasone (J8540) are used in conjunction with one of the anticancer chemotherapeutic
agents listed in the Indications and Limitations of Coverage section of this policy, a KX modifier should be added to
each code.”
The Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) LCD will be updated to include this language in
a future publication.
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Benefit Integrity
TriCenturion Program Safeguard Contractor Contact
Information
TriCenturion is the Program Safeguard Contractor (PSC) responsible for all benefit integrity functions for Region B
DMERC suppliers. Questions regarding benefit integrity issues should be directed to TriCenturion at the following
contacts:
Telephone: 803-264-7700
Web address: www.tricenturion.com
Mailing address:
TriCenturion, LLC
7909 Parklane Road, Suite 190
To report suspected Medicare fraud, suppliers should complete the Referral to Benefit Integrity form found on the
TriCenturion Web site at the following links: www.tricenturion.com/content/report_fraud.cfm
Coverage and Billing
CMS-1500 Claim Form Instructions—Box 11
Prior to February 1, 2006, AdminaStar Federal accepted all Medicare Part B and durable medical equipment, prosthetics,
orthotics and supplies (DMEPOS) paper claims when Box 11 on the CMS-1500 claim form was left blank. The Centers
for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims
Processing manual, chapter 26 at section 10.2 states:
“If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c.
Items 4, 6, and 7 must also be completed. If there is no insurance primary to Medicare, enter the word ‘NONE’ in box
11 and proceed to item 12.”
For all paper claims received on or after February 1, 2006, AdminaStar Federal started rejecting all Medicare Part B and
DMEPOS paper claims when Box 11 is left blank. All physicians and suppliers must enter the insured’s policy or group
number in Box 11. If there is no insurance primary to Medicare, the word “NONE” must be entered into Box 11—
otherwise the claim will be rejected.
Note: This instruction applies to paper claims only.
Change Payment Floor Date for Paper Claims*
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AdminaStar Federal
Implementation Date: March 13, 2006
Physicians, providers, and suppliers who use paper claims to bill Medicare carriers, including durable medical
equipment regional carriers (DMERCs), and fiscal intermediaries, including regional home health intermediaries
(RHHIs)
•
•
Change Request 4284 changes the payment floor date for paper claims from the 27th day to the 29th date after
receipt of a claim.
Effective January 1, 2006, Medicare carriers, DMERCs, fiscal intermediaries and RHHIs will not pay paper
claims prior to the 29th day after receipt of the claim.
Background
The Social Security Act, section 1816b(c)(3)(B)(ii) and section 1842(c)(3)(B)(ii) provides for payment waiting periods
for Medicare claims before a claim is paid by the Medicare contractor. Congress has amended the Social Security Act to
extend the waiting period for paper claims from 27 to 29 days, effective January 1, 2006.
Implementation
The implementation date for this instruction is March 13, 2006.
The official instructions issued to your carrier regarding this change can be found at
Change in the Long Descriptor for HCPCS Code Q4080*
Physicians, suppliers, and providers billing Medicare carriers, including DMERCs and/or fiscal intermediaries, including
RHHIs, for services related to ILOPROST inhalation treatment of Medicare beneficiaries
This article is based on Change Request 4324, which provides information on the revised code dosage descriptor for
Q4080. This is a nonsystems change Change Request.
Background
The Centers for Medicare & Medicaid Services (CMS) established Healthcare Common Procedure Coding System
(HCPCS) code Q4080 that was effective July 1, 2005, with a code descriptor that read:
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AdminaStar Federal
•
“Iloprost, inhalation solution, administered through DME, 20 micrograms.”
Effective January 1, 2006, the long code descriptor for HCPCS code Q4080 will read:
•
“Iloprost, inhalation solution, administered through DME, up to 20 mcg.”
The short descriptor for HCPCS code Q4080 will continue to read:
•
“Iloprost inhalation solution.”
Change Request 4324 provides clarification on the change in the long descriptor for HCPCS code Q4080 effective
January 1, 2006.
Implementation
The implementation date for the instruction is March 13, 2006.
regarding this change. That instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R209OTN.pdf on
the CMS Web site.
Eliminate the Use of Surrogate Unique Physician
Identification Numbers on Medicare Claims*
MLN Matters Number: MM4177 Revised
Related Change Request Release Date: November 10, 2005
Note: This article was rescinded on March 21, 2006, because Change Request 4177 was rescinded. A new Change
Request will be released on this issue in the future. [See following article.]
Rescind Change Request 4177—Eliminate the Use of
Surrogate UPINs (OTH000) on Medicare Claims*
Related Change Request Transmittal #: R145PI
Physicians, nonphysician practitioners, suppliers and providers billing Medicare carriers, DMERCs, fiscal intermediaries
or RHHIs for diagnostic, radiology, consultation services and equipment
This article is based on Change Request 5019, which rescinds Change Request 4177. Change Request 4177 eliminated
the use of the surrogate Unique Physician Identification Number (UPIN) OTH000 on claims submitted by billers,
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suppliers, physicians and nonphysician practitioners. Change Request 5019 instructs Medicare contractors to discontinue
all work to eliminate the use of the surrogate UPIN “OTH000” in claims processing, and continue to use surrogate UPIN
“OTH000” for submitted claims and other internal purposes.
Background
The Social Security Act (section 1833[q]; www.ssa.gov/OP_Home/ssact/title18/1833.htm) requires that:
•
•
All physicians meeting the definition of a physician (section 1861[r];
www.ssa.gov/OP_Home/ssact/title18/1861.htm) must have a UPIN, and
All claims for services ordered or referred by one of these physicians must include the names and UPINs of the
ordering/referring physician
Currently, durable medical equipment (DME) suppliers, physicians and nonphysician practitioners are allowed to use a
Surrogate UPIN to bill for the following:
•
•
•
•
Diagnostic services
Radiology services
Consultation services, and
DME
Change Request 4177 (Transmittal R752CP, dated November 10, 2005) instructed Medicare affiliated contractors
(carriers, DMERCs, fiscal intermediaries and RHHIs) not to accept the surrogate UPIN “OTH000” on Medicare claims
submitted by billers, suppliers, physicians and nonphysician practitioners.
However, because of the possibility that this will adversely impact the ability of providers to bill the Medicare program,
the CMS is rescinding Change Request 4177.
Surrogate UPINs are intended to be used during an interim period when a UPIN has been requested but has not yet been
received. Currently, DME suppliers, physicians and nonphysician practitioners are allowed to use a surrogate UPIN to
bill for:
•
•
•
•
Diagnostic services
Radiology services
Consultation services, and
DME
Change Request 5019 instructs your Medicare contractor(s) to:
•
•
Discontinue all work to eliminate the use of the surrogate UPIN “OTH000” in claims processing; and
Continue to use surrogate UPIN “OTH000” for submitted claims and other internal purposes.
Implementation
The implementation date for Change Request 5019 is April 3, 2006.
regarding this change. That instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R145PI.pdf on the
CMS Web site.
Inquirers can obtain providers’ UPINs at www.upinregistry.com/.
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AdminaStar Federal
Durable Medical Equipment Regional Carrier Information Form*
Medlearn Matters Number: MM4241 Revised
Note: This article was revised on February 28, 2006, to correct the reference to Change Request 4241 in the first bullet
point under “Impact on Providers.” The original article mistakenly referenced Change Request 4240.
Suppliers billing Medicare DMERCs for immunosuppressive drugs
Impact on Providers
•
•
Change Request 4241 eliminates the need for the DMERC Information Form (DIF), DMERC form 08.02, when
billing for immunosuppressive drugs for dates of service on or after April 1, 2006.
The DIF for immunosuppressive drugs is a form that collects additional data on the beneficiary before Medicare
payment is made for immunosuppressive drugs.
.
Section 1861(s)(2)(J) of the Social Security Act no longer imposes a limitation on the period of time for coverage of
immunosuppressive drugs; thus, the information captured on the DIF (i.e., information regarding the dates of the
beneficiary’s transplant and other diagnosis information) can be obtained through other means.
•
This policy is effective for services on or after April 1, 2006. Claims submitted for services prior to April 1, 2006,
without the fully completed DIF, will be rejected.
•
The CMN for Parenteral Nutrition (CMS Form 852) is still required.
•
If March 2006 and April 2006 dates of service are on the same claim for immunosuppressive drugs, Medicare
DMERCs will replicate the claims to divide the March 2006 services from the April 2006 services on separate
claims. Then, the services provided on or after April 1, 2006, will be processed without the DIF.
•
The following HCPCS codes for immunosuppressive drugs are identified as those no longer requiring the DIF after
April 1, 2006:
Category 11: J0215, J2920, J7500, J7501, J7502, J7504, J7505, J7506, J7507, J7509, J7510, J7511, J7513, J7515,
J7516, J7517, J7518, J7520, J7525, J7599, J8530, J8610, J9212, J9213, J9214, J9215, J9216 and J2930.
Implementation
The implementation date for this instruction is April 3, 2006.
The official instruction issued to the DMERC regarding this change can be viewed by going to
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AdminaStar Federal
Denial of Claims Not Timely Filed*
Providers billing fiscal intermediaries, RHHIs, carriers and DMERCs for services provided to Medicare beneficiaries
This article is based on information contained in Change Request 4041, which clarifies that a determination relating to
the untimely submission of a Medicare claim by a provider or supplier is not an initial determination and cannot be
appealed.
Claims that are filed after the “timely filing period” will be denied as specified in the CMS Internet-Only Manual (IOM),
Publication 100-04, Medicare Claims Processing manual, chapter 1, section 70.1. When a claim is denied because it was
filed after the timely filing period, the denial will not constitute an “initial determination.” As such, the determination
that a claim was not filed timely cannot be appealed.
Be aware of the time limits for filing Medicare claims and the consequences of untimely filing.
Background
The CMS issued a technical correction to the June 30, 2005 Federal Register, Interim Final Rule, “Medicare Program:
Changes to the Medicare Claims Appeal Procedures (42 CFR parts 401 and 405),” that clarified that a determination
regarding the untimely submission of a Medicare claim is not an initial determination and cannot be appealed.
Specifically, 42 CFR section 405.926(n) indicates that a determination that a provider or supplier failed to submit a
claim timely or failed to submit a timely claim, despite being requested to do so by the beneficiary or the beneficiary’s
subrogee, is not an initial determination and cannot be appealed.
Change Request 4041 informs all Medicare providers of the above technical correction to the June 30, 2005 Interim
Final Rule, “Medicare Program: Changes to the Medicare Claims Appeal Procedures” and revises the CMS IOM
Publication 100-04, Medicare Claims Processing manual, chapter 1 (General Billing Requirements), sections 70.4 and
70.8.6 to incorporate these changes.
For complete details, including the revised sections of the CMS IOM Publication 100-04, Medicare Claims Processing
manual and a table that illustrates the timely filing limit for dates of service in each calendar month, please see the
official instruction issued to your carriers, fiscal intermediaries, DMERCS or RHHIs regarding this change. That
instruction may be viewed by going to www.cms.hhs.gov/Transmittals/downloads/R830CP.pdf on the CMS Web site.
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AdminaStar Federal
Full Replacement of Change Request 4349—Hold on Medicare
Payments—Change Request 4349 Is Rescinded*
Related Change Request Release Date: May 10, 2006
Effective Date: September 22, 2006
Note: This article was revised on May 11, 2006, to reflect a new Change Release date, transmittal number and Change
Request 5047 Web address. These were changed to reflect that Change Request 5047 was revised by CMS on May 10.
All other information in the article remains the same.
Providers and physicians who bill Medicare contractors (fiscal intermediaries including RHHIs and carriers) for their
services
Key Points
•
•
•
A brief hold will be placed on Medicare payments for all claims (e.g., initial claims, adjustment claims and
Medicare Secondary Payer [MSP] claims) for the last nine days of the federal fiscal year, i.e., September 22, 2006–
September 30, 2006.
− In essence, no payments on claims will be made from September 22–30, 2006. Providers need to be aware of
these payment delays, which are mandated by section 5203 of the Deficit Reduction Act of 2006.
− Accelerated payments using normal procedures will be considered.
No interest will be accrued or paid, and no late penalty will be paid to an entity or individual for any delay in a
payment by reason of this one-time hold on payments.
All claims held as a result of this one-time policy that would have otherwise been paid on one of these nine days
will be paid on October 2, 2006.
This policy applies only to claims subject to payment. It does not apply to full denials and no-pay claims. It also does
not apply to periodic interim payments, home health request for anticipated payments, cost reports settlements, and other
nonclaim payments.
Additionally, Medicare contractors will continue to apply the 14-day electronic claim payment floor and the 29-day
paper claim payment floor. On a case-by-case basis, Medicare fiscal intermediaries, RHHIs or carriers may make
adjustments, after October 1, 2006, for extenuating circumstances raised by a provider. For example, adjustments may be
made to not charge a provider interest on an overpayment for those days for which offsets could not be made due to the
hold of payments required by this Deficit Reduction Act provision.
Please note that:
•
•
Payments will not be staggered, and
No advance payments during the 9-day hold will be allowed
Change Request 5047 is the official instruction issued to your fiscal intermediary, RHHI or carrier regarding changes
mentioned in this article. Change Request 5047 may be found by going to
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AdminaStar Federal
Revised CMS-1500 Claim Form*
Effective Date: October 1, 2006
Implementation Date: October 2, 2006
Physicians, providers, and suppliers who are excluded from the mandatory electronic claims submission requirements
and submit claims to Medicare carriers using the CMS-1500 paper claim form
Change Request 4293 describes the claim form CMS-1500 (12-90) that is being revised to accommodate the reporting of
the National Provider Identifier (NPI) and will then be named CMS-1500 (08-05). The following timeline outlines the
schedule for using the revised CMS-1500 claim form:
•
•
•
October 1, 2006: Health plans, clearinghouses, and other information support vendors should be ready to handle and
accept the revised CMS-1500 (08-05) claim form.
October 1, 2006–January 31, 2007: Providers can use either the current CMS-1500 (12-90) version or the revised
CMS-1500 (08-05) version of the claim form.
February 1, 2007: The current CMS-1500 (12-90) version of the claim form is discontinued; only the revised CMS1500 (08-05) form is to be used. All rebilling of claims should use the revised CMS-1500 (08-05) form from this
date forward, even though earlier submissions may have been on the current CMS-1500 (12-90) claim form.
Background
The form CMS-1500 form answers the needs of many health insurers. It is the basic form prescribed by the CMS for the
Medicare program and is accepted only from physicians and suppliers that are excluded from the mandatory electronic
claims submission requirements set forth in the Administrative Simplification Compliance Act, Public Law 107-105
(ASCA), and the implementing regulation at 42 CFR 424.32.
The CMS-1500 (12-90) claim form is being revised to accommodate the reporting of the NPI. The intent of the new
form is to best accommodate the NPI with minimal changes to the current claim form. The CMS-1500 (08-05) version
will be effective October 1, 2006, but will not be mandated for use until February 1, 2007. Therefore, there will be a
period when the current and the revised forms will both be acceptable.
The change log that lists the various changes made to the CMS-1500 (08-05) version can be viewed at the National
Uniform Claim Committee (NUCC) Web site at www.nucc.org/images/stories/PDF/change_log.pdf.
Implementation
The implementation date for the instruction is October 2, 2006.
The official instructions issued to your [carrier and/or] fiscal intermediary regarding this change can be found at
You may also wish to review Medlearn Matters articles:
•
SE0555, “Medicare's Implementation of the National Provider Identifier (NPI): The Second in the Series of Special
Edition MLN Matters Articles on NPI-Related Activities” available at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0555.pdf on the CMS Web site, and/or
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AdminaStar Federal
•
SE0528, “CMS Announces the National Provider Identifier (NPI) Enumerator Contractor and Information on
Obtaining NPIs” available at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0528.pdf on the CMS Web site
New Durable Medical Equipment Prosthetic, Orthotics &
Supplies Certificates of Medical Necessity and Durable
Medical Equipment Medicare Administrative Contractor
Information Forms for Claims Processing*
Related Change Request Transmittal #: R142PI
Note: This article was revised on March 3, 2006, to reflect changes to Change Request 4296, which CMS revised on
March 2. The Change Request release date, transmittal number, and Web address have been revised, but no other
changes were made to the article. Please note, however, that the revised Change Request 4296 states that “New forms
located at www.cms.hhs.gov/CMSForms/CMSForms/list.asp will not be available until the end of summer…” However,
you can find copies of the forms at the end of Change Request 4296 located at
www.cms.hhs.gov/Transmittals/downloads/R142PI.pdf on the CMS Web site.
Physicians, providers, and suppliers using Certificates of Medical Necessity (CMNs) and DME Medicare Administrative
Contractor Information Forms (DIFs) when billing to Medicare DMERCs
The CMS has developed improved CMNs and DIFs and consequently there are changes to the forms.
There is a transition period for claims with initial dates of service from October 1, 2006 through December 31, 2006,
where claims for items requiring a CMN or DIF will be accepted with either the old or the new form. The improved
forms also permit the use of a signature and date stamp.
Make certain that your billing staff is aware of the changes in chapters 3 and 5 of the CMS IOM Publication 100-08,
Medicare Program Integrity manual that are outlined in this article. The new series of forms is available as part of the
official instructions (Change Request 4296) issued to your DMERC.
CMNs provide a mechanism for suppliers of DME (defined in 42 U.S.C. section 1395x[n]) and medical equipment and
supplies (defined in 42 U.S.C. section 1395j[5]), to demonstrate that the item they provide meets the minimal criteria for
Medicare coverage. Medicare DMERCs review the documentation provided by physicians, suppliers, and providers on
the CMNs and DIFs and determine if the medical necessity and applicable coverage criteria for selected durable medical
equipment, orthotics, prosthetics and supplies (DMEPOS) were met.
The changes to the CMN forms have resulted in the following:
•
CMS IOM Publication 100-08, Medicare Program Integrity manual, chapter 5 (Items and Services Having Special
DME Review Considerations) has been revised.
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AdminaStar Federal
•
•
•
•
The improved forms permit the use of a signature and date stamp which has resulted in revision of the CMS IOM
Publication 100-08, Medicare Program Integrity manual, chapter 3, section 3.4.1.1 (Documentation Specifications
for Areas Selected for Prepayment or Post Payment Medical Review).
These new forms were approved by the Office of Management and Budget (OMB).
For the CMS-484 form, the OMB # is 0938-0534.
For the CMS forms 846, 847, 848, 849, 854, 10125 and 10126, the OMB # is 0938-0679.
Claims Accepted During Transition Period
The following table identifies the CMNs for claims with [an] initial date of service that will be accepted during the
transition period from October 1, 2006, through December 31, 2006. (As of January 1, 2007, 2006, the old forms will no
longer be accepted.)
DMERC Form
484.2
01.02A
01.02B
04.03B
04.03C
06.02B
07.02A
09.02
10.02A
10.02B
11.01
CMS Form
484
841
842
846
847
848
849
851
852
853
854
Items Addressed
Home Oxygen Therapy
Hospital Beds
Support Surfaces
Lymphedema Pumps (Pneumatic Compression Devices)
Osteogenesis Stimulators
Transcutaneous Electrical Nerve Stimulators (TENS)
Seat Lift Mechanisms
Parenteral Nutrition
Enteral Nutrition
Section C Continuation Form
Newly Revised CMNs Accepted During Transition Period
The following table identifies the newly revised CMNs that will be accepted during the transition period for claims with
[an] initial date of service from October 1, 2006, through December 31, 2006. As of January 1, 2007, these forms will
become effective for claims for items requiring a CMN.
Noteworthy changes include changing the title of CMS-484 from Home Oxygen Therapy to Oxygen. In addition, the
title of CMS-846 was changed from Lymphedema Pumps to Pneumatic Compression Devices.
DME MAC Form
484.03
04.04B
04.04C
06.03B
07.03A
11.02
CMS Form
484
846
847
848
849
854
Items Addressed
Oxygen
Pneumatic Compression Devices
Osteogenesis Stimulators
TENS
Seat Lift Mechanisms
Section C Continuation Form
New DIFs Accepted During Transition Period
The following table identifies the new DIFs that will also be accepted during the transition period for claims with [an]
initial date of service from October 1, 2006, through December 31, 2006. As of January 1, 2007, the new forms will
become effective for claims for items requiring a DIF.
Noteworthy changes include changing CMS-851 for Infusion Pumps to a CMS-10125, External Infusion Pump DIF. In
addition, CMS-852 for Parenteral Nutrition and CMS-853 for Enteral Nutrition were combined into a CMS-10126
Enteral and Parenteral Nutrition DIF.
DME MAC Form
09.03
10.03
CMS Form
10125
10126
Items Addressed
Enteral and Parenteral Nutrition
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AdminaStar Federal
The use of the CMNs for hospital beds (CMS-841) and support surfaces (CMS-842) will be eliminated for claims with
initial DOS on or after October 1, 2006.
CMNs Eliminated
The following table identifies the CMNs that will be eliminated for claims with initial DOS on or after October 1, 2006.
DME MAC Form
01.02A
01.02B
CMS Form
841
842
Items Addressed
Hospital Beds
Support Surfaces
Note: Medicare is developing a crosswalk to link legacy supplier numbers (National Supplier Clearinghouse [NSC]) to
the new National Provider Identifiers (NPI). Until that crosswalk is completed, DMERCs will require you to continue to
submit your legacy/NSC number. If you choose to submit your NPI as of October 1, 2006, you must still report your
legacy/NSC number until that crosswalk is operational. Similarly, treating physicians should report their UPIN
(preceded by an “XX” qualifier) and their NPI (preceded by a “1G” qualifier) until the crosswalk is operational. CMS
will issue further instructions when the crosswalk approaches operational status.
Implementation
The implementation date for the instruction is October 2, 2006.
The official instructions issued to your DMERC regarding this change can be found at
www.cms.hhs.gov/Transmittals/downloads/R142PI.pdf on the CMS Web site. These instructions include copies of the
new forms.
Remittance Advice Remark Code and Claim Adjustment
Reason Code Update*
Physicians, providers and suppliers who submit claims to Medicare contractors (carriers, fiscal intermediaries, RHHIs
and DMERCs) for services
The complete list, including changes made from July 1, 2005, through October 30, 2005, of X12N 835 Remittance
Advice Remark Codes (RARCs) and X12N 835 Claim Adjustment Reason Codes (CARCs) have been posted. The most
current and complete code list will be found at www.wpc-edi.com/codes.
Please refer to the Additional Information section of this article for remark and reason code changes approved between
July 1, 2005, to October 30, 2005, and in September 2005, respectively. By April 3, 2006, all applicable code text
changes and new codes should be in use and the deactivated codes terminated.
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AdminaStar Federal
The above codes are updated three times a year. Be sure your staff is aware of these changes in order to ensure correct
interpretation of the electronic or paper remittance advice notices sent by Medicare.
Background
Two code sets—the claim adjustment reason code set and the remittance advice remark code set—must be used to report
payment adjustments in remittance advice transactions. The reason codes are also used in some coordination of benefits
transactions.
The RARC list is maintained by the CMS and used by all payers. Additions, deactivations and modifications to the code
list may be initiated by Medicare and non-Medicare entities. This list is updated three times a year, and posted at
http://wpc-edi.com/codes.
The RARC database has expanded rapidly in the last couple of years. CMS has developed a new Web site to help
navigate the database more easily. A tool is provided to help search if you are looking for a specific category of code.
You can also find at this site some other information that is available from the WPC Web site. The new Web site address
is: www.cmsremarkcodes.info/
Note: This Web site is not replacing the WPC Web site as the official site where the most current RARC list resides. If
there is any discrepancy, always use the list posted at the WPC Web site.
Implementation
The following list summarizes changes made from July 1, 2005, through October 30, 2005.
Remittance Advice Remark Code Changes
Code
New, Modified,
Deactivated,
Retired
N357
New
N358
New
N359
N360
New
New
N361
New
N362
New
N363
New
N364
New
Current Narrative
Comment
Time frame requirements between this service
procedure/ supply and a related service
procedure/supply have not been met.
This decision may be reviewed if additional
documentation as described in the contract or
plan benefit documents is submitted.
Missing/incomplete/invalid height.
Coordination of benefits has not been
calculated when estimating benefits for this
pre-determination. Submit payment
information from the primary payer with the
secondary claim.
Charges are adjusted based on multiple
diagnostic imaging procedure rules.
The number of Days or Units of Service
exceeds our acceptable maximum.
Alert: in the near future we are implementing
new policies/procedures that would affect this
determination.
According to our agreement, you must waive
the deductible and/or coinsurance amounts.
Medicare Initiated
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Not Medicare Initiated
Medicare Initiated
AdminaStar Federal
Code
New, Modified,
Deactivated,
Retired
M16
Modified
MA02
Modified
MA03
Modified
N9
Modified
N34
N207
N355
Modified
Modified
Modified
Current Narrative
Comment
Please see our Web site, mailings, or bulletins
for more details concerning this
policy/procedure/decision.
If you do not agree with this determination,
you have the right to appeal. You must file a
written request for an appeal within 180 days
of the date you receive this notice. Decisions
made by a Quality Improvement Organization
(QIO) must be appealed to that QIO within 60
days.
If you do not agree with the approved amounts
and $100 or more is in dispute (less deductible
and coinsurance), you may ask for a hearing
within six months of the date of this notice. To
meet the $100, you may combine amounts on
other claims that have been denied, including
reopened appeals if you received a revised
decision. You must appeal each claim on time.
Adjustment represents the estimated amount a
previous payer may pay.
Incorrect claim form/format for this service.
Missing/incomplete/invalid weight.
The law permits exceptions to the refund
requirement in two cases: –If you did not
know, and could not have reasonably been
expected to know, that we would not pay for
this service; or –If you notified the patient in
writing before providing the service that you
believed that we were likely to deny the
service, and the patient signed a statement
agreeing to pay for the service. If you come
within either exception, or if you believe the
carrier was wrong in its determination that we
do not pay for this service, you should request
appeal of this determination within 30 days of
the date of this notice. Your request for review
should include any additional information
necessary to support your position. If you
request an appeal within 30 days of receiving
this notice, you may delay refunding the
amount to the patient until you receive the
results of the review. If the review decision is
favorable to you, you do not need to make any
refund. If, however, the review is unfavorable,
the law specifies that you must make the
refund within 15 days of receiving the
unfavorable review decision. The law also
permits you to request an appeal at any time
within 120 days of the date you receive this
notice.
However, an appeal request that is received
more than 30 days after the date of this notice,
does not permit you to delay making the
refund. Regardless of when a review is
Modified effective 11/18/05
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(1)
(2)
AdminaStar Federal
Code
M78
New, Modified,
Deactivated,
Retired
Current Narrative
Deactivated
requested, the patient will be notified that you
have requested one, and will receive a copy of
the determination. The patient has received a
separate notice of this denial decision. The
notice advises that he/she may be entitled to a
refund of any amounts paid, if you should have
known that we would not pay and did not tell
him/her. It also instructs the patient to contact
our office if he/she does not hear anything
about a refund within 30 days.
Missing/incomplete/invalid HCPCS modifier.
Comment
Deactivated effective
5/18/06, consider using
reason code 4
Claim Adjustment Reason Code Changes
Code
New, Modified,
Deactivated,
Retired
190
New
191
New
192(3)
New
182
Modified
B18
Modified
52
Retired
B17
Retired
Current Narrative
Comment
Payment is included in the allowance for a
skilled nursing facility (SNF) qualified stay.
Claim denied because this is not a work related
injury/illness and thus not the liability of the
workers’ compensation carrier.
Non standard adjustment code from paper
remittance advice.
Payment adjusted because the procedure
modifier was invalid on the date of service.
Payment adjusted because this procedure code
and modifier were invalid on the date of
service.
The referring/prescribing/rendering provider is
not eligible to refer/prescribe/order/perform the
service billed.
Payment adjusted because this service was not
prescribed by a physician, not prescribed prior
to delivery, the prescription is incomplete, or
the prescription is not current.
New as of 10/05
New as of 10/05
New as of 10/05
Modified 8/8/05
Modified 8/8/05
Inactive as of 2/1/06
Inactive as of 2/1/06
1
This modification is effective January 1, 2006, and has been communicated in a separate instruction (Change Request
4326).
2
Medicare will not use MA03 effective from January 1, 2006, and that has been communicated in Change Request
4326.
3
This new code was created at the request of Medicare because:
• Providers who do not qualify for Administrative Simplification Compliance Act (ASCA) exemption must submit
claims electronically;
• If Medicare is secondary, and the primary payer has sent a paper remittance advice with proprietary code(s), the
provider could not send a compliant electronic claim unless a crosswalk between the payer proprietary codes and the
standard CARC is available.
In Change Request 4123, Medicare contractors were instructed to complete entry of 192 as a valid code, and accept
claims containing this code for adjudication. CMS encourages providers to utilize this code, and submit COB claims
electronically.
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Reason Codes 1 and 2
In September, CMS requested two new codes to be used in lieu of current reason codes 1 (Deductible) and 2
(Coinsurance amount) when a provider is not allowed to collect any deductible and/or any coinsurance.
Section 630 of the Medicare Modernization Act (MMA) of 2003 permits Indian health service (IHS) facilities to directly
bill Medicare for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Federal government
agencies do not permit providers to collect coinsurance or deductible payments from IHS patients.
The committee did not approve the CMS request for new codes, but suggested that reason codes 1 and 2 should be used
with Group Code CO (Contractual obligation) instead of PR (Patient responsibility). Currently, in most situations Group
Code PR is used with reason codes 1 and 2. Medicare contractors must use Group code CO under this special situation
with codes 1 and 2. (See related Change Request 3845 and the Medlearn Matters article at
www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3845.pdf on the CMS Web site.)
The official instructions (Change Request 4314) issued to your Medicare carrier, fiscal intermediary, DMERC or RHHI
regarding this change can be found at www.cms.hhs.gov/Transmittals/downloads/R859CP.pdf on the CMS Web site.
Remittance Advice Remark Code and Claim Adjustment
Reason Code Update*
Providers, physicians, and suppliers who bill Medicare fiscal intermediaries, including RHHIs and Medicare carriers,
including DMERCs
Key Points
•
Effective December 29, 2005, Remark Code MA02 was updated to reflect the following narrative:
“If you do not agree with this determination, you have the right to appeal. You must file a written request for an
appeal within 180 days of the date you receive this notice. Decisions made by a Quality Improvement Organization
(QIO) must be appealed to that QIO within 60 days.”
•
Within 30 days of release of Change Request 4326, Remark Code MA03 will not be used for Medicare fee-forservice and Medicare will update the current narrative of remark code MA02 in the same timeframe.
•
Please use the text posted on the WPC Web site if there are discrepancies between any code text included in this
article and the corresponding text on the WPC Web site: www.wpc-edi.com/codes.
Background
There are two code sets that must be used to report payment adjustments, appeal rights, and related information for
transaction 835 (Health Care Claim Payment/Advice) and standard paper remittance (SPR) advice. These code sets,
updated on a regular basis, include:
•
•
Claim Adjustment Reason Code, and
Remittance Advice Remark Code
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Additionally, for transaction 837 COB, Claim Adjustment Reason Code must be used.
Change Request 4326 is the official instruction issued to your fiscal intermediary/RHHI or your carrier/DMERC
regarding changes mentioned in this article, MM4326. Change Request 4326 may be found by going to
Quarterly Medicare Summary Notice Printing Cycle*
Related Change Request Release Date: May 12, 2006
Effective Date: Carriers—June 12, DMERCs—July 1, Fiscal Intermediaries—September 1
Implementation Date: Carriers—June 12, DMERCs—July 1, Fiscal Intermediaries—September 1
Physicians, providers, and suppliers submitting claims to Medicare carriers, DMERCs, fiscal intermediaries and/or
RHHIs for services provided to Medicare beneficiaries
Impact on Providers
This article is based on Change Request 5062, which instructs Medicare contractors (carriers, DMERCs, fiscal
intermediaries and RHHIs) to print and mail No-Pay Medicare Summary Notices (MSNs) on a quarterly schedule (rather
than the current monthly schedule).
Background
Current CMS instructions require all Medicare contractors to issue a MSN to each beneficiary for whom a claim was
processed during the last 30 days (possibly for services received more than 30 days ago) to inform the beneficiary of the
disposition of all claims (i.e., a record of services received, the status of any deductibles, and appeal rights).
In an effort to reduce overall operating costs, Change Request 5062 instructs your intermediary/carrier to change from
their current monthly (30 day) No-Pay MSN mailing schedule to a quarterly (90 day) No-Pay MSN mailing schedule.
All MSN information should continue to print; however, summations will occur on a quarterly basis as opposed to a
monthly basis.
Note: No-Pay MSNs are the standard, system-generated MSNs produced for beneficiaries in which Medicare did not
issue payment to the beneficiary for the respective claim. Beneficiaries often need these MSNs in order to obtain
payment from another payer/insurer.
In those situations where a No-Pay MSN is needed or lost by a beneficiary, they can request a No-Pay MSN by calling
1-800 MEDICARE. On-demand requests will be generated and mailed once the request is made.
In summary, Change Request 5062 provides the following instructions:
•
•
•
Beginning no later than October 1, 2006, Medicare contractors will issue No-Pay MSNs on a quarterly/90-day
mailing cycle as opposed to the previous monthly/30-day mailing cycle;
MSNs with checks will continue to be mailed out as processed; and
If a beneficiary requests a monthly No-Pay MSN (as opposed to the quarterly MSN), then Medicare contractors
must generate and mail out the MSN at the time of the request.
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Implementation
The implementation date for the instruction is June 12, 2006, for carriers, July 1, 2006, for DMERCs, and September 1,
2006 for fiscal intermediaries.
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That
instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R945CP.pdf on the CMS Web site.
Appeals
MMA—Changes to Chapter 29—Appeals of Claims Decisions:
Administrative Law Judge; Departmental Appeals Board; U.S.
District Court Review*
Physicians, providers and suppliers who submit Part A or Part B fee-for-service claims to Medicare for services
Background
The Medicare claim appeals process was amended by the Medicare, Medicaid and SCHIP Benefits Improvement and
Protection Act (BIPA) of 2000. Section 1869(c) of the Social Security Act (the Act), as amended by BIPA, requires a
new second level in the administrative appeals process called a reconsideration. It is different from the previous first
level of appeal for Part A claims performed by fiscal intermediaries. Reconsiderations will be processed by Qualified
Independent Contractors (QICs).
The purpose of this article is to notify you about changes to the manual provisions that address Administrative Law
Judge, Departmental Appeals Board and U.S District Court review levels of appeal.
Key Points
Administrative Law Judge—The Third Level of Appeal
Parties to an appeal who are not satisfied with decisions made by the QIC at the second level of appeal (reconsideration),
have the right to request an Administrative Law Judge (ALJ) hearing as long as all of the ALJ hearing request
requirements are met (see Centers for Medicare & Medicaid Services [CMS] Internet-Only Manual [IOM] Publication
100-04, Medicare Claims Processing manual, chapter 29, section 330 for details). Outlined below is some pertinent
information about the ALJ level of the appeal process.
ALJ Hearing Amount in Controversy
Parties requesting an ALJ hearing must meet the amount in controversy requirements:
•
The amount remaining in controversy requirement for requests made before January 1, 2006 is $100.
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•
•
The amount remaining in controversy will increase to $110 for requests made on or after January 1, 2006.
Beginning in 2005, for requests made for an ALJ hearing or judicial court review, the dollar amount in controversy
requirement will increase by the percentage increase in the medical care component of the consumer price index for
all urban consumers (U.S. city average) for July 2003 to the July preceding the year involved. Any amount that is
not a multiple of $10 will be rounded to the nearest multiple of $10.
Time Limits and Responsibilities
Decisions: The official ALJ decision is a signed copy of the ALJ decision. When issuing decisions, the ALJ will either:
•
•
Issue a decision based on the request for ALJ hearing; or
Issue an order of dismissal of the appellant’s request for ALJ hearing.
Effectuation (No Agency Referral): Often, the ALJ’s decision will require an effectuation action (payment of the
claim) on the Medicare contractor’s part. Contractors will effectuate ALJ decisions within 30 days of the receipt of the
official ALJ decision if:
•
•
•
The decision is partially or wholly favorable
The decision gives a specific amount to be paid, and
There is no agency referral to the Departmental Appeals Board (DAB)
Computation of the Amount (No Agency Referral): If the amount must be computed by the Medicare contractor, the
decision must be effectuated within 30 days after the contractor computes the amount to be paid to the appellant. The
computation should be done as soon as possible, but no later than 30 calendar days of the date of receipt of the official
ALJ decision or effectuation notice.
Clarification (No Agency Referral): If clarification from the ALJ is necessary, then the date of the clarification is
considered to be the final determination for purposes of effectuation.
If clarification is needed from the physician/supplier (e.g., splitting charges), this clarification should be requested as
soon as possible and the amount payable should be computed within 30 calendar days after the receipt of the necessary
clarification. The date of receipt of the clarification is considered to be the final determination for purposes of
effectuation.
Departmental Appeals Board—The Fourth Level of Appeal
The DAB evaluates requests for review, and makes final decisions whether to review, or to decline to review, decisions
of ALJs as well as orders of dismissal by ALJs.
DAB Effectuation Time Limits: DAB decisions requiring contractor effectuation must be initiated within 30 days of
receipt of a DAB decision. Effectuation must be completed within 60 days.
U.S. District Court—The Fifth Level of Appeal
A party may request court review of the DAB’s decision. Medicare contractors are not responsible for reviewing ALJ
decisions issued by the Department of Health and Human Services ALJs to determine if an agency referral is
appropriate, and will not accept a request for U.S District Court review by a party.
Relevant Links
The official instruction issued to your fiscal intermediary (including regional home health intermediaries [RHHIs]), or
carrier (including durable medical equipment regional carriers [DMERCs]), regarding this change may be found by
going to www.cms.hhs.gov/Transmittals/downloads/R862CP.pdf on the CMS Web site. The new sections of chapter 29
of the CMS IOM Publication 100-04, Medicare Claims Processing manual are attached to Change Request 4152.
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Department Updates
New Hours of Operation for the Region B DMERC Customer
Service Unit Effective March 6, 2006
Effective Monday, March 6, 2006, the hours of operation for Region B DMERC Customer Service Unit have been
changed to 8:00 a.m.–4:00 p.m. Eastern Time (ET).
Effective with this change, the customer service representatives will not be available after 4:00 p.m. However, the
Interactive Voice Response (IVR) Unit is available daily 6:00 a.m.–7:00 p.m.
Source: CMS Joint Signature Memorandum 06-310
Reminder: Immediate Offset Requests
Due to an increased volume in immediate offset requests, suppliers may experience difficulty in getting through to the
Payment Correction Unit (PCU) fax line. The Durable Medical Equipment Regional Carrier (DMERC) Customer
Service Unit has currently been advising suppliers to mail in their immediate offset request forms in the event the fax
line is busy. However, by submitting a request for immediate offset by mail, suppliers are causing a delay in the
process—thus defeating the intended use of the form. AdminaStar Federal is currently researching options to obtain an
additional fax line to accept the increased volume in immediate offset requests.
By following a few simple suggestions, suppliers can help both themselves and the PCU ensure receivables are offset
immediately, as intended.
•
The fewest number of fax requests are received between 6:00 p.m. and 8:00 a.m. Eastern Time (ET). This is usually
the best time to call.
•
A request for immediate offset may be submitted via fax at 317-913-6164 or by mail. However, if the request is
submitted via mail, it does not guarantee that interest will not accrue. Please use the following address to submit
immediate offset requests by mail:
Payment Correction Unit:
PCU–DMERC–Indiana
Lockbox #660078
Indianapolis, Indiana 46266-0078
•
Secure all pertinent information prior to completing the immediate offset request. This includes:
−
−
−
−
•
Supplier number
Patient specific information (i.e., health insurance claim number [HICN], date[s] of service, unit[s] of service,
claim control number[s])
HCPCS
Document control number from initial demand letter (if applicable)
Suppliers are encouraged to include a copy of their initial demand letter with the fax request to ensure the correct
receivable is placed into offset.
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Reminder: Voluntary Refund Checks Submitted to Incorrect
DMERC Regions
AdminaStar Federal has received multiple high dollar voluntary refund checks from suppliers for claims that have been
processed by other DMERCs. The CMS Internet-Only Manual (IOM) Publication 100-06, Medicare Financial
Management manual instructs all Medicare contractors to deposit unsolicited voluntary refund checks from providers,
physicians and suppliers within 24-hours of receipt. Voluntary refund checks received for claims that have not been
processed by the Region B DMERC will be deposited and a miscellaneous check will be sent to the appropriate
Medicare contractor who processed the claim. This will cause a delay in the posting of checks, which could cause
interest to accrue. Providers are encouraged to cross check their remittance advice and patient account records with
overpayments to ensure that voluntary checks are being submitted to the appropriate DMERC for reimbursement.
Voluntary Refund Clarification
The PCU has identified a trend where suppliers are submitting voluntary refund forms with incomplete or insufficient
information to process the refund. Voluntary refunds are being submitted with statements such as “Overpayment,”
“Deceased,” or “Bene didn’t receive.” The above referenced statements are too vague for the PCU to determine how the
particular claim(s) or date(s) of service should be adjusted.
It is imperative that suppliers complete all fields on the voluntary refund form to ensure the claim is adjudicated
accordingly. Additionally, if the supplier would like for the identified overpayment to be offset immediately, the
immediate offset request fax form must also be completed. Both the offset by fax and voluntary refund form must be
faxed to the PCU to ensure that all pertinent information is captured to process the overpayment identified by the
supplier and the immediate offset request. A request for immediate offset may be submitted via fax to: 317-913-6164, or
by mail. However, if the immediate offset request is submitted via mail, it does not guarantee that interest will not
accrue. Please use the following address to submit immediate offset requests by mail:
Payment Correction Unit:
Lockbox #660078
In situations where the voluntary refund form is not clear, the money will be applied to the receivable. However, no
appeals rights will be forwarded.
Note: More than one patient or date of service may be requested at a time. However, suppliers must be specific in their
request by including the HICN, claim control number, date of service, HCPCS and units and service for each patient, and
their date of service.
Electronic Data Interchange
E-Commerce Connection
The April 2006 issue of the E-Commerce Connection—AdminaStar Federal’s electronic data interchange (EDI) online
newsletter—is available at www.adminastar.com/Providers/EDI/DMERC/ECommerceConnection.html
This newsletter, created by the E-Commerce Consultants, is published on a quarterly basis to make EDI information
readily available for EDI submitters, software vendors, billing services and clearinghouses. Every E-Commerce
Connection issue contains useful tips on how to resolve electronic billing issues, up to date information regarding
HIPAA and EDI, AdminaStar Federal’s software products, an opportunity to meet an EDI associate and much more!
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Because AdminaStar Federal values the opinions of its customers, a Feedback Survey is also included in each issue. This
survey gives suppliers the opportunity to comment and make suggestions for future issues. The next E-Commerce
Connection is scheduled for July 2006.
Download your copy today—available in .HTML and .PDF formats.
It is the goal of the E-Commerce Consultants to enhance the lines of communication between AdminaStar Federal and
its EDI customers.
Stage 1 Use and Editing of National Provider Identifier Numbers
Received in Electronic Data Interchange Transactions, via
Direct Data Entry Screens, or Paper Claim Forms*
Implementation Date: January 3, 2006
Physicians, providers, and suppliers who submit claims to Medicare carriers, including durable medical equipment
regional carriers (DMERCs), fiscal intermediaries and regional home health intermediaries (RHHIs)
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires issuance of a unique national
provider identifier (NPI) to each physician, supplier and other provider of health care (45 CFR Part 162, Subpart D
(162.402-162.414).
To comply with this requirement, the Centers for Medicare & Medicaid Services (CMS) began accepting applications
for and issuing National Provider Identifiers (NPIs) on May 23, 2005. Applications can be made by mail, and online at
https://nppes.cms.hhs.gov on the CMS Web site.
CMS has endorsed the Workgroup for Electronic Data Interchange (WEDI) Dual NPI-Legacy Identifier strategy for
cross-health care industry implementation of the NPI.
The Dual Use of NPI & Legacy Identifiers paper is available at www.wedi.org/snip/public/articles/. (Once at the site,
scroll down and look for the paper issued on 01/22/2006.)
The remainder of this article describes CMS’ current plans for a staged process leading to full implementation of the
adoption of the NPI in Medicare transactions involving providers.
Background
Implementation involves acceptance and processing of transactions that use the NPI in lieu of the previously used
OSCAR, UPIN, PIN and National Supplier Clearinghouse (NSC) numbers. The WEDI strategy provides for four stages
during which system change schedules of trading partners will occur independently of each other.
Medicare fee-for-service transaction implementation for NPI will occur in the following stages.
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Stage 1 (January 1, 2006–October 1, 2006)
During this stage, the NPI will be accepted on inbound claims, other than National Council for Prescription Drug
Program (NCPDP) claims, and other transactions but will not be used for Medicare processing. Change Request 4320
focuses primarily on Stage 1 of the NPI implementation process. During stage 1:
•
The “Legacy Identifier” (pre-NPI provider identifiers) will be used to identify providers while Medicare carriers,
DMERCs, and intermediaries make sure that X12 837, version 4010A1 claims and other X12 HIPAA adopted
transactions are not rejected due to the presence of an NPI.
(Transactions may be submitted with or without an NPI during stage 1, as long as the Medicare legacy identifier is
still reported.)
•
Additionally, NPIs will be edited to verify that they meet basic structure requirements established for NPIs.
•
Medicare will allow NPIs on the X12 270 version 4010A1 eligibility inquiry and the 276 claim status inquiry and
return them in the respective X12 271 or 277 response, as long as the legacy identifier is also reported in the 270 or
the 276.
•
NPIs, as well as legacy identifiers, will be reported in coordination of benefit claims sent to trading partners when
submitted on claims submitted to Medicare.
•
NPIs will not be reported in the following outbound transactions during Stage 1, even if an NPI was submitted on
related claims:
−
−
•
X12 835 claims; or
SPRs (standard paper remittance) formats
Medicare carriers, DMERCs, and intermediaries must reject the following transactions if submitted with NPIs, since
it is not possible to report both NPIs and legacy identifiers for providers in these transactions:
−
−
−
−
NCPDP claims
DDE claims, claim status and eligibility inquiries
UB-92 (CMS-1450) paper claims (the National Uniform Billing Committee [NUBC] announced that the use
of the UB-04, which is able to report the NPI and a legacy identifier for each provider involved with a claim,
will begin March 1, 2007, and that May 22, 2007, is the last day that a payer should accept a UB-92 form).
Since it is not possible to report both a legacy identifier and an NPI on the UB-92, submitters of the UB-92 will
be limited to reporting of their legacy identifier on those claims, and
CMS-1500 paper claims until the National Uniform Claim Committee (NUCC) implements a revised 1500
and CMS announces its implementation of that revised form
The NUCC has approved a revised CMS-1500 form and has announced that payers should begin to accept the
revised form effective October 1, 2006. Between October 1, 2006, and January 31, 2007, payers should accept either
the current or the revised CMS-1500 form. Effective February 1, 2007, and later, payers should accept only the
revised CMS-1500 form. Both the NPI and the legacy identifier can be reported on the revised CMS-1500 form, but
not on the form currently in use. Until a provider begins to use the revised form, that provider will be limited to
submission of legacy identifiers on the non-revised CMS-1500 form.
Stage 2: (October 2, 2006–May 22, 2007)
During this stage:
•
Providers, clearinghouses, and billing services will be directed to provide a Medicare legacy identifier as a
secondary identifier when NPIs are submitted as the primary provider identifiers in their X12 837 claims.
•
The legacy identifier alone can still be used to identify those providers that have not yet obtained an NPI.
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•
The transitional Dual NPI-Legacy Identifier Strategy includes the development of a crosswalk between Medicare
legacy numbers and their associated NPIs. The crosswalk should help Medicare validate most NPIs to ascertain that
they were actually issued to the providers for which reported, and will help to identify transcription errors in a
reported NPI. The crosswalk will begin operating at the onset of stage 2.
•
If you use free billing software supplied by your carrier, DMERC, or fiscal intermediary/RHHI, it will be modified
for stage 2 to permit reporting of your NPI, once received, and your legacy Medicare provider identifier. You will
need to download the new version of the software when notified it is available.
The 835 PC-Print and Easy Print software for printing of remittances will also be updated for stage 2 to permit
reporting of NPIs as well as legacy numbers when both are reported in an 835 transaction. Be sure to download the
new version of that software when notified it is available.
•
DDE screens will be modified for this stage to accept and return both NPIs, when available, and legacy identifiers.
•
NPIs, when available in Medicare provider files, as well as legacy identifiers will be returned in 835 transactions
and SPRs during stage 2.
Stage 3 (May 23, 2007–and Later)
Stage 3 involves the transition to full use of the NPI for acceptance and processing of transactions, except for
coordination of benefits (COB) claims that Medicare sends to small trading partners.
•
HIPAA prohibits the reporting of any provider legacy identifiers to other than small health plans during this period
(e.g., plans with less than $5 million in annual receipts).
•
All claims, including NCPDP claims, and 270, 276 and 277 attachment transactions sent to Medicare, must contain
the NPI in lieu of the legacy identifier (please see Stage 4 below regarding claims). Those that do not are to be
rejected.
•
Legacy identifiers will no longer be sent to COB trading partners or on outbound electronic or paper Medicare
transactions or correspondence.
Stage 4 (May 23, 2007–May 22, 2008)
Stage 4 involves completion of transition to the full use of NPI by all small trading partners. NPIs, rather than legacy
identifiers, will be reported in all 837, version 4010A COB and NCPDP claims sent to small trading partners.
Change Request 4320 is the official instruction issued to your fiscal Intermediary, including RHHI, or carrier, including
DMERC, regarding changes mentioned in this article. Change Request 4320 can be found at
www.cms.hhs.gov/Transmittals/downloads/R204OTN.pdf on the CMS Web site.
You may also want to review Medlearn Matters Special Edition SE0555, concerning the NPI. That article is available at
www.cms.hhs.gov/MedlearnMattersArticles/downloads/SE0555.pdf on the CMS Web site.
National Provider Identifier Tip
When applying for an NPI, CMS urges providers/suppliers to include their legacy identifiers, not only for Medicare—
but for all payers. If reporting a Medicaid number, include the associated state name. This information is critical for
payers in the development of crosswalks to aid in the transition to the NPI
CMS has released three new educational products on the NPI:
•
“Guidance for Organization Health Care Providers Who Apply for National Provider Identifiers (NPIs) for
Their Health Care Provider Employees” Tip Sheet: Contains helpful information for organization health care
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•
•
providers who wish to apply for NPIs, or submit updates using the NPPES Web-based process, on behalf of their
employed health care providers. This is not the electronic file interchange (EFI) process.
“Tips for Health Care Professionals—Preparing Your Office Staff for NPI” Tip Sheet: Provides basic steps to
prepare your office staff, and your business, for NPI implementation.
“NPI Overview” PowerPoint Presentation: Provides basic information on the NPI that is suitable for selfeducation, as well as training purposes. CMS gave this presentation at a recent WEDI meeting.
To view these new products, visit the Educational Resources page on the CMS NPI Web site at
www.cms.hhs.gov/NationalProvIdentStand/04_education.asp
Source: CMS Joint Signature Memorandum 06-403
National Council for Prescription Drug Program Coordination
of Benefits Workaround Instructions*
Suppliers who submit claims to Medicare DMERCs for prescription drugs provided to Medicare beneficiaries that are
also sent to other Medicare trading partners for COB.
Background
Certain Medicare trading partners cannot accept the NCPDP version 5.1 batch standard 1.1 for COB crossover purposes
due to missing data elements within the transaction. Change Request 4290 contains workaround instructions that provide
current trading partners with the data elements in the NCPDP version 5.1 batch standard 1.1 for COB crossover
purposes. This will enable affected supplier claims to be processed by these trading partners.
Key Points
The following information is important for trading partners regarding the NCPDP version 5.1 batch standard 1.1 for
COB crossover purposes:
•
•
•
•
Drugs will always be paid as mandatory assignment.
Health Insurance Claim (HIC) numbers will always be passed in the “Patient ID” field (332-CY) with a “99”
(Other) qualifier in the Patient ID Qualifier field (331-CX).
For non-claim based Medigap crossovers, the “Cardholder ID” field (302-C2) in the “Insurance Segment” will
contain the beneficiary’s policy number as submitted on the carriers eligibility file.
When the “Patient Location” field (307-C7) is not “1” (Home), the supplier name and address will be populated in
lieu of the facility name and address in the 500-byte-free formatted field.
Change Request 4290 is the official instruction issued to your DMERC regarding this change. Change Request 4290
may be found by going to www.cms.hhs.gov/MedlearnMattersArticles/2005MMA/List.asp on the CMS Web site.
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2005 Revised American National Standards Institute X12N
837 Professional Health Care Claim Companion Document*
Effective Date: March 24, 2006
Physicians and suppliers who submit electronic X12N 837 claim forms to Medicare carriers, including DMERCs
Key Points
The CMS is updating the current inbound 837 professional companion document to provide revisions, correct errors and
implement additional language to cover the new NPI.
This companion document, which is attached to Change Request 4260, supplements (but does not contradict) the X12N
837 Professional Implementation Guide and clarifies Medicare carrier and DMERC expectations regarding data/claim
submission, processing, and adjudication. The revised companion guide will be available through your Medicare carrier
and DMERC via their newsletter, Web site and and/or Listserv postings.
Background
The most important changes to the X12N 837 professional health care claim companion document clarify the specific
processing or adjudication of the X12 837, and include the following.
Additions
•
•
•
New NPI information statement – “The National Provider Identifier (NPI) must be submitted in the NM109 segment
(NM108 = XX)”
Revised taxonomy code set statement for an updated Washington Publishing Company (WPC) URL, which is
www.wpc-edi.com/codes/taxonomy
New “Application Receiver Code” title to GS03 statement
Corrections/Clarifications
•
•
•
Corrected qualifier statement to show that only valid qualifiers may be submitted and qualifiers submitted for
Medicare processing that are not defined for use by Medicare could result in claim/transaction rejection
Correction of the SV104 anesthesia value statement—changing “units” to “minutes” and correcting the
Implementation Guide page reference from “400” to “403”
Clarification of the SV104 and PS102 language to show that negative values submitted in these fields could result in
claim rejection
Please note the following message, which will be included in the revised X12N 837 companion document:
“The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicare, and all other health
insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of
Health and Human Services. The X12N 837 implementation guides have been established as the standards of
compliance for submission of claims for all services, supplies, equipment, and health care other than retail pharmacy
prescription drug claims. The implementation guides for each X12 transaction adopted as a HIPAA standard are
available electronically at http://www.wpc-edi.com. This companion document supplements, but does not contradict
any requirements in the X12N 837 Professional Implementation Guide.”
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Relevant Links
Change Request 4260 is the official instruction issued to your carrier, including your DMERC, regarding this change.
Change Request 4260 may be found by going to www.cms.hhs.gov/Transmittals/downloads/R871CP.pdf on the CMS
Web site.
Medicare to Stop Mailing Standard Paper Remittance for
Those Providers/Suppliers Also Receiving the Electronic
Remittance Advice
Beginning June 1, 2006, the SPR received through the mail will no longer be available to providers/suppliers who also
receive an ERA, whether the ERA is received directly or through a billing agent, clearing house or other entity
representing a provider/supplier.
In response to the provider/supplier communities continued need for the SPR advice, the CMS has developed a free
software program called Medicare Remit Easy Print (MREP) that gives providers/suppliers a tool to read and print a
remittance advice from the HIPAA-compliant Health Care Claim Payment/Advice (835) file. The MREP software was
designed to incorporate new functionality to save providers/suppliers time and money. The paper output generated by
MREP is similar to the SPR format. The CMS has worked with other payers to insure their acceptance of the SPR
generated by the MREP software for COB claim submission. Additionally, CMS has worked with clearinghouses to
assure similar software is available to read and print an ERA for those providers/suppliers that utilize clearinghouse
services.
Providers/suppliers currently receiving the ERA who do not use software to read and print the remittance advice from
these files are encouraged to begin using MREP (or other similar software) before the June 1st cutoff. Please go to
www.adminastar.com/Providers/EDI/EDI.html for further information regarding MREP software.
CMS appreciates the continued cooperation of the supplier community as the Medicare program moves toward a more
electronic environment.
Suppression of Standard Paper Remittance Advice to
Providers and Suppliers Also Receiving Electronic Remittance
Advice for 45 Days or More*
Implementation Date: June 1, 2006
All Medicare providers, physicians, suppliers and qualified nonphysician practitioners billing Medicare carriers
and DMERCs
Change Request 4376 provides notice that beginning June 1, 2006, carriers and DMERCs will stop SPR advices to you
(or a billing agent, clearinghouse, or other entity representing you) if you have been receiving 835s or electronic
remittance advice (ERA) transactions, either directly or through a billing agent, clearinghouse, or other entity
representing you, for 45 days or more.
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If you need a paper copy of a remittance advice for accounts reconciliation or to forward to secondary/tertiary payers, be
aware that the CMS has developed software that gives you a tool to view and print an 835 in a readable format locally on
your computer. This software is called Medicare Remit Easy Print (MREP). See the Additional Information section of
this article to learn how to access MREP software. Your clearinghouse may also offer software that allows you to view
and print your remittance advice.
Make certain that your billing staffs are aware of these changes. Try MREP software to view and print your own
remittance and see the benefits for yourself. Or, check with your clearinghouse to see if it provides similar software.
Background
The CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing manual, chapter 22, section
40.1 (Remittance Advice), describes the instructions issued by CMS to carriers and DMERCs.
The section instructs carriers and DMERCs to eliminate SPRs to those providers/suppliers who were receiving ERA
transactions for 45 days or more.
MREP was developed in response to comments CMS received from the provider/supplier community that they need a
paper document for accounts reconciliation, and claim submission for secondary/tertiary payments. Providers/suppliers
who use the MREP software package have the ability to print paper remittances and reports that can be used to reconcile
accounts receivable, as well as to create document(s) that can be included with claim submissions to secondary/tertiary
payers. The output of MREP is similar to the current SPR format.
Benefits of using MREP software include the ability to:
Save Time and Money
You can print remittance information directly from your computer the day the HIPAA 835 is available. No more time is
spent waiting for the mail.
Create and Print Special Reports
With MREP, you can run, export, or print several useful reports including:
•
•
•
Deductible Service Lines Report: Shows claim service lines that have deductible amount.
Adjusted Service Lines Report: Shows claims within a single remittance that have a claim status 22 (reversed
claim).
Denied Service Lines Report: Shows only claim service lines that have an allowed amount of zero and are
associated with a claim that does not have a claim status 22 (reversed claim).
Print and Forward Claims for Other Payers
MREP provides the ability to print remittance information for individual or multiple selected claims, and it allows you to
forward only those claims that are needed by other payers for secondary payment. You may view and/or print as many or
as few claims as needed. This eliminates the need for you to darken individually identifiable data on the SPR, as you
may do today, that does not pertain to the claim for which you are requesting payment.
Navigate and View Remittance Information
MREP organizes and presents information in a manner that makes it easy for you to view. It also provides separate tabs
to access the following:
•
•
•
•
A list of claims
Details for individually selected claims
Summary information
Glossary information containing CARCs, RARCs and their definitions
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•
•
A data view that allows you to look at the various loops and segments containing data in the HIPAA 835, and
A search function to find claims containing specific information
Note: MREP software will be revised three times per year to accommodate Claim Adjustment Reason and Remittance
Advice Remark Code set changes. You can sign up to be notified automatically when a new version of MREP is
available at your carrier’s/DMERC’s Web site.
Search for Claim(s) Information Quickly and Easily
MREP’s search function can help you find a claim (or multiple claims) based on your customized search criteria. Using
it, you can search by names, numbers, and even portions of information such as:
•
•
•
•
•
•
•
Health Insurance Claim Number (HICN)
Beneficiary last name
Internal Control Number (ICN)
Beneficiary account number
Procedure code
Service date, and
Rendering provider number
Note: MREP’s search capability provides a powerful way to save time and money when examining remittance
information.
Eliminate Need for Physical Filing and Storage Space
MREP software imports a HIPAA 835 (once you have received it from your carrier/DMERC) and saves the information
as a separate Import file to help ensure that the original HIPAA 835 file remains intact.
It also provides an easy-to-use method to archive, restore, and delete these Import files as you maintain your remittance
records (further reducing the need for physical filing of printed copies and additional storage space).
As you gain familiarity with the MREP software, you will be able to take advantage of the numerous keystroke shortcuts
designed to streamline use of the software and save you time while viewing your remittance information.
Implementation
The implementation date for this instruction is June 1, 2006.
To learn about more MREP benefits, download the brochure available at
www.cms.hhs.gov/MLNProducts/downloads/remit_easy_print.pdf on the CMS Web site. Or, you can view Special
Edition Medlearn Matters article SE0611 at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0611.pdf on the
CMS Web site.
For more information about the MREP software and how to receive the HIPAA 835, please contact your
carrier/DMERC. Medicare Part B EDI helpline phone numbers are available at
www.cms.hhs.gov/ElectronicBillingEDITrans/ on the CMS Web site.
The official instructions issued to your carrier/DMERC regarding this change can be found at
www.cms.hhs.gov/transmittals/downloads/R885CP.pdf on the CMS Web site.
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Options for Providers/Suppliers Affected by Change Request
4376: Suppression of Standard Paper Remittance Advice to
Providers and Suppliers Also Receiving Electronic Remittance
Advice for 45 Days or More*
Physicians, suppliers, qualified nonphysician practitioners, and other providers billing Medicare carriers, including
DMERCs
This Special Edition reminds providers that as of June 1, 2006, if you have been receiving both an ERA, either directly
from your Medicare carrier/DMERC or indirectly from a clearinghouse, billing agent, or other entity representing you,
and a SPR from your carrier/DMERC for 45 days or more, that you will no longer be mailed an SPR by your
carrier/DMERC, in accordance with Change Request 4376. This article outlines some of the options available to
providers who will no longer receive the SPR directly from their carrier/DMERC.
Are you receiving an ERA? Make sure you know if and how you receive the ERA. You may be receiving your ERA
directly from your carrier/DMERC or you may be receiving your ERA indirectly through a billing agent, clearinghouse,
or other entity representing you. No matter how you receive your ERA, if you are also receiving an SPR from your
carrier/DMERC in addition to receiving an ERA for 45 days or more, after June 1, 2006, your carrier/DMERC will no
longer mail you an SPR. If you still need both, take appropriate action now.
If you need the SPR, take action now so you can avoid any business disruption associated with the June 1, 2006, cutoff
of the SPR. If your clearinghouse, billing agent, or other entity cannot offer a way (e.g., print software) for you to
receive or generate a paper remittance, it may be beneficial to explore other options.
Determine Which of the Following Scenarios Represents Your Situation:
1.
You are receiving the ERA directly from your carrier in the HIPAA-compliant 835 format: Use the MREP
software.1 MREP requires that you import ERAs in the HIPAA-compliant 835 format. (See the Additional
Information section of this article for further information.) MREP is free software that allows you to:
•
•
•
•
•
•
•
2.
Print the ERA for individual or multiple selected claims in a format mirroring the SPR, so you can forward your
remittance to secondary/tertiary payers
Easily navigate and view remittance information
Quickly access claim information
Print and export useful reports about ERAs including denied, adjusted, and deductible service lines
Receive the latest version of Claim Adjustment Reason and Remittance Advice Remark Code sets, three times
a year
Archive, restore, and delete imported ERAs, and
Eliminate physical filing and storage space needs
You are receiving a HIPAA-compliant 835 from a billing agent, clearinghouse, or other entity: Use MREP or
software offered by the billing agent, clearinghouse, or other entity representing you to view and print your paper
remittance advice.
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3.
You are receiving the ERA directly in a format that is not the HIPAA-compliant 835 format: Transition to the
HIPAA-compliant 835 format now, so you can begin using MREP. CMS ended the contingency plan for nonHIPAA claims, i.e., 837 transaction, in 2005. CMS will be ending the contingency plan for the non-HIPAA
remittance advice, i.e., the 835, next.
4.
You are receiving an ERA that is not the HIPAA-compliant 835 format from your billing agent,
clearinghouse, or other entity representing you and they do not offer software or other means that allows you
to view and print your remittance advice: Work with them so that they will send you a HIPAA-compliant 835, so
you can use MREP.
5.
You have a need for the paper remittance advice and your clearinghouse, billing agent, or other entity
representing you is receiving the ERA on your behalf, but does not currently forward the ERA to you: Work
with your clearinghouse, billing agent, or other entity to receive the ERA and use MREP. This may be your situation
if the clearinghouse, billing agent, or other entity representing you receives the ERA for you, but until now there has
been no business reason to forward the ERA to you.
1
This software was developed by the CMS for use by Medicare providers/suppliers to view and print a HIPAAcompliant Medicare 835. Medicare has no liability and takes no responsibility for any other use of this software.
Background
CMS has an initiative for moving to a more electronic transaction environment and reducing the cost associated with
producing and mailing the paper remittances sent by CMS contractors. The CMS IOM Publication 100-04, Medicare
Claims Processing manual, chapter 22, section 40.1 (Remittance Advice), describes the instructions issued by CMS to
carriers and DMERCs. The section instructs carriers and DMERCs to eliminate SPRs to those providers/suppliers who
were receiving ERA transactions for 45 days or more.
Implementation
The implementation date is June 1, 2006.
To learn about more MREP benefits, download the brochure available at
www.cms.hhs.gov/MLNProducts/downloads/remit_easy_print.pdf on the CMS Web site. Or, you can view Special Edition
MLN Matters article SE0611 at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0611.pdf, or a related MLN Matters
article (MM4376) at www.cms.hhs.gov/MLNMattersArticles/downloads/MM4376.pdf on the CMS Web site.
carrier/DMERC. Medicare Part B EDI helpline phone numbers are available at
www.cms.hhs.gov/ElectronicBillingEDITrans/ on the CMS Web site.
Medicare Remit Easy Print Software*
Medlearn Matters Number: SE0611
Providers, physicians, suppliers, and qualified nonphysician practitioners billing Medicare carriers, including DMERCs
This Special Edition provides an overview of the new Medicare Remit Easy Print (MREP) software developed by the
CMS, which is now available for you to view and print the HIPAA compliant ERA.
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With the new MREP software, you can view and print as many or as few claims as needed. This is especially helpful
when you need to print only one claim from the remittance advice when forwarding the claim to a secondary payer.
See the Background section of this article for further details regarding this free software.
Background
In June 2005, CMS announced to carriers (including DMERCs) their remittance advice Initiative, which included plans
to reduce the number of SPRs printed and mailed, as well as increase usage of the ERA.
Medicare Remit Easy Print Software
As part of the Remittance Advice Initiative, CMS developed MREP software to enable physicians and suppliers to read
and print the HIPAA-compliant ERA (also known as Transaction 835 or “the 835”).
MREP software uses the ERA file that is sent to you by your carrier/DMERC in the HIPAA-compliant 835 format.1
Other electronic formats cannot be used.2
With the new MREP software, you will be able to:
•
•
•
•
•
Navigate and view the ERA using your personal computer
Search and find ERA/claims information easily
Print the ERA in the SPR format
Print and export reports about ERAs including denied, adjusted and deductible applied claims, and
Archive, restore, and delete imported ERAs
To utilize the MREP software, you will need to receive a HIPAA-compliant ERA (HIPAA 835). Contact your
carrier/DMERC to find out more about MREP and/or for information on how to receive HIPAA compliant ERAs.
Note: MREP software will be revised three times per year to accommodate Claim Adjustment Reason and Remittance
Advice Remark Code set changes. You can sign up to be notified automatically when a new version of MREP is
available at your carrier’s/DMERC’s Web site.
1
Beginning October 1, 2005, new Medicare contractors are called Medicare administrative contractors (MACs). Also,
from October 2004 through October 2011, all existing fiscal intermediaries and carrier contracts will be transitioned into
MAC contracts, using competitive procedures. Providers may access the most current Medicare Contracting Reform
information to determine the impact of these changes at www.cms.hhs.gov/MedicareContractingReform/ on the CMS
Web site.
2
CMS plans to end the use of other formats soon.
Availability and Cost
MREP software can save you time resolving Medicare claim issues, and it provides features unavailable with the SPR.
MREP is available to you free-of-charge, and further information on the software (including how to obtain a free copy)
is available at your carrier’s or DMERC’s Web site.
Benefits o f Using MREP Soft ware
1. Save Time and Money
You can print remittance information directly from your computer the day the HIPAA 835 is available. No more time is
spent waiting for the mail!
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2. Create and Print Special Reports
With MREP, you can run several useful reports including:
•
•
•
Deductible Service Lines Report: Shows claim service lines that have a deductible amount.
Adjusted Service Lines Report: Shows claims within a single remittance that have a claim status 22 (reversed
claim).
Denied Service Lines Report: Shows only claim service lines that have an allowed amount of zero and are
associated with a claim that does not have a claim status 22 (reversed claim).
3. Print and Forward Claims for Other Payers
MREP provides the ability to print remittance information for individual or multiple selected claims, and it allows you to
forward only those claims that are needed by other payers for secondary payment. You may view and/or print as many or
as few claims as needed. This eliminates the need for you to darken individually identifiable data on the SPR, as you
may do today, that does not pertain to the claim for which you are requesting payment.
4. Navigate and View Remittance Information
MREP organizes and presents information in a manner that makes it easy for you to view. It also provides separate tabs
to access the following:
•
•
•
•
•
•
A list of claims
Details for individually selected claims
Summary information
Glossary information containing Claim Adjustment Reason Codes, Remittance Advice Remark Codes, and their
definitions
A data view that allows you to look at the various loops and segments containing data in the HIPAA 835, and
A search function to find claims containing specific information
5. Search for Claim(s) Information Quickly and Easily
MREP’s search function can help you find a claim (or multiple claims) based on your customized search criteria. Using
it, you can search by names, numbers, and even portions of information such as:
•
•
•
•
•
•
•
HICN
Beneficiary last name
ICN
Beneficiary account number
Procedure code
Service date, and
Rendering provider number
Note: MREP’s search capability provides a powerful way to save time and money when examining remittance
information.
6. Eliminate Need for Physical Filing and Storage Space
MREP software imports a HIPAA 835 (once you have received it from your carrier/DMERC) and saves the information
as a separate Import file to help ensure that the original HIPAA 835 file remains intact.
It also provides an easy-to-use method to archive, restore, and delete these Import files as you maintain your remittance
records (further reducing the need for physical filing of printed copies and additional storage space).
As you gain familiarity with the MREP software, you will be able to take advantage of the numerous keystroke shortcuts
designed to streamline use of the software and save you time while viewing your remittance information.
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Installing and Using MREP Software
To install and use the MREP software, your computer system(s) must meet the following minimum criteria:
•
•
•
•
•
•
IBM-compatible PC
Windows XP (recommended), Windows 2000, Windows NT or Windows 98 SE
2.0 GHz processor
256 MB RAM
3 MB hard disk space, and
NET Framework version 1.1 or higher
carrier/DMERC at their toll-free number which may be found at www.cms.hhs.gov/MedlearnNetworkGenInfo/ on the
CMS Web site.
In addition, Part B EDI Helpline phone numbers are available at www.cms.hhs.gov/ElectronicBillingEDITrans/ on the
CMS Web site.
MREP Software Disclaimer
This software was developed by the CMS for use by Medicare providers/suppliers to view and print a HIPAA-compliant
Medicare 835. Medicare has no liability and takes no responsibility for any other use of this software.
Medicare Remit Easy Print Enhancements and Clarification of
Check Issue/Electronic Funds Transfer Effective Date*
Providers and suppliers billing Medicare carriers, including DMERCs, for services to Medicare beneficiaries
This article is based on Change Request 4289, which instructs ViPs (the company that maintains the MREP software),
carriers, and DMERCs to add enhancements to the current version of the MREP software and provides clarification of
the check issue/electronic funds transfer (EFT) effective date.
Background
On October 11, 2005, the CMS made available the MREP software to enable Medicare providers and suppliers to view
and print the HIPAA-compliant 835 (ERA). Using the HIPAA 835 files, MREP enables providers and suppliers to view
and print Medicare Part B and DMERC 835 in a human readable format. The format is on the current SPR format
Medicare uses. MREP provides the ability to:
•
•
•
•
View the 835
Search the 835
Print the 835 in a format providers are familiar with, and
View and print special reports
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Providers who use MREP can print reports to reconcile accounts receivable as well as create document(s) that can be
included with claim submission to COB payers. MREP is available free to Medicare providers and suppliers, and it can
be installed on a personal computer or network. Please contact your Medicare contractor to download a copy of the
MREP software.
Keeping MREP Up to Date
In order to continuously improve this product, CMS set up a process to collect valuable suggestions and
recommendations to improve MREP’s functionality and effectiveness from providers, contractors (carriers and
DMERCs) and CMS staff. Using the suggestions and recommendations received before the cutoff date of November 15,
2005, CMS determined enhancements that were needed for MREP, and Change Request 4289 includes a summary page
attachment listing the MREP enhancements to be implemented in the MREP software release in July 2006. ViPs will
update the MREP software to incorporate the listed enhancements.
Enhancement updates to be implemented in October 2006 will include suggestions/recommendations received between
November 16, 2005, and the next cut-off date. Annual enhancement updates to MREP will be scheduled for each year in
October.
Note: If you are on the contractor list serve, you will be notified when the CARC and RARC file is updated three times a
year, in April, August and December. This file is the master listing of CARC and RARC used in printing the glossary on
the MREP printout. WPC publishes updates to this list three times a year. An update to the MREP application will be
issued to correspond to the WPC updates. Your Medicare carrier will post a notification when these updates will be
available, and a Medlearn Matters article is usually published to explain the changes in these updates.
Clarification of the Check Issue/EFT Effective Date
An issue was reported to contractors by providers receiving both electronic and SPR.
•
•
The MREP software populates the “Check Issues/EFT Effective Date” from the BPR16 data field (in the 835
transaction).
The SPR uses the information contained in the “Production Date” from the DTM 02 data field (in the 835
transaction).
These two dates are the same if:
•
the qualifier in the BPR 04 data field (in the 835 transaction) is either “CHK” or “NON”
However, if the qualifier in BPR 04 data field is “ACH” (for electronic funds transfer), then the BPR 16 data field may
be different than the “Production Date.”
This acknowledges the fact that it may take a few days to have the funds electronically moved from the Medicare
financial institution to the provider’s financial institution.
CMS requires that the SPR must mirror the ERA, and any software reading the ERA must have the same information in
the output as in the ERA.
Change Request 4289 repeats the instruction originally included in Change Request 1953 (Transmittal B-01-76, dated
December 11, 2001, www.cms.hhs.gov/Transmittals/Downloads/B0176.pdf), which states that the information for
Check Issue/EFT Effective Date must:
•
•
Be populated from the BPR16 data field, and
Not from the DTM 02 data field
Implementation
The implementation date for this instruction is July 3, 2006.
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For complete details, please see the official instruction issued to your carrier/DMERC regarding this change. That
instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R833CP.pdf on the CMS Web site. Attached to
that instruction is the list of enhancements that will be incorporated in the July 3, 2006, version of the MREP software.
Medicare Remit Easy Print Update*
Physicians, suppliers, and providers billing Medicare carriers, including DMERCs, for services provided to Medicare
beneficiaries.
This article is based on Change Request 5032 which advises providers to use MREP software to read and print the
HIPAA-compliant ERA for accounts reconciliation and crossover claims submission to secondary/tertiary payers.
Change Request 5032 also includes instructions for Medicare’s system maintainer (ViPS) to update MREP software with
additional functionalities, and directs carriers and DMERCs to test and communicate to the end users about the software
update.
See the Background section of this article for further details regarding this update.
Background
The CMS developed MREP software as a tool providers can use to read and print an ERA in a human readable format.
The format is based on the current SPR format. Providers who use the MREP software package can:
•
•
Print paper documentation that can be used to reconcile accounts receivable; and
Create document(s) that can be included with claim submissions to COB payers.
The MREP software became available on October 11, 2005, to providers (Part B and DMERC) through their respective
Medicare carrier/DMERC, and it was updated this year in April and July.
Change Request 5032 further encourages providers to use the MREP software to read and print the HIPAA-compliant
ERA for accounts reconciliation and crossover claims submissions to secondary/tertiary payers.
CMS created a process to receive suggestions from providers, Medicare contractors and CMS staff in order to
continuously improve and enhance MREP’s functionality and effectiveness. A summary listing of the improvements to
be implemented in the October 2006, update of MREP is included in the Additional Information section of this article.
Note: This update to MREP software includes suggestions for improvements received before the cut off date of March
15, 2006.
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Beginning June 1, 2006, Medicare contractors and DMERCs (and later DME MACs) will start suppressing the issuance
of SPRs to providers/suppliers, billing agents, clearing houses, or other entities representing providers, who also have
been receiving ERA transactions for 45 days or more. MREP is an option for providers to print their own remittances at
their own computer.
After the October 2006 update, annual updates of MREP will be provided every October unless a critical error affecting
production needs to be corrected. The software will also be updated three times a year to implement the Claim
Adjustment Reason and Remittance Advice Remark code changes.
Note: See Special Edition MLN Matters article at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0627.pdf on
the CMS Web site for options for providers affected by this change.
Implementation
The implementation date for Change Request 5032 is October 2, 2006. Your carrier/DMERC will post a notice to their
Web site on or after October 2, 2006, to alert you that the new version of the MREP software is available for download
and that the software includes the latest version of the CARCs and RARCs.
For complete details, please see the official instruction issued to your carrier/DMERC regarding this change. That
instruction may be viewed at www.cms.hhs.gov/Transmittals/downloads/R927CP.pdf on the CMS Web site.
List of Improvements to be Implemented in October 2006
Synopsis of Change
A provider would like to have the Provider ID added after the Payee Name. This way, when they have multiple
providers and provider locations, they can sort them easier. The Provider ID will be displayed after the Payee Name on
the MREP Main Page.
New report/listing of accounts NOT FORWARDED to supplemental or crossovers.
A new report is added to show “Late Filing.”
A new report will be created showing only those items with coinsurance.
Print reason/remark codes on same page as Remittance; or, can there be a check box that will either print the codes or
not? The MREP software is being changed to include a check box to allow the user to have the remit print with or
without the reason/remark codes.
The program should automatically import the 835 file. CMS is looking into this possibility or identifying and displaying
the 835 file and path.
Searchable “Help” menu and Index. The analysis is underway to determine the appropriate level of a help facility.
Electronic Remittance Advice and Medicare Remittance Easy
Print Testimonials
If you currently receive the standard paper remittance (SPR,) you can increase your productivity by switching to the
electronic remittance advice (ERA). By receiving ERAs, you can take advantage of:
•
•
•
faster communication;
faster payment information; and
reduced paperwork.
If your current software program does not have the capability to view and print the ERA, the CMS offers Medicare
Remit Easy Print (MREP) software. This free software program allows suppliers to receive and print the ERA.
AdminaStar Federal’s E-Commerce Consultants recently requested ERA and MREP testimonials from the AdminaStar
Federal supplier community. Here is what your peers are saying about these two great products:
“I did not think the ERA would have been as easy as it is. I am sorry I waited so long to get started.”
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“ERA download went very smoothly with close communication with customer service. No interruption in claim
processing.”
“The conversion to ERA was painless. The reduced labor costs alone made the transition beneficial. Within fourteen
days of submitting a claim, we had the claim adjudicated and when applicable, on its way to secondary processing. In
the case of denials, we were able to act on them within days of submission. This has enabled us to, according to
DMERCs new reporting tool; submit approximately 99% of claims cleanly. “
“The ERA is relatively simple once the programming is in place. Cuts down on staff manually having to post these
transactions.”
Note: MedAComm communications software is available to use with the MREP software. It is free and can be
downloaded from the AdminaStar Federal Website.
To get more information on the ERA and MREP, visit the AdminaStar Federal Web site at
www.adminastar.com/Providers/EDI/DMERC/ERA/ERA.html
For additional information, please contact the AdminaStar Federal EDI Helpdesk at 1-877-ASF-4EDI (1-877-273-4334)
or via e-mail at [email protected].
Source: CMS Joint Signature Memorandum 06-422 dated May 9, 2006
Update to Chapter 24 (EDI Support Requirements) of the
Medicare Claims Processing Manual to Show New CMS Web
Site URL References*
Physicians, providers, and suppliers who submit claims for services to the CMS Medicare contractors (carriers, fiscal
intermediaries, RHHIs and DMERCs)
Background
This article, based on Change Request 4398, highlights the fact that the www.cms.hhs.gov Web site has been completely
redesigned. Currently, chapter 24 of the CMS IOM Publication 100-04, Medicare Claims Processing manual contains
URLs that no longer direct the user to the new CMS Web site. If used, the following message will appear. “We’re sorry.
The page you requested cannot be found. CMS has recently launched a web site redesign and many addresses have
changed.”
This instruction updates the URLs that are currently in chapter 24, removes the URLs that no longer apply, and replaces
them with the new URLs.
Key Points
The key new Web addresses are as follows:
•
www.cms.hhs.gov/ElectronicBillingEDITrans/01_Overview.asp is the new address for accessing and
downloading the CMS EDI instructions.
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•
•
•
•
•
•
•
The X12N 837 implementation guide (IG) version 4010A1 for Institutional (I) and Professional (P) claims is now at
www.cms.hhs.gov/ElectronicBillingEDITrans/08_HealthCareClaims.asp on the CMS Web site.
The implementation guide for coordination of benefits (COB) with other payers is at
www.cms.hhs.gov/ElectronicBillingEDITrans/12_COB.asp on the CMS Web site.
The NCPDP Telecommunications Standard Specifications and IG version 5.1 and Batch Standard 1.1 for retail
prescription drug claims (Billed to Medicare DMERCs only) and COB are at
www.cms.hhs.gov/ElectronicBillingEDITrans/08_HealthCareClaims.asp on the CMS Web site.
The X12 835 IG version 4010A1 for Remittance Advice is at
www.cms.hhs.gov/ElectronicBillingEDITrans/11_Remittance.asp on the CMS Web site.
The X12 276/277 IG version 4010A1 for Claim Status Inquiry and Response is located at
www.cms.hhs.gov/ElectronicBillingEDITrans/10_ClaimStatus.asp on the CMS Web site.
Information on the X12 270/271 IG version 4010A1 transactions for Beneficiary Eligibility Inquiry and response
are at www.cms.hhs.gov/ElectronicBillingEDITrans/09_Eligibility.asp on the CMS Web site.
HIPAA IG “companion documents” are available at www.cms.hhs.gov/ElectronicBillingEDITrans on the CMS
Web site. Once at that site, select the specific transaction desired from the left side of the screen and you will then
get a link to the companion document at the bottom of the page for that transaction.
The official instructions issued to your carrier or intermediary regarding this change can be found at
Shared Systems Medicare Secondary Payer Balancing Edit
and Administrative Simplification Compliance Act
Enforcement Update*
Physicians, suppliers and providers billing Medicare Secondary Payer (MSP) claims to Medicare carriers, fiscal
intermediaries, DMERCs and RHHIs
Key Points for Providers
Change Request 4261 makes two key changes to Medicare claims processing as follows:
•
First, Change Request 4261 states that inbound MSP claims will be rejected if the paid amounts and the adjusted
amounts paid by the primary payer do not equal the billed amounts at the line level and if the claim lacks standard
claim adjustment reason codes to identify adjustments performed.
While Medicare may be able to handle such a discrepancy because it does not always use this information, it may
pass such claims to other payers. Such other payers may then reject the claims because they do not comply with the
837 version 4010A1 institutional and professional implementation guides. As a result, Medicare will not accept such
claims in order to be fully compliant with HIPAA.
•
Second, if a provider’s paper claims have been denied due to Administrative Simplification Compliance Act
(ASCA) electronic claims provision enforcement by Medicare contractors (carriers, fiscal intermediaries, RHHIs
and DMERCs), the provider may resubmit the paper claims if they submit appropriate documentation that
establishes that they meet the criteria for submitting paper claims.
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Providers have until the 91st day after the initial ASCA letter to submit documentation that proves eligibility for
submission of paper claims. If a provider establishes eligibility later than the 91st day of the initial enforcement
letter and then resubmits paper claims, payment will be denied for dates of service between the 91st day and the
effective date for submission of claims.
Implementation
The implementation date for the instruction is July 3, 2006.
For details of enforcement of the ASCA, please see related Medlearn Matters article MM3440, “Administrative
Simplification Compliance Act (ASCA) Enforcement of Mandatory Electronic Submission of Medicare Claims,” at
www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM3440.pdf on the CMS Web site.
The official instruction on this change, Change Request 4261, may be viewed at
Fee Schedule
April 2006 Quarterly Average Sales Price Medicare Part B
Drug Pricing File and Revisions to January 2005, April 2005,
July 2005, October 2005 and January 2006 Quarterly
Average Sales Price Medicare Part B Drug Pricing Files*
All Medicare providers who bill Medicare for Part B drugs
Change Request 4319 provides notice of the updated payment allowance limits for Medicare Part B drugs, effective
April 1, 2006 through June 30, 2006, as well as revised payment files for the January 2005, April 2005, July 2005,
October 2005 and January 2006 quarter average sales price (ASP) Medicare Part B drug pricing files.
Be aware that certain Medicare Part B drug payment limits have been revised and that the Centers for Medicare &
Medicaid Services (CMS) updates the payment allowance quarterly. The revised payment limits included in the revised
ASP and Not Otherwise Classified (NOC) payment files supersede the payment limits for these codes in any publication
published prior to Change Request 4319.
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Make certain that your billing staffs are aware of these changes.
Background
According to section 303 (c) of the Medicare Modernization Act (MMA) of 2003, CMS will update the payment
allowances for Medicare Part B drugs on a quarterly basis.
Beginning January 1, 2005, Part B drugs that are not paid on a cost or prospective payment basis) are paid based on 106
percent of the ASP.
Additionally, in 2006, all end-stage renal disease (ESRD) drugs furnished by both independent and hospital-based ESRD
facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the
outpatient prospective payment system (OPPS), will be paid based on the ASP methodology. The ASP methodology is
based on quarterly data submitted to CMS by manufacturers. CMS will supply Medicare contractors with the ASP drug
pricing files for Medicare Part B drugs on a quarterly basis.
Beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on
a cost or prospective payment basis are 106 percent of the ASP.
Beginning January 1, 2006, the payment allowance limits for all ESRD drugs when separately billed by freestanding and
hospital-based ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with passthrough status under the OPPS, will be paid based on 106 percent of the ASP. CMS will update the payment allowance
limits quarterly.
Exceptions to General Rule
There are exceptions to this general rule as summarized below.
Blood and Blood Products
For blood and blood products (with certain exceptions such as blood clotting factors), payment allowance limits are
determined in the same manner they were determined on October 1, 2003.
The payment allowance limits for blood and blood products are 95 percent of the average wholesale price (AWP) as
reflected in the published compendia. The payment allowance limits will be updated on a quarterly basis.
Infusion Drugs
For infusion drugs furnished through a covered item of durable medical equipment (DME) on or after January 1, 2005,
payment allowance limits will continue to be 95 percent of the AWP reflected in the published compendia as of October
1, 2003, regardless of whether or not the DME is implanted.
The payment allowance limits were not updated in 2005. For infusion drugs furnished through a covered item of DME
that were not listed in the published compendia as of October 1, 2003 (i.e., new drugs), the payment allowance limits are
95 percent of the first published AWP.
Influenza, Pneumococcal, Hepatitis B Vaccines
For influenza, pneumococcal and hepatitis B vaccines, payment allowance limits are 95 percent of the AWP as reflected
in the published compendia.
Drugs Not Included in ASP Medicare Part B Drug Pricing File or Not Otherwise Classified
Pricing File
For drugs (other than new drugs) not included in the ASP Medicare Part B drug pricing file or NOC pricing file,
payment allowance limits are based on the published wholesale acquisition cost (WAC) or invoice pricing.
In determining the WAC-based payment limit, Medicare contractors (carriers, including durable medical equipment
regional carriers [DMERCs] and fiscal intermediaries, including regional home health intermediaries [RHHIs]) will
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follow the methodology specified in the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims
Processing manual for calculating the AWP, but substitute WAC for AWP. (See CMS IOM Publication 100-04,
Medicare Claims Processing manual, chapter 17 [Drugs and Biologicals] at
www.cms.hhs.gov/manuals/downloads/clm104c17.pdf on the CMS Web site.) The payment limit is 100 percent of the
lesser of the lowest brand or median generic WAC.
Your Medicare contractor may, at their discretion, contact CMS to obtain payment limits for drugs not included in the
quarterly ASP or NOC files. If available, CMS will provide the payment limits either directly to the requesting
contractor or will post them in an MS Excel file on the CMS Web site. If the payment limit is available from CMS,
contractors will substitute the CMS-provided payment limits for pricing based on WAC or invoice pricing.
Radiopharmaceuticals
The payment allowance limits for radiopharmaceuticals are not subject to ASP. Your carrier/fiscal intermediary will
determine payment limits for radiopharmaceuticals based on the methodology in place as of November, 2003.
New Drugs Produced or Distributed under a New Drug Application Approved by the Food and
Drug Administration
The payment allowance limits for new drugs and biologicals not included in the ASP Medicare Part B Drug Pricing File
or NOC Pricing File are based on 106 percent of the WAC. This policy applies only to new drugs that were first sold on
or after January 1, 2005.
How the ASP is Calculated
The ASP is calculated using data submitted to CMS by manufacturers on a quarterly basis and each quarter, CMS will
update your carrier payment allowance limits with the ASP files. On or after March 20, 2006, revised January 2005,
April 2005, July 2005, October 2005 and January 2006 ASP and NOC payment files and the April 2006 ASP and NOC
files will be available for download.
•
•
•
•
•
•
The revised January 2005 payment allowance limits apply to dates of service January 1, 2005 through March 31,
2005.
The revised April 2005 payment allowance limits apply to dates of service April 1, 2005 through June 30, 2005.
The revised July 2005 payment allowance limits apply to dates of service July 1, 2005 through September 30, 2005.
The revised October 2005 payment allowance limits apply to dates of service October 1, 2005 through December
31, 2005.
The revised January 2006 payment allowance limits apply to dates of service January 1, 2006 through March 31,
2006.
The April 2006 payment allowance limits apply to dates of service April 1, 2006 through June 30, 2006.
Note: The absence or presence of a Healthcare Common Procedure Coding System (HCPCS) code and its associated
payment limit does not indicate Medicare coverage of the drug or biological. Similarly, the inclusion of a payment limit
within a specific column does not indicate Medicare coverage of the drug in that specific category. The carrier
processing your claim will make these determinations.
For any drug or biological not listed in the ASP or NOC drug pricing files, your Medicare contractor will determine the
payment allowance limits in accordance with the policies described in Change Request 4319 and fiscal intermediaries
will seek payment allowances from the local Medicare carrier.
Implementation
The official instructions issued to your carrier/fiscal intermediary/RHHI/DMERC regarding this change can be found at
More information is available at www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/ on the CMS Web site.
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April Quarterly Update for 2006 Durable Medical Equipment,
Prosthetics, Orthotics and Supplies Fee Schedule*
RHHIs, for services paid under the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee
schedule
This article is based on Change Request 4335 and provides specific information regarding the quarterly update for the
April 2006 DMEPOS fee schedule.
Background
The DMEPOS fee schedules are updated on a quarterly basis in order to:
•
•
Implement fee schedule amounts for new codes, and
Revise any fee schedule amounts for existing codes that were calculated in error
Payment on a fee schedule basis is required for:
•
•
Durable medical equipment (DME), prosthetics, orthotics and surgical dressings by the Social Security Act (sections
1834[a][h][i]), and
Parenteral and enteral nutrition (PEN), by regulations contained in the Code of Federal Regulations (42 CFR
414.102)
Changes made in this update include the following:
•
The fee schedule amounts for HCPCS code K0730 (Controlled dose inhalation drug delivery system) were added to
the fee schedule file on April 1, 2006, and are effective for claims with dates of service on or after April 1, 2005.
If processed claims for code K0730 with dates of service on or after April 1, 2005, are resubmitted as adjustments
after April 1, 2006, carriers and DMERCs will adjust the claim.
•
The fee schedule amounts for HCPCS code E1010 (Wheelchair accessory, addition to power seating system, power
leg elevation system, including leg rest) were inadvertently dropped from the January fee schedule file and are being
added back to the file as part of the April 2006 update.
•
The payment categories for codes E0471 and E0472 are being revised to move respiratory assist devices from the
DME category for frequently serviced items to the DME payment category for capped rental items, effective on
April 1, 2006.
Implementation
The implementation date for this instruction is April 3, 2006.
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The official instructions issued to your intermediary, carrier or DMERC regarding this change can be found at
July Quarterly Update for 2006 Durable Medical Equipment,
Prosthetics, Orthotics and Supplies Fee Schedule*
RHHIs, for services paid under the DMEPOS fee schedule.
Providers Action Needed
This article is based on Change Request 5017 and provides specific information regarding the quarterly update for the
July 2006 DMEPOS fee schedule.
Background
The DMEPOS fee schedules are updated on a quarterly basis to:
•
•
Implement fee schedule amounts for new codes; and
Revise any fee schedule amounts for existing codes that were calculated in error.
Payment on a fee schedule basis is required for:
•
•
DME, prosthetic devices, orthotics, prosthetics and surgical dressings by the Social Security Act (sections
1834[a][h][i]); and
PEN by regulations contained in the Code of Federal Regulations (42 CFR 414.102).
Changes Made in the Update
Changes made in this update include the following:
The fee schedule amounts for the following HCPCS codes are added to the fee schedule file as part of this update and
are effective for claims with dates of service on or after January 1, 2006:
L0624
L3766
L3977
L7403
L0629
L3905
L3978
L7404
L0632
L3913
L5703
L7405
L0634
L3919
L5858
E1238
L2034
L3921
L5971
E1812
L2387
L3933
L6621
E2291
L3671
L3935
L6677
E2292
L3672
L3961
L6883
E2293
L3673 L3702 L3763 L3764 L3765
L3967 L3971 L3973 L3975 L3976
L6884 L6885 L7400 L7401 L7402
E2294
The fee schedule amounts for HCPCS code K0733 (Power wheelchair accessory, 12 to 24 amp hour sealed lead acid
battery, each [e.g., gel cell, absorded glass mat]) are added to the fee schedule file on July 1, 2006, and is effective for
claims with dates of service on or after July 1, 2006.
The fee schedule amounts for HCPCS code E0762 (Transcutaneous electrical joint stimulation device system, includes
all accessories) are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of
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service on or after January 1, 2006. In addition, the payment category for code E0762 is being revised to move the joint
stimulation device from the DME payment category for capped rental items to the DME payment category for
inexpensive and routinely purchased items, effective July 1, 2006.
The fee schedule amounts for HCPCS codes L6694 and L6698 are added to the fee schedule file on July 1, 2006, and
are effective for claims with dates of service on or after January 1, 2005.
The fee schedules for HCPCS code L2232 (Addition to lower extremity orthosis, rocker bottom for total contact ankle
foot orthosis, for custom fabricated orthosis only) are added to the fee schedule file on July 1, 2006, and are effective for
claims with dates of service on or after January 1, 2005.
Code E0705 (Transfer board or device, any type, each) was added to the HCPCS effective January 1, 2006. The
payment category for E0705 is being revised to the inexpensive and routinely purchased payment category and the fee
schedule amounts for previous HCPCS code E0972 will be crosswalked to code E0705 for use in paying claims with
dates of service on or after January 1, 2006.
The fee schedules for HCPCS code K0606 (Automatic external defibrillator, with integrated electrocardiogram analysis,
garment type) are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of
service on or after January 1, 2006.
The fee schedule amounts for HCPCS code E1812 (Dynamic knee, extension/flexion device with active resistance
control) are added to the fee schedule file on July 1, 2006, and are effective for claims submitted with dates of service on
or after January 1, 2006.
As part of this update, the common working file category for HCPCS code B4185 will be switched from Common
Working File (CWF) category 9 to CWF category 20, effective January 1, 2006. B4185 was added to the HCPCS on
January 1, 2006, to replace codes B4184 and B4186 and describes parenteral nutrients (CWF category 20) as opposed to
enteral nutrients (CWF category 9).
Per Change Request 4267, the following four adjustable wheelchair cushions codes are added to the HCPCS, effective
July 1, 2006:
K0734
K0735
K0736
K0737
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth
Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
(See the MLN Matters article at www.cms.hhs.gov/MLNMattersArticles/downloads/MM4267.pdf on the CMS Web site.)
The fee schedule amounts for the above codes, K0734, K0735, K0736 and K0737, are added to the fee schedule file on
July 1, 2006 and are effective for claims submitted with dates of service on or after January 1, 2006.
HCPCS codes A6531 and A6532 were added to the HCPCS January 1, 2006, to replace L8110 and L8120; therefore,
all billing and payment requirements for HCPCS codes L8110 and L8120 crosswalk directly to A6531 and A6532,
including the requirement to bill modifier AW when items are furnished for use as surgical dressings (see Transmittal
AB-03-100).
Implementation
The implementation date for the instruction is July 3, 2006.
The official instructions issued to your intermediary, carrier, or DMERC regarding this change can be found at
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Medicare Part B Drug Pricing Update—Payment Limit for
J7620 (Albuterol and Ipratropium Bromide,
Noncompounded)*
Suppliers billing Medicare DMERCs and RHHIs for albuterol and ipratropium bromide
The payment allowance limit for HCPCS code J7620 (Albuterol and ipratropium bromide, noncompounded) in the
January 2006 quarterly average sales price (ASP) Medicare Part B pricing file is incorrect.
Change Request 4333, from which this article was developed, corrects the HCPCS code J7620 Medicare Part B pricing
file payment allowance limit for dates of service on or after January 1, 2006, and on or before March 31, 2006.
Make sure that your billing staffs are aware of this correction.
Background
The payment allowance limit contained in the January 2006 quarterly ASP Medicare Part B pricing file for J7620
(Albuterol and ipratropium bromide, noncompounded) is incorrect. In order to prevent overpayment, Change Request
4333 informs the DMERCs and RHHIs to correct this payment allowance limit for dates of service on or after January 1,
2006, and on or before March 31, 2006. The correct payment allowance limit is displayed in the following table.
Correct Payment Allowance Limit for HCPCS Code J7620
HCPCS
J7620
Long Description
Albuterol, up to 2.5 mg and
ipratropium bromide, up to
0.5 mg, noncompounded
inhalation solution,
administered through DME
HCPCS Code Dosage
Albuterol, up to 2.5 mg and
ipratropium bromide, up to
0.5 mg
Payment Allowance Limit
$1.024
While DMERCs and RHHIs will not be routinely searching and adjusting claims that have been processed prior to this
Change Request’s implementation date, they will be using this corrected payment allowance limit for HCPCS drug code
J7620 when asked to retroactively adjust claims (with dates of service January 1, 2006–March 31, 2006) that were
processed with the January 2006 Medicare Part B ASP pricing file.
You can find more information about the new payment allowance limit for HCPCS code J7620 by going to
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Miscellaneous
Top Ten Region B DMERC Supplier Telephone Inquiries
This article provides a review of the top ten telephone inquiries for durable medical equipment prosthetic orthotics and
supplies (DMEPOS) for the second quarter of fiscal year 2006 (January through March). The External Affairs staff
works closely with the Supplier Customer Service Unit to develop educational materials to ensure the Region B supplier
community is knowledgeable on the top telephone inquiries.
1. DMEPOS Claim Denials and Issues (16,407)
Suppliers are encouraged to review the individual medical policies for coverage criteria, which can be found on the
TriCenturion Web site at www.tricenturion.com. Suppliers may also access the Medical Review link on the AdminaStar
Federal Web site for detailed instructions on billing and coverage for several medical policies. The Medical Review page
can be located by copying the following Web address into an Internet browser:
www.adminastar.com/Providers/DMERC/MedicalReview/MedicalReviewarticlesFAQs.cfm
If additional clarification is needed, the Region B Durable Medical Equipment Regional Carrier (DMERC) Customer
Service Unit can be reached by calling 1-877-299-7900.
2. Submitted to Incorrect Program (16,226)
The Medicare health insurance program has two parts: Part A and B. Part A covers hospital care, hospice care and home
health care services. Part B covers outpatient physician and hospital services, clinical laboratory services and DMEPOS.
Suppliers should refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM)
Publications to find the Medicare coverage criteria requirements of items and services specific for each Medicare
program. The CMS IOM can be located by copying the following Web address into an Internet browser:
www.cms.hhs.gov/Manuals/IOM/list.asp
3. General Information—Other Issues (9,070)
Suppliers are encouraged to visit the AdminaStar Federal Web site at www.adminastar.com on a frequent basis to stay
abreast of Medicare changes. For the latest Medicare news, policy changes, claim filing issues and other important
information, visit the Region B DMERC “What’s New” link of the AdminaStar Federal Web site.
4. Beneficiary Eligibility—Part B Entitlement (7,340)
Suppliers should verify the beneficiary’s Medicare benefits prior to submitting a claim to the Region B DMERC by
obtaining a copy of the beneficiary’s Medicare card. Participating and nonparticipating suppliers may access eligibility
information through the Claim Status Inquiry (CSI).
5. Claim Status—Payment Explanation/Calculation (7,107)
DMEPOS items and/or services are paid based on three payment methodologies: (1) fee schedules, (2) reasonable
charge, and (3) drugs and biologicals.
Most payments of durable medical equipment (DME) are based on a fee schedule. A standard fee is established for each
DMEPOS item by state. The beneficiary’s permanent address, rather than the location of the DMEPOS supplier, will
determine the amount allowed by Medicare for a particular service. Payment is calculated using either the fee schedule
amount or the actual charge submitted on the claim, whichever is lower. The fee schedule allowances include the
application of national floors and ceilings. The most current fee schedule information can be located by copying the
following Web address into an Internet browser: www.adminastar.com/Providers/DMERC/FeeSchedule/DMERCPricing.htm
Note: The fee schedule is updated on an annual basis.
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6. Frequency Limitation Claim Denials (6,158)
Suppliers should review the documentation section of each individual medical policy to verify the documentation
requirements needed when billing for quantities of supplies greater than those described in the policy as the usual
maximum amounts. Each claim submitted for quantities of supplies greater than those described in the policy must
include documentation supporting the medical necessity for the higher utilization. This information must be attached to a
hard copy claim or entered into the narrative field of an electronic claim. Additionally, there must be clear
documentation in the patient’s medical records that corroborate the order and any additional documentation that pertains
to the medical necessity of the items and quantities billed. The medical policies are located on the TriCenturion Web site
at www.tricenturion.com.
7. Claim Denials—Medical Necessity (3,766)
Suppliers should refer to each individual medical policy of the Region B DMERC Supplier Manual to verify coverage
criteria for an item and/or service. The medical policies can be found on the TriCenturion Web site at
www.tricenturion.com. For medical necessity denials, suppliers are given the option to submit the claim along with
supporting documentation as an appeal request. Suppliers should submit redetermination requests to the following address:
Redeterminations
P.O. Box 50403
8. Entitlement/Eligibility—HMO record (3,292)
Suppliers should verify the beneficiary’s Medicare benefits prior to submitting a claim to the DMERC by obtaining a
copy of the beneficiary’s Medicare card. Participating and nonparticipating suppliers may access eligibility information
through the CSI. Suppliers may also contact the Coordination of Benefits Contractor at 1-800-999-1118 to help identify
the health benefits available to a particular Medicare beneficiary.
9. Claim Denials—Duplicate (3,216)
Suppliers should allow at least 14 days for electronically submitted claims and 29 days for hard copy claims before
resubmitting the claim for payment. Suppliers should utilize CSI or the Interactive Voice Response (IVR) Unit at 1-877299-7900 to check claim status.
10. Policy Coverage Rules (3,034)
Suppliers should reference the TriCenturion Web site at www.tricenturion.com for coverage and documentation
requirements for each individual medical policy.
Top Ten Region B DMERC Supplier Written Inquiries
This article provides a review of the top ten supplier written inquiries for DMEPOS for the second quarter of fiscal year
2006 (January through March). The External Affairs staff works closely with the Written Correspondence Unit to
develop educational materials to ensure the Region B supplier community is knowledgeable on the top written inquiries.
1. Claim Denials—DMEPOS Issues (694)
Suppliers should refer to each individual medical policy to verify coverage criteria for an item and/or service. The
medical policies can be found on the TriCenturion Web site at www.tricenturion.com. For medical necessity denials,
suppliers are given the option to submit the claim along with supporting documentation as an appeal request. Suppliers
should submit review/redetermination requests to the following address:
Redeterminations
P.O. Box 50403
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2. Claim Status—Payment Explanation/Calculation (642)
DMEPOS items and/or services are paid based on three payment methodologies: (1) fee schedules, (2) reasonable
charge, and (3) drugs and biologicals.
Most DME payments are based on a fee schedule. A standard fee is established for each DMEPOS item by state. The
beneficiary’s permanent address, rather than the location of the DMEPOS supplier, will determine the amount allowed
by Medicare for a particular service. Payment is calculated using either the fee schedule amount or the actual charge
submitted on the claim, whichever is lower. The fee schedule allowances include the application of national floors and
ceilings. The most current fee schedule information can be located by copying the following Web address into an
Internet browser: www.adminastar.com/Providers/DMERC/FeeSchedule/DMERCPricing.htm
Note: The fee schedule is updated on an annual basis.
3. Appeals—Status/Explanation Resolution (505)
Suppliers should utilize the IVR Unit at 1-877-299-7900 and select option 3 to check the status of a redetermination
request.
4. General Information—Other Issues (264)
Suppliers are encouraged to visit the AdminaStar Federal Web site at www.adminastar.com on a frequent basis to stay
abreast of Medicare changes. For the latest Medicare news, policy changes, claim filing issues and other important
information, visit the Region B DMERC “What’s New” link of the AdminaStar Federal Web site.
5. Unprocessable—Submitted to Incorrect Program (186)
The Medicare health insurance program has two parts: Part A and B. Part A covers hospital care, hospice care and home
health care services. Part B covers outpatient physician and hospital services, clinical laboratory services and DMEPOS.
Suppliers should refer to the CMS IOM Publications for Medicare coverage criteria requirements of items and services
specific for each Medicare program. The CMS IOM Publications can be located by copying the following Web address
into an Internet browser: www.cms.hhs.gov/Manuals/IOM/list.asp
6. Claim Denials—Medical Necessity (181)
Suppliers should refer to each individual medical policy of the to verify coverage criteria for an item and/or service. The
medical policies can be found on the TriCenturion Web site at www.tricenturion.com. For medical necessity denials,
suppliers are given the option to submit the claim along with supporting documentation as an appeal request. Suppliers
should submit redetermination requests to the following address:
Redeterminations
P.O. Box 50403
7. Claim Denials—Duplicate (164)
Suppliers should allow at least 14 days for electronically submitted claims and 29 days for hard copy claims before
resubmitting the claim for payment. Utilize the CSI or the IVR Unit at 1-877-299-7900 to check claim status.
8. Claim Status—Additional Development Request Letters (144)
Suppliers should submit the additional documentation being requested to the address indicated on the Additional
Development Request (ADR) letter within 30 days and include a copy of the letter with the requested documentation.
9. Financial Information—Refunds (134)
Suppliers should send refund requests to the AdminaStar Federal Payment Correction Unit (PCU) with a copy of the
original refund request letter received from the PCU. Also, be sure to reference the document control number (DCN) in
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any communication with the Region B DMERC. This DCN is used to track the refund. This letter is the only notification
from the DMERC prior to an offset occurring. Suppliers are encouraged to respond to all refund request letters received
from the Region B DMERC to prevent an offset from occurring. Please send all overpayment requests to the following
address:
Payment Correction Unit
Lockbox #660078
Suppliers may also access chapter 14 (Pricing and Overpayments) of the Region B DMERC Supplier Manual for
additional information on the overpayment process.
10. Financial Information—Credit Balance/Account Receivable (101)
All voluntary refund requests should be sent to the PCU at AdminaStar Federal. Information should be included to
identify the claim(s) for which the refund is made along with the reason for the refund. Submit voluntary refunds to the
following address:
AdminaStar Federal
Lockbox #660078
The AdminaStar Federal PCU has created an offset form for suppliers to utilize when the supplier has identified an
overpayment and would like the DMERC to take the money back via an offset versus sending in the overpayment. This
form can also be utilized for voluntary refund requests. To review this form, please enter the following Web address into
an Internet browser: www.adminastar.com/Providers/DMERC/MedicareManuals/files/OffsetRequestForm.pdf
The IVR Unit has also been upgraded to allow suppliers to research offset information and voluntary refunds. Suppliers
should utilize the IVR Unit at 1-877-299-7900 for both offset and voluntary refund information.
Top Ten Claim Submission Errors for Fiscal Year 2006
Second Quarter
The Region B DMERC conducted claim analysis of issues related to claim submission errors for the second quarter of
fiscal year 2006 (January through March 2006). The following chart identifies the top claim submission errors, as well as
helpful tips on how to decrease the number of errors.
ANSI
Code
January
2006
February
2006
March
2006
2nd
Quarter
Total
% of
Denials
Category
Denial Type
CO-18
Duplicate claim
Duplicate
40,472
40,521
48,740
129,733
16.83%
CO-173
CO-176
CO-175
CO-176
CO-57
Item cannot be paid without a
new, revised or renewed
Certificate of Medical
Necessity (CMN)
Equipment is the same or
similar to equipment already
being used
The patient did not have
Medicare coverage at the time
of service
Return/Reject
22,984
21,095
27,176
71,255
9.24%
Return/Reject
11,012
9,674
12,509
33,195
4.31%
Eligibility
10,930
9,258
11,934
32,122
4.17%
PR-27
CO-13
PR-27
PR-31
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ANSI
Code
PR-26
OA 109
CO B-15
OA 109
CO-22
CO-16
CO-16
CO-16
February
2006
March
2006
2nd
Quarter
Total
% of
Denials
Category
Denial Type
January
2006
This claim should be handled
by another contractor
Jurisdiction
7,634
7,238
7,866
22,738
2.95%
A skilled nursing facility
(SNF) is responsible for
payment
Secondary payment cannot be
made without other carrier
information
Unprocessable claim as
explained by remark code
Missing/incomplete/invalid
HCPCS modifier
Missing/incomplete/ invalid
name or provider identifier
Jurisdiction
5,096
4,729
5,906
15,731
2.04%
MSP
4,749
4,534
5,811
15,094
1.96%
Return/Reject
745
889
11,353
12,987
1.68%
Return/Reject
2,325
1,895
2,006
6,226
0.81%
Return/Reject
1,904
1,504
1,385
4,793
0.62%
1. Duplicate claims: The Region B DMERC receives a large quantity of claims that result in duplicate denials. The
duplicate claim submission is the number one claims submission error. Generally claim submission errors are
services/items previously processed for the same patient, date of service and HCPCS code.
Suppliers are reminded to allow 14 days for electronically submitted claims and 29 days for hard copy claims before
resubmitting a claim to the DMERC. Suppliers should utilize the CSI or the IVR Unit at 1-877-299-7900 before
resubmitting the claim for payment.
2. Item cannot be paid without a new, revised or renewed CMN: The Region B DMERC encourages suppliers to
review each individual medical policy to verify what items and/or services require an initial, revised or recertification
CMN. When submitting claims that require a CMN, suppliers should ensure that all sections of the CMN are completed
prior to claim submission to the DMERC. Suppliers should submit the CMN with the initial claim only and wait 24-48
hours before submitting any subsequent claims.
3. Equipment is the same or similar to equipment already being used: Suppliers should determine the patient’s
history during the intake process to determine if same or similar equipment was previously obtained. However, if a claim
denies because the patient has previously received same/similar equipment, and the supplier was unaware of the previous
purchase, the supplier should refund the beneficiary or exercise his/her appeal rights and request a redetermination.
Redetermination requests should be submitted to the following address:
Redeterminations
P.O. Box 50403
4. The patient did not have Medicare coverage at the time of service: Medicare Part B coverage was not valid when
the patient received this item and/or service. Expenses incurred after coverage was terminated, prior to coverage, date of
death precedes the date of service and if Medicare was unable to identify the patient as an insurer. Suppliers should
check the patient records for valid coverage dates and for correct patient information prior to claim submission.
5. This claim should be handled by another contractor: AdminaStar Federal is the Region B DMERC that processes
DMEPOS claims for the states of Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, West Virginia and
Wisconsin, as well as the District of Columbia. DMEPOS jurisdiction is based on the beneficiaries address on file with
the Social Security Administration. Suppliers should verify that the address they have on file for the beneficiary is the
same address on file with the Social Security Administration. This will help to ensure claims are sent to the correct
DMERC region for processing. Claims submitted to an incorrect DMERC region will receive a denial indicating “Claim
not covered by this payer/contractor. You must send the claim to the correct payer/contractor.”
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For example, a claim with a date of service of 02/01/05–02/05/05 was received by the Region B DMERC. The address
on file for the beneficiary was a New York address. DMEPOS claims for beneficiaries who reside in New York are
processed by the Region A DMERC. This claim should be submitted to Region A for claims processing.
6. A SNF is responsible for payment: The Region B DMERC encourages suppliers to verify the dates that the patient
was in a SNF prior to submitting the claim to the DMERC. Medicare Part B does not pay for an item or service when the
records show that the patient was in a SNF on the date of service billed. Claims submitted to the DMERC that are
covered by a SNF will reject as “Medicare Part B does not pay for this item or service since our records show that the
patient was in a SNF on this date.” Suppliers must bill this service to the SNF.
7. Secondary payment cannot be made without other carrier information: The Region B DMERC’s records indicate
that Medicare is the secondary payer. Suppliers must send the claim to the correct payer/contractor first and then
resubmit the claim to Medicare with a copy of the primary payment notice. When claims are submitted to Medicare as
primary and another insurer is actually the primary payer, claims will be denied as, “Our records show that Medicare is
your secondary payer. This claim must be sent to your primary insurer first. Resubmit this claim with a copy of the
primary payment notice.” Suppliers must send these claims to the correct payer/contractor first and then resubmit the
claim to Medicare with a copy of the primary payment notice or the Explanation of Benefits. Region B DMERC also
recommends suppliers advise the beneficiary to contact the Coordination of Benefits Contractor at 1-800-999-1118 to
have their Medicare Secondary Payer control file updated.
8. Unprocessable claim as explained by Remark Code: Claims were submitted to the Region B DMERC that
contained incomplete or invalid information and cannot be processed as submitted. Refer to the remark code (REM) on
the standard paper remittance (SPR) advice, which can be found on the far-left side of the SPR. The REM advises what
information is missing or incomplete on the claim. Suppliers should resubmit a new claim with the missing/incomplete
information.
9. Missing/incomplete/invalid HCPCS modifier: Claims submitted with missing, incomplete and/or invalid modifiers
will be returned to the supplier. Suppliers may resubmit the claims with the correct or missing information. Each medical
policy indicates the proper modifier that applies to the Healthcare Common Procedure Code System (HCPCS) codes
indicated for the policy. Please refer to the various medical policies to verify what modifiers are needed and the proper
usage of those modifiers. A listing of the HCPCS modifiers may also be found on the TriCenturion Web site at
www.tricenturion.com. Claims denied due to medical necessity may be submitted to the Redeterminations Unit as an
appeal with the missing and/or correct modifier along with supporting documentation for review.
10. Missing/incomplete/invalid name or provider identifier: The Region B DMERC has returned a high volume of
claims due to missing and/or invalid 10-digit supplier numbers. Please verify that the ten-digit supplier number issued by
the National Supplier Clearinghouse is entered on the claim. When more than one supplier number is used, a separate
CMS-1500 claim form should be used to bill for each supplier number.
Announcing a New Name for Medicare’s Provider Education
Articles—Medicare Learning Network Matters*
All Medicare physicians, providers and suppliers
Background
The Medicare Learning Network is pleased to announce a new name for our very popular provider education articles. To
more closely associate these articles with the Medicare Learning Network, i.e., the official educational information
source for Medicare fee-for-service providers, the articles previously known as Medlearn Matters articles will now be
known as MLN Matters articles (the MLN standing for “Medicare Learning Network”).
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You will also notice a new logo at the top of the articles indicating the name change. The CMS knows that you have
come to rely on these articles to help you more easily understand new or changed Medicare policy and to help you gain
quick access to accurate Medicare program information.
The articles can now be accessed from www.cms.hhs.gov/MLNMattersArticles on the CMS Web site. If you have
previously bookmarked the “Medlearn Matters” page, please update your bookmark to the new URL.
We hope that you will continue to utilize these articles that are always prepared with the affected provider audience in
mind.
In conjunction with the above referenced change, the URLs for the Medicare Learning Network (MLN) Web pages have
also been changed. You can reach our MLN Web pages from the cms.hhs.gov main page—just click on “Outreach and
Education.” The full URLs to access the various MLN sections on the CMS Web site are:
•
•
MLN General Information: www.cms.hhs.gov/MLNGenInfo
MLN Products: www.cms.hhs.gov/MLNProducts
Also, note that if you know the specific number of an article you are after, such as SE0620, you can go directly to the
specific URL for an article by using the format below. For example, the Web site for SE0620 is
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0620.pdf.
For any other article, just substitute its number for the SE0620 in this URL to go directly to the PDF version of the
article on the CMS Web site.
Revisions to Instructions for Contractors Other Than the
Religious Nonmedical Health Care Institutions Specialty
Contractor Regarding Claims for Beneficiaries with Religious
Nonmedical Health Care Institutions Elections*
Related Change Request Transmittal #: R35GI, R45BP, and R851CP
Physicians, providers, and suppliers who may treat Medicare patients who have elected religious nonmedical health care
institution (RNHCI) care and bill Medicare fiscal intermediaries, regional home health intermediaries (RHHIs), carriers
and DMERCs for those services.
This Change Request (1) replaces the current process that develops claims via telephone inquiry for beneficiaries with
RNHCI elections with a letter using “yes” or “no” questions; (2) places into the CMS Internet-Only Manual (IOM)
Publication 100-04, Medicare Claims Processing manual religious nonmedical health care institution (RNHCI) claims
processing instructions; (3) restructures much of the existing RNHCI manual material to be more complete and
accessible; (4) defines the RNHCI; and (5) lists the qualifying criteria for RNHCI benefits.
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Note the business requirements in this Change Request that apply to your billing area.
For providers other than RNHCIs, use the letter issued by your contractor that asks questions key to determining
excepted versus nonexcepted care. For RNHCIs, incorporate the new claims submission instructions into your billing
procedures.
Background
The transmittal publishes enhancements to Medicare manuals to more clearly explain the RNHCI benefit. The majority
of these manual changes do not create any new business requirements. However, the transmittal revises instructions from
Program Memorandum AB-03-145.
That Program Memorandum changed the development process for claims for beneficiaries with RNHCI elections from a
review of medical records to a telephone contact process. The intent of Program Memorandum AB-03-145 was to
simplify the development process.
Since the issuance of Program Memorandum AB-03-145, a number of Medicare contractors (i.e., carriers and fiscal
intermediaries) other than the RNHCI specialty contractor have expressed sufficient concerns about the telephone
contact process to cause the CMS to revise that process.
Nonspecialty contractors with high volumes of RNHCI-related claims rejects reported difficulty contacting providers. In
addition, they reported beneficiaries were not willing or able to supply the necessary information to enable the contractor
to determine whether the care was excepted or nonexcepted care under RNHCI benefit policies.
These contractors also expressed concerns about the lack of written documentation from the provider in the telephonebased process. To address these concerns without reverting to a review of medical records, CMS has developed the
requirements listed below that will be incorporated into the letter issued to providers.
Briefly, if you bill Medicare for services provided to a patient who has elected RNHCI coverage, the following
requirements of Change Request 4218 will apply.
Requirements of Change Request 4218
Development Letters for Providers Other than RNHCIs
Upon receipt of a claim rejected by Medicare systems due to an RNHCI election on file for that Medicare beneficiary,
contractors must issue a development letter designed to determine whether care was excepted or nonexcepted.
Contractors must issue RNHCI development letters that ask questions about the following:
•
•
•
Whether the beneficiary paid for the services out of pocket in lieu of requesting payment from Medicare
Whether the beneficiary was unable to make his/her beliefs and wishes known before receiving the services that
have been billed, and
Whether, for a vaccination service, the vaccination performed was required by a government jurisdiction
The letters will phrase questions in RNHCI to be answered with a Yes or No response. The wording and format of this
letter will be based on the experience of your contractor in effectively communicating with their community of
providers.
Determinations Based on Development Letter
•
•
Contractors will make determinations of excepted or nonexcepted care based on provider responses to development
letters.
Contractors will make determinations within 30 days of receipt of the provider’s response.
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•
•
•
•
•
•
Contractors will make determinations of excepted care when a provider responds ‘Yes’ to any of the questions in the
letter.
Contractors will make determinations of nonexcepted care when a provider responds ‘No’ to all of the questions in
the letter.
Contractors will make an excepted/nonexcepted determination based on the evidence presented by the claim itself if
the provider does not reply in a timely manner to the development letter.
For claims for which no timely response was received, contractors will make a determination of nonexcepted care if
the claim contains durable medical equipment or prosthetic/orthotic devices.
For claims for which no timely response was received, contractor staff with a clinical background will use the
diagnoses and procedures reported on the claim to make their best determination whether the services were excepted
or nonexcepted care.
For claims for which no timely response was received, contractors will make determinations of excepted or
nonexcepted care within 30 days of the end of the timely response period.
For RNHCI Providers
Change Request 4218 provides complete instructions for completion of claims to Medicare. RNHCIs should review the
instructions in Change Request 4218 and ensure their current billing processes are consistent with these instructions. The
“Related Instructions” section of this article provides information on accessing the transmittals that comprise Change
Request 4218.
Implementation
The implementation date for the instruction is May 11, 2006.
Related Instructions
For a beneficiary to receive benefits under section 1821 of the Social Security Act (the Act) and payment under the
Medicare program upon admission to a RNHCI and prior to the RNHCI billing for services, the beneficiary must make a
written election.
The document detailing the process for a beneficiary to elect RNHCI care or to terminate that election is attached to
transmittal R45BP of Change Request 4218. Change Request 4218 may be viewed at
www.cms.hhs.gov/Transmittals/downloads/R45BP.pdf on the CMS Web site.
The ten qualifying provisions that must be met for a provider to de defined as an RNHCI, as contained in section
1861(ss) (1) of the Act for RNHCIs, are defined in transmittal R35GI of Change Request 4218. The transmittal may be
viewed at www.cms.hhs.gov/Transmittals/downloads/R35GI.pdf on the CMS Web site.
Chapter 3 (Inpatient Hospital Billing) of the CMS IOM Publication 100-04, Medicare Claims Processing manual was
also completely revised and is contained in transmittal R851CP of Change Request 4218. Transmittal R851CP is
available at www.cms.hhs.gov/Transmittals/downloads/R851CP.pdf on the CMS Web site.
The official instructions issued to the RNHCI intermediary regarding this change can be found in three parts, i.e., the
transmittals parts as shown in the Web addresses provided above.
2006 Jurisdiction List*
Effective Date: June 26, 2006
Implementation Date: June 26, 2006
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Physicians, providers, and suppliers who submit claims to Medicare DMERCs and Part B local carriers
Change Request 4363 provides notice of the spreadsheet containing the annual updated list of HCPCS for DMERC and
Part B local carrier jurisdictions.
The Excel spreadsheet containing these codes is available within the official instructions (Change Request 4363) issued
to your DMERC contractor and Part B carrier, which may be viewed at
www.cms.hhs.gov/Transmittals/downloads/R893CP.pdf
The list will also be available at www.cms.hhs.gov/center/dme.asp on the CMS Web site.
The above codes are updated on an annual basis. Be sure your billing staff is aware of these changes.
Background
The HCPCS is updated annually to reflect changes in medical practice and the provision of health care. The CMS
provides a file containing updated HCPCS codes to Medicare carriers, DMERCs, and intermediaries and to Medicaid
State Agencies 60 to 90 days before the implementation of the annual update.
CMS publishes a recurring update notification annually to notify the DMERCs and Part B carriers that the list has been
updated and is available on the CMS Web site.
Both the DMERCs and the local carriers publish this list to educate providers as to which contractor—the DMERC or
local Part B carrier—to bill for codes provided on that list.
Implementation
The implementation date for this instruction is June 26, 2006.
The official instructions issued to your DMERC and carrier regarding this change can be found at
New! Drug Coverage Materials for Health Care Professionals
For access to for a comprehensive list of links to agency-wide resources for providers on Medicare Rx coverage, visit the
CMS Web site at www.cms.hhs.gov/center/provider.asp, then scroll down to the “Part D Tools for Health Care
Professionals” link. The resources found at this link can help providers, suppliers and office staff access direct phone
numbers to a Medicare drug plan’s coverage determination staff, as well as obtain model forms that will help speed the
process. Additionally, a new fact sheet, as well as other educational products for the fee-for-service community, is now
available at www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site.
Source: CMS Joint Signature Memorandum 06-312, issued March 30, 2006
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Instructions for Provider Notification Regarding Streamlined
Drug Coverage Materials for Health Care Professionals, a
New Fact Sheet and Script for Recent Audio Conference*
MLN Matters Number: SE0619 Revised
Note: This article was revised to contain web addresses that conform to the new CMS Web site and to show they are
now MLN Matters articles. The Web address on page 2 for the fact sheet was also changed. All other information
remains the same.
Providers, physicians and suppliers and their staff who prescribe medications for Medicare patients
Key Points
The CMS has developed three new products as part of the Medicare Prescription Drug Coverage (Part D) campaign for
health care professionals:
Consolidated List of Links
A consolidated list of links to resources for prescribers is located at www.cms.hhs.gov/center/provider.asp on the CMS
Web site.
At this Web page, offices can get access to direct telephone numbers to a Medicare drug plan’s coverage determination
staff, as well as to obtain model forms that will help speed this process.
Educational information for fee-for-service providers is always available through our Medicare Learning Network drug
coverage page at www.cms.hhs.gov/MLNProducts/23_DrugCoverage.asp on the CMS Web site.
Transition Policy Fact Sheet
A new fact sheet regarding the new transition policy, as well as the exceptions and appeals process for Medicare
prescription drug coverage, is available for use in prescriber offices. This resource fact sheet provides ready links to
tools that will streamline the prescribing process under the new coverage.
CMS continues to work with groups representing physicians, pharmacists, patients and Part D plans to simplify and
standardize the information that physicians need to provide to plans.
The fact sheet is at www.cms.hhs.gov/MLNProducts/downloads/Part_D_Resource_Fact_sheet_revised.pdf on the CMS
Web site.
An Important Message for Providers Regarding Medicare Part D from CMS
Administrator Dr. Mark McClellan
Dr. McClellan’s message to providers describes the steps CMS is taking to implement the new Medicare prescription
drug coverage. Dr. McClellan also discusses helpful resources for providers. Streaming video of this message is
available at http://media.cms.hhs.gov/cms/McClellanPartDProvider.wmv on the CMS Web site.
Phone Conference Training Session
A PowerPoint presentation and audio replay of a recent phone conference training session is available, entitled “Working
with Plan Formularies: Transition Supplies, Prior Authorization, Quantity Limits, Step Therapy, and Exceptions.”
This training session is geared towards guiding office staff through the exceptions process. These materials are located at
http://media.cms.hhs.gov/cms/partner03022006.wma on the CMS Web site.
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Other Special Edition Articles
Other special edition articles regarding the prescription drug program include, but are not limited to, the following:
•
•
•
•
SE0618: “2006 Standard Medicare Prescription Drug Coverage: Understanding Costs to Beneficiaries,” available at
SE0603: “Medicare Prescription Drug Coverage: Essential Information and Resources for Prescribing Health Care
Professionals – The Eleventh in the MLN Matters Series on the New Prescription Drug Plans,” available at
SE0557: “Clarification on Part D and Fee-for-Service (FFS) Providers,” available at
SE0502: “The Facts for Providers Regarding the Medicare Prescription Drug Program,” is available at
An Important Message for Providers Regarding Medicare Part
D from the Centers for Medicare & Medicaid Services
Administrator, Dr. Mark McClellan
“Prescribers are vital to the well being of their patients, and the [Centers for Medicare & Medicaid Services] CMS is
doing everything we can to streamline the new Part D coverage to make it easier for you to help your patients, while not
infringing on the scarce clinical time you have with them. The following link will take you to a video that we hope
explains what we are doing during the transition to help prescribers and their office staffs smooth the process of prior
authorizations, exceptions and appeals. Go to our provider center at www.cms.hhs.gov/center/provider.asp (go to Part D
tools) and select the video. There are a number of other useful lists that we have assembled there to help ease the process
of helping your patients with their new drug coverage.
CMS has a dedicated e-mail for prescriber questions at [email protected], as well as a standing teleconference every
Tuesday at 2:00 p.m. by calling (1-800) 619-2457, Passcode: RBDML”
Centers for Medicare & Medicaid Services Seeks Provider
Input on Satisfaction with Medicare Fee-for-Service
Contractor Services*
Medlearn Matters Number: SE0602 Revised
Implementation Date: January 3, 2006
Note: This article was revised on March 17, 2006, to show the data collection period will continue through April 2006.
Sample of 25,000 Medicare providers served by 42 Medicare fee-for-service contractors, including fiscal intermediaries,
carriers, DMERCs and RHHIs
The CMS would like to provide a channel for you to voice your opinions about the services you receive from your feefor-service contractors. The Medicare Contractor Provider Satisfaction Survey (MCPSS) is designed to gather
quantifiable data on provider satisfaction with the performance of fee-for-service contractors. The MCPSS is one of the
tools CMS will use to measure provider satisfaction levels, a requirement of the Medicare Modernization Act (MMA).
Specifically, the survey will enable CMS to gauge provider satisfaction with key services performed by the 42
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contractors that process and pay the more than $280 billion in Medicare claims each year. Those Medicare contractors
will use the results to improve service. CMS will use the results to improve its oversight of and increase the efficiency of
the administration of the Medicare program.
The first national implementation of the MCPSS will begin January 3, 2006. If you have been selected, you will receive
a notification packet in the mail with background information about the survey, as well as an instruction sheet with
information on how to access and complete the survey instrument via a secure Internet Web site. The letter will also
include a phone number that you can call to request a paper copy of the survey instrument to submit your responses by
mail or fax, if you prefer to do so.
Be alert for a notification packet in the mail. If you are selected and receive the notification packet, please take the time
to complete and submit your survey responses as soon as possible. The data collection period will continue through April
2006.
Background
The 2006 survey will query approximately 25,000 randomly selected providers—those physicians, healthcare
practitioners and facilities that serve Medicare beneficiaries across the country—on the seven key areas of the providercontractor interface:
•
•
•
•
•
•
•
Provider communications
Provider inquiries
Claims processing
Appeals
Provider enrollment
Medical review
Provider audit and reimbursement
It contains a total of 76 questions and takes approximately 21 minutes to complete. The target date to respond is
approximately three weeks after receipt of the notification packet. CMS will analyze the data and release a summary
report in July that will be made available on the Internet. Each contractor will also receive an individual report on their
performance in June. The MCPSS will be conducted on an annual basis.
CMS has awarded a contract to Westat, a survey research firm, to administer the MCPSS.
For questions or additional information about the MCPSS, please visit www.cms.hhs.gov/MCPSS/ on the CMS Web site.
Facilitating Your Medicare Enrollment*
All Medicare physicians, providers, and suppliers
Background
On May 1, 2006, the CMS issued the revised CMS-855 Medicare enrollment applications. Providers and suppliers
should begin to use the new Medicare enrollment applications immediately. Initially, these applications will be available
only from the CMS provider enrollment Web site. The link for that CMS Web site is listed in the Additional Information
section of this article.
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Key Points
This Medicare Learning Network Special Edition article provides additional information regarding the submission of a
Medicare enrollment application.
All Provider Enrollment Applications
To ensure timely processing of your application, make certain to completely fill out the application and provide all
required supporting documentation at the time of filing.
Section 17 of the Medicare enrollment application lists the types of supporting documentation that you will need to
submit with your enrollment application. In addition to providing the documentation previously required, all applicants
are required to:
•
•
Submit their National Provider Identifier (NPI) and a copy of the NPI notification furnished by the National Plan
and Provider Enumeration System (NPPES) with each enrollment application; and
Complete the Authorization Agreement for Electronic Funds Transfer (CMS-588) when initially enrolling or—if
they are currently not receiving payments via EFT—making a change to their enrollment information.
To obtain a list of specific supporting documentation that you must submit with your enrollment application, contact the
designated Medicare fee-for-service contractor serving your area before submitting your application.
Contractor Request for Additional Information
At any time during the enrollment process, your carrier or fiscal intermediary may request documentation to support or
validate information that you have reported on your application. Applicants are responsible for providing this
documentation in a timely manner. Failure to provide documentation in a timely manner may delay your enrollment into
the Medicare program.
Applications Received Through June 2, 2006
Medicare contractors will continue to accept the 11/2001 version of the Medicare enrollment applications through June
2, 2006, as long as the application is complete and contains the NPI notification from NPPES. In addition, providers and
suppliers who choose to use the 11/2001 version of the 855 will be required to complete and submit Section 1 or Section
4 (completed by the provider) of the 04/2006 version of the CMS-855. Providing this information will ensure that
Medicare is able to link existing Medicare identification number(s) to the NPI that the provider or suppliers plan to use
for billing purposes.
Specifically, Section 1 must be completed by Physician Assistants and providers reassigning all of their benefits, as this
is where NPI data is reported. All other providers must furnish the NPI and Medicare Identification Number in Section 4
of the CMS-855; this is the only data that must be reported in Section 4.
Applications Received On or After June 5, 2006
All applications received on or after June 5, 2006, must be filed using the 04/2006 version of the CMS-855 and contain
all supporting documentation, including the NPI notification and the CMS-588.
For additional information regarding the Medicare enrollment process, including the mailing address and telephone
number for the carrier or fiscal intermediary serving your area, visit www.cms.hhs.gov/MedicareProviderSupEnroll on
the CMS Web site.
Medicare Learning Network Special Edition articles SE0612 and SE0632 contain helpful information about the
Medicare enrollment process. You may review the article on the CMS Web site at
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0612.pdf, and
www.cms.hhs.gov/MLNMattersArticles/downloads/SE0632.pdf, respectively, on the CMS site.
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AdminaStar Federal
MMA—The Centers for Medicare & Medicaid Services
Recovery Audit Contractor Initiative*
Physicians, providers and suppliers, especially in California, Florida and New York
Based on comments received during provider open door forums and community meetings, CMS has amended the
payment methodology for the Recovery Audit Contractors (RACs) to include payment for the identification of Medicare
underpayments.
Background
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, section 306, directs the
secretary of the U.S. Department of Health and Human Services (HHS) to demonstrate the use of RACs under the
Medicare Integrity Program in: (1) identifying underpayments and overpayments; and (2) recouping overpayments under
the Medicare program (for services for which payment is made under Part A or Part B of Title XVIII of the Social
Security Act).
Update
The RACs are paid on a contingency basis; that is, the RACs receive a portion of what they identify and collect.
Beginning with underpayments identified on or after March 1, 2006, the RACs will receive an equivalent percentage for
all underpayment and overpayment identifications.
The RACs will use the same methodologies of automated and complex reviews to identify potential Medicare
underpayments.
Important Things Providers Need to Know About the Underpayment Identification
Portion of the Recovery Audit Contractor Demonstration
•
The RAC may request a medical record for an underpayment determination. However, the medical record request
letter will not indicate if the medical record is being requested for overpayment or underpayment review. When
responding to a medical record request from the RAC, the provider may attach its own opinion regarding an
underpayment. However, the findings from the RAC may differ from that of the provider.
•
Upon identification of a potential underpayment, the RAC will forward the claim and all supporting documentation
to the appropriate Medicare fiscal intermediary, carrier or DMERC for their review. An underpayment identification
will not be final unless the fiscal intermediary, carrier or DMERC agrees with the identification. The RAC or the
fiscal intermediary, carrier or DMERC will not ask the provider to correct and resubmit the claim. Under the RAC
demonstration, the RAC contractors have no authority to make refunds. Therefore, once the underpayment has been
validated by the appropriate fiscal intermediary, carrier or DMERC, the RAC will send the provider written notice
of the underpayment determination. This notice will include claim and beneficiary details.
•
The RACs do not have the authority to review unsolicited cases from providers where underpayment is thought to
have occurred. Outside of the RAC program if a provider feels they have received an underpayment they may
resubmit a corrected claim if the timely filing limit has not yet passed.
•
The provider does not have any official appeals rights in relation to an underpayment determination. The provider
may utilize the RAC rebuttal process and discuss the underpayment determination with the RAC. If the provider
disagrees with the RAC that an underpayment exists, the RAC will defer to the billing provider’s judgment.
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AdminaStar Federal
Definition of an Underpayment
For purposes of the RAC demonstration, a Medicare underpayment is defined as those lines or payment groups
(ambulatory payment classification [APC], resource utilization group [RUG]) on a claim that were billed at a low level
of payment but should have been billed at a higher level of payment. The RAC will review each claim line or payment
group and consider all possible occurrences of an underpayment in that one line or payment group.
If changes to the diagnosis, procedure or order of diagnoses would change a line or payment group on the claim from a
low level of payment to a higher level of payment (and the medical record supports such a change), an underpayment
exists. Service lines or payment groups that a provider failed to include on a claim are not considered underpayments for
the purposes of this demonstration.
Note: CMS has excluded the review of physician evaluation and management codes relevant to the level of an office
visit or the medical necessity of the level of office visit from the RAC demonstration. This includes the review of
overpayments and underpayments.
Examples of an Underpayment
The following are considered underpayments:
•
•
•
•
The provider billed for 15 minutes of therapy when the medical record clearly indicates 30 minutes of therapy was
provided. (This provider type is paid based on a fee schedule that pays more for 30 minutes of therapy than for 15
minutes of therapy.)
The provider billed for a particular service and the amount the provider was paid was lower than the amount on the
CMS physician fee schedule.
A diagnosis/condition was left off the minimum data set (MDS) but appears in the medical record. Had this
diagnosis or condition been listed on the MDS, a higher payment group would have been the result.
The physician submitted a claim for a surgical procedure using a code for a simpler procedure when in fact the
procedure was a more complex one such as in the case of skin repair which can be billed at a simple, intermediate,
or complex level depending upon size and complexity.
The following are not considered underpayments:
•
•
•
The medical record indicates that the provider performed additional services such as an EKG, but did not bill for the
service.
The provider billed for 15 minutes of therapy when the medical record clearly indicates 30 minutes of therapy was
provided; however, the additional minutes do not affect the GROUPER or the PRICER. (This provider type is paid
based on a prospective payment system that does not pay more for this much additional therapy.)
The medical record indicates that the provider implanted a particular device for which a device APC exists (and is
separately payable over and above the service APC), but the provider did not bill for the device APC.
Questions concerning the RAC demonstration may be directed to a special e-mail address CMS has established
specifically for the demonstration: cms [email protected].
Find out more about the MMA of 2003 at www.cms.hhs.gov/MMAUpdate/ on the CMS Web site.
Cultural Competency: A National Health Concern*
This article is for informational purposes only and does not affect Medicare billing processes.
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AdminaStar Federal
Background
The increasing diversity of the racial, ethnic and linguistic composition of the United States challenges providers as they
strive to deliver health care services. Cultural and language differences between patients and providers may generate
miscommunication of critical health care information, a lack of compliance with prescribed treatment or medication, or
other factors that negatively influence clinical situations and health outcomes. The existence of racial and ethnic
disparities in health has been well documented by organizations such as the Institute of Medicine and the Agency for
Healthcare Research and Quality.
Cultural competency, or the ability of health care providers to work effectively with colleagues and patients in crosscultural situations, is a vital component of professional competence. Culturally competent practice can offer a variety of
benefits to health care providers and their organizations, including:
•
•
•
•
•
Improved patient care and satisfaction
Decreased malpractice risk
Enhanced operational efficiency
Increased compliance with state and federal regulations
Reduction in health disparities
Highlights of the CMS’ Activities to Address Health Disparities
To ensure that providers are prepared for the challenges they face to deliver the right care to every person every time,
CMS’s Quality Improvement Organizations (QIOs) are working with healthcare providers to become more effective and
culturally aware of how they provide care to diverse populations. As part of a national initiative, QIOs are recruiting health
providers to participate in a free online (Web-based) program, “A Family Physician’s Practical Guide to Culturally
Competent Care,” to ensure that Medicare providers are prepared to effectively serve the increasingly diverse patient
population. QIOs have adopted the guide as the “Program of Choice” for health care provider cultural competency
education. The guide is an innovative educational product designed to equip health care providers with the cultural and
linguistic competencies required to improve the quality of care for minority, immigrant and ethnically diverse communities.
A “Family Physician’s Practical Guide to Culturally Competent Care” is anchored in the three themes of the National
Standards for Culturally and Linguistically Appropriate Services in Health Care, and serves a key initiative in helping
the Department of Health and Human Services’ Office of Minority Health to achieve its mission of “improving the
health of racial and ethnic minority populations’ through the development of effective health policies and programs that
help to eliminate disparities in health care.”
A “Family Physician’s Practical Guide to Culturally Competent Care” is a case study based curriculum, featuring video
vignettes and a diverse group of providers and clinic staff at a fictional practice setting that reinforce learning points
throughout the modules. Participants can also share their reactions to the case studies in an online bulletin-board feature.
This program was designed with the busy health care provider in mind, offering “anytime, anywhere” continuing
education credit in an engaging and innovative format.
This curriculum is available to all health care providers at www.thinkculturalhealth.org. The program is accredited for
Continuing Medical Education credits for physicians and Continuing Education Units for nurses and pharmacists.
Please visit www.thinkculturalhealth.org to access the free accredited continuing education program, “A Family
Physician’s Practical Guide to Culturally Competent Care,” and to view updates about the nursing program.
To access the free program, “A Family Physician’s Practical Guide to Culturally Competent Care,” please visit
www.thinkculturalhealth.org.
The National Standards for Culturally and Linguistically Appropriate Services in Health Care are available at
www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15.
For more information about the QIO cultural competency initiative, please visit www.qsource.org/uqiosc/.
Additional information about the Office of Minority Health is available at www.omhrc.gov/.
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AdminaStar Federal
CMS Regional Offices’ Online Quarterly Publication—The
Pulse of CMS, Spring 2006—Now Available for Viewing
The Philadelphia CMS regional office is pleased to share with suppliers the spring 2006 edition of The Pulse of CMS.
This edition is an abbreviated edition due to the high volume of Medicare Part D-related casework that the CMS regional
offices have been involved with since January.
The spring 2006 edition features highlights several topics, including:
•
•
•
An update on enrollment into Medicare Part D plans
The Medicare Contractor Provider Satisfaction Survey, and
Preparing for an Avian Flu Outbreak
The next edition of The Pulse of CMS is scheduled to be published in June 2006.
Region B Suppliers can view the spring 2006 The Pulse of CMS issue on the AdminaStar Federal Web site at the
following link: www.adminastar.com/News/DMERCNews/files/PhillySpring2006.pdf
AdminaStar Federal Contact Information
AdminaStar Federal Web Site
www.adminastar.com
Administrative Law Judge
P.O. Box 50448
Advance Determination of Medicare Coverage (ADMC)
TriCenturion, LLC
ADMC Region B
7909 Parkland Road, Suite 190
Fax: 803-419-6080
Beneficiary Customer Service
1-800-MEDICARE (1-800-633-4227)
TDD 317-841-4677
Claim Filing Addresses
DMEPOS Assigned
P.O. Box 7027
Indianapolis, Indiana
46207-7027
DMEPOS Nonassigned
P.O. Box 7031
46207-7031
Oxygen Assigned
P.O. Box 7048
46207-7048
Oxygen Nonassigned
P.O. Box 7052
46207-7052
PEN Assigned
P.O. Box 7037
46207-7037
PEN Nonassigned
P.O. Box 7042
46207-7042
Coordination of Benefits (COB)
Medicare—Coordination of Benefits
P.O. Box 5041
New York, New York 10274-5041
1-800-999-1118
DMEPOS Additional Documentation Requests (ADR)
P.O. Box 7061
-88-
AdminaStar Federal
Electronic Data Interchange (EDI)
Helpdesk:
1-877-ASF-4EDI (1-877-273-4334)
8:00–11:30 a.m./12:00–4:00 p.m. (ET) M–W, F
8:30–11:30 a.m. /12:00–4:00 p.m. (ET) TH
E-Commerce:
804-746-7082—Lisa Hare
414-774-4556—Pat Graham
Fair Hearings (for Redeterminations made prior to
January 1, 2006)
AdminaStar Federal
P.O. Box 50462
Reconsiderations (for Redeterminations made on or
after January 1, 2006)
Q2 Administrators, LLC
Part B/DME West Operations
P.O. Box 100213
Columbia, South Carolina 29202-0213
Fraud and Abuse
TriCenturion, LLC
7909 Parklane Rd. Suite 190
803-264-7700
Freedom of Information (FOI)
P.O. Box 50454
Medicare Secondary Payer (MSP)
Medicare MSP DMERC
Lockbox #660065
(refund checks and refund correspondence)
Medicare Secondary Payer
P.O. Box 7091
(correspondence only)
National Supplier Clearinghouse (NSC)
National Supplier Clearinghouse
P.O. Box 100142
Columbia, South Carolina 29202-3142
1-866-238-9652
Customer Services/Interactive Voice Response
(IVR) Unit
1-877-299-7900 (8:00 a.m.–5:30 p.m. (ET)
Refunds
Payment Correction Unit
PCU—DMERC—Indiana
Lockbox #660078
P. O. Box 50403
317-841-1307
8:00 a.m.–4:00 p.m. (ET)
Redeterminations
Telephone Reopenings
317-841-1307
Written Correspondence
P.O. Box 240
-89-
AdminaStar Federal
Attachments
•
•
TriCenturion ADMC Request Form
The Pulse of CMS, Spring 2006 Edition
-90-
AdminaStar Federal
Advance Determination of Medicare Coverage
Request Coversheet
Tricenturion
7909 Parklane Road
Suite 190
Please use this coversheet for Advance Determination of Medicare Coverage (ADMC). This information will help
in the timely processing of your ADMC request.
Please indicate which Region you are requesting an ADMC:
Region A _____
Region B _____
Please complete the following fields:
ADMC HCPCS code(s) and narrative for base wheelchair: ______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Company Name:__________________________________________________________________________________
Company Address:________________________________________________________________________________
________________________________________________________________________________________________
Supplier #:_______________________________________________________________________________________
Contact Name: ___________________________________________________________________________________
Phone #: ________________________________________________________________________________________
Beneficiary Name: ________________________________________________________________________________
Beneficiary Address: ______________________________________________________________________________
________________________________________________________________________________________________
HICN#: ________________________________________
Date Faxed:_____________________________________
Number of Pages (including coversheet):_____________
Mail ADMC Requests To:
Tricenturion
Attention: ADMC
7909 Parklane Road
Suite 190
Fax Number: 803-419-6080, Attention: ADMC
SPRING 2006
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Philadelphia Regional Office
The Pulse of CMS
“A quarterly regional publication for health care professionals”
Maryland, Pennsylvania,
Pennsylvania,Virginia,
Virginia, West
West Virginia
Virginia and
and the
the District
District of Columbia.
Columbia.
Serving Delaware, Maryland,
CALLING ALL DOCS: SIGN UP NOW FOR THE PHYSICIAN VOLUNTARY REPORTING
PROGRAM!! GO TO THE PVRP PAGE ON THE CMS WEBSITE FOR MORE INFO.
More Than 27 Million Beneficiaries Are Now
Enrolled in Prescription Drug Coverage
The number of Medicare beneficiaries receiving
prescription drug coverage continues to grow with
more than 27 million Medicare beneficiaries
covered as mid-March. This number includes the
7.2 million beneficiaries who have signed up
individually for coverage since the enrollment
period began on November 15. HHS Secretary
Michael Leavitt noted that those with coverage
include not only those in new stand-alone
prescription drug plans, but also those in Medicare
Advantage plans made stronger by the new law,
as well as retirees who are in employer/unionsponsored plans that are getting support from
Medicare for the first time.
For the vast majority of seniors, the benefit is
working, with more than one million prescriptions
being filled every day. At the same time, CMS
continues to monitor and identify problems that
any beneficiary may have in obtaining their
State
Stand-Alone
Prescription
Drug Plan
Delaware
District of
Columbia
Maryland
Pennsylvania
Virginia
West Virginia
Total in
Region III
Total in the
U.S.
medications. CMS is taking steps to ensure a
smoother process when dual-eligible beneficiaries
switch plans, especially when changes occur near
the end of the month. CMS is also providing
extended transitional coverage of beneficiaries’ prior
drugs and making sure plans follow this requirement.
Medicare beneficiaries are still being encouraged to
sign up for drug coverage early in the month before
they want coverage. “Signing up before the 15th
makes it more likely that you will get your
prescriptions filled quickly the first time you use your
coverage, says CMS Administrator Mark B.
McClellan, M.D., Ph.D. The enrollment period
continues through May 15, 2006.
The table below shows the enrollment figures for the
states in Region III as of March 18, 2006. For more
information and resources, visit the Part D
Information for Physicians page of the CMS website.
MedicareMedicaid
(AutoEnrolled)
Medicare
Retiree
Drug
Subsidy
34,907
5,259
Medicare
Advantage
with
Prescription
Drugs
587
4,810
30,043
2,956
Estimated
Federal
Retirees
(Tricare,
FEHB)
12,125
23,179
9,849
15,587
127,080
221,178
195,376
70,653
654,453
30,589
498,227
32,465
10,325
577,003
6,360,414
5,671,199
Total with
Drug
Coverage
87,511
51,791
58,234
156,977
105,323
42,179
388,149
117,950
274,615
107,356
81,860
614,780
132,136
124,021
196,905
21,140
509,506
465,989
1,275,018
637,425
226,157
2,743,891
5,772,171
6,221,371
3,545,473
27,570,628
Make Your Voice Heard:
Medicare Contractor
Provider Satisfaction Survey
On January 3, 2006, CMS launched the first
national implementation of the Medicare
Contractor Provider Satisfaction Survey (MCPSS).
This new initiative measures the satisfaction of
fee-for-service providers with each of the 42
contractors who are responsible for services such
as educating providers about changes, responding
to provider inquiries, and processing and paying
the more than $280 billion in Medicare claims
each year. Many Medicare providers are taking
the opportunity to voice their opinions on the
administration of the Medicare program. The
views of every provider asked to participate are
important to the success of this survey, as each
one represents many other organizations that are
similar in size, practice type and geographical
location. The feedback from providers will be
used to improve the program’s efficiency.
If you are one of the 25,000 providers randomly
chosen to participate in the MCPSS, please take
the time to complete the survey if you have not
already done so. CMS will contact nonrespondents by telephone in the coming weeks to
encourage their participation. Survey
administration will continue through April and
results will be available to contractors and the
public in July 2006.
Additional information about the MCPSS is
available at: http://www.cms.hhs.gov/MCPSS/
Inside this Issue...
Update on CMS Website.....................................2
Preparing for a Pandemic....................................2
Medicare Part D Transitional Coverage
Toolkit is now available!!
Electronic File Interchange……………………..2
The Pulse of CMS
Page 2
Update
on the CMS Website
CMS launched its redesigned website at
Preparing
for a Pandemic: What
Can You Do?
Preparedness is crucial for all involved in the
preparedness plans. Encourage your hospitals to
www.cms.hhs.gov on December 15, 2005. The new
website features consistent organization and
navigation; timely, relevant and accurate content;
and an improved Google search feature. The new
website has one-stop-shopping areas called Centers
that are targeted to your specific professional needs.
For example, if you are a provider or partner you will
have the option to browse the website by your area
of interest.
delivery of health care. CMS has been working
with our partners to ensure that all beneficiaries
have access to care and that all essential
business functions will continue in the event of an
emergency including Avian Influenza Pandemic.
The Department of Health and Human Services
(HHS) has been sponsoring Pandemic Summits
throughout the country since the beginning of the
year. States are in the process of developing
pandemic plans to respond in the event of an
outbreak of the avian flu. HHS pandemic planning
checklists and updated avian flu information is
available at www.pandemicflu.gov.
CMS will continue to evaluate the new website in
order to provide the best organization and navigation
– so you can continue to retrieve the information you
are looking for in the most efficient way possible.
CMS welcomes your feedback and encourages you
to let us know how we can improve your visit to our
website. Please visit the Submit Feedback form to
offer your suggestions.
Provider Outreach Staff:
Barbara Cerbone
Phone: (215) 861-4320
Kathy Nguyen
Phone: (215) 861-4163
Marcia Dashevsky
Phone: (215) 861-4194
Maureen Savory
Phone: (215) 861-4292
Patrick Hamilton
Phone: (215) 861-4097
Stanley Sokolove
Phone: (215) 861-4257
Mark Vogel
Phone: (215) 861-4323
Philadelphia Regional
Office:
150 S. Independence Mall West
The Public Ledger Building, Suite 216
Philadelphia, PA 19106
Phone: 215-861-4140
Fax: 215-861-4240
Email: [email protected]
Information Disclaimer:
The information provided in this newsletter is intended only
to be general summary information to the Region III
provider community. It is not intended to take the place of
either the written law or regulations.
Links to Other Resources:
Our newsletter may link to other federal agencies. You are
subject to those sites’ privacy policies. Reference in this
newsletter to any specific commercial products, process,
service, manufacturer, or company does not constitute its
endorsement or recommendation by the U.S. government,
HHS or CMS. HHS or CMS is not responsible for the
contents of any “off-site” resource identified.
The most vigorous preparations for any type of
emergency are done at the local level. In the event
of an outbreak, local health services will be quickly
overwhelmed. Given that providers practice at the
local level, some may be first responders. It is
essential that providers work with their local
hospitals to make sure they are involved and
knowledgeable about the institutions emergency
provide training for providers and participate in the
hospitals training exercises.
What can providers do now to be prepared?
First, providers need to remain up to date about
emerging infectious disease trends and threats, as
well as current immunization recommendations.
Consider encouraging your patients to maintain at
least a one week supply of medications available
for emergencies. It is also very important that all
providers develop an office preparedness plan
that would include how acute medical issues will
be addressed in the event containment and
quarantine is in place. On the business side, ask
your carriers about their payment plans during an
emergency.
The Centers for Disease Control has an excellent
provider communication website available at
www.bt.cdc.gov/coca which members of the
medical community can visit for up-to-date
information regarding disease outbreaks.
The Latest on the Electronic File Interchange Process
CMS just released several documents on the
Electronic File Interchange (EFI) process. EFI,
also referred to as “bulk enumeration,” is a
process by which a health care provider or group
of providers can have a particular organization
apply for National Provider Identifiers (NPIs) on
their behalf. For example, a large group practice
may want to have its staff handle the NPI
applications for all its members. If an
organization/provider employs all or a majority of
its physicians and is willing to be considered an
EFI submitter, EFI enumeration may be a good
solution for that group of providers. EFI
documents posted to the web include a summary,
user’s guide and technical companion manual.
A new fact sheet for health care providers who are
individuals is also now available.
Visit
http://www.cms.hhs.gov/NationalProvidentStand/
to download these new items.
The EFI Steps
Once EFI is available, concerned entities will
follow these steps:
An organization that is interested in being an
EFI organization will log on to an EFI home
page (currently under construction) on the
NPPES web site and download a
certification form.
The organization will send the completed
certification form to the Enumerator to be
considered for approval as an EFI
organization (EFIO).
Once notified of approval as an EFIO, the
entity will send files in a specified format,
containing NPI application data, to the
NPPES.
Providers who wish to apply for their NPI(s)
through EFI must give the EFIO permission
to submit their data for purposes of applying
for an NPI.
Files containing NPI application data, sent to
NPPES by the EFIO, will be processed.
NPI(s) will be assigned and the newly
assigned NPI(s) will be added to the files
submitted by the EFIO.
The EFIO will then download the files
containing the NPI(s) and will notify the
providers of their NPI(s). An EFIO may also
be used for updates and deactivations, if the
providers agree to do so.

Region B DMERC Supplier Bulletin, June 2006, Volume

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