How to Enroll in Medicare Electronic Data Interchange
The Centers for Medicare & Medicaid Services (CMS) Standard Electronic Data Interchange (EDI) Enrollment Form must be completed prior to submitting electronic media claims (EMC) or other EDI transactions to Medicare. The agreement must be executed by each provider of health care services, physician, or supplier that intends to submit EMC or use EDI, either directly with Medicare or through a billing service or clearinghouse.
Each new EMC biller must sign the form and submit it to their local Medicare carrier, durable medical equipment regional carrier (DMERC), or fiscal intermediary. For more information regarding the CMS Standard EDI Enrollment Form, please contact your local Carrier, DMERC or Intermediary.
An organization comprising of multiple components that have been assigned Medicare provider numbers, supplier numbers, or UPINs may elect to execute a single EDI Enrollment Form on behalf of the organizational components to which these numbers have been assigned. The organization as a whole is held responsible for the performance of its components.
Showing posts with label Provider Enrollment tips. Show all posts
Showing posts with label Provider Enrollment tips. Show all posts
Do we need to report Medicare when new location opened?
Q: If a provider/supplier establishes a new practice, opens a new facility, or closes/changes the address of an existing practice/facility, how long does the provider/supplier have to inform Medicare of the “reportable event”? How should the change be reported?
A: Any change in practice or facility location (e.g., establish new location, move existing location, close existing location) address must be reported to the provider/supplier’s Medicare administrative contractor (MAC) no later than 30 days after the “reportable event” occurred.
Providers and suppliers should utilize the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) external link to update their Medicare enrollment record. Registered users may use the system for initial enrollment as well as to change, reactivate, or voluntarily terminate an existing enrollment record.
When to complete a CMS-460
The CMS-460 may only be completed by new physicians, practitioners, and suppliers looking to become participating providers during initial enrollment and during annual participation open enrollment.
When to complete an EFT (CMS-588)
An EFT (CMS-588) is to be used to enroll in electronic payments. All providers enrolling in Medicare are required to submit an EFT in order to receive payments.
Where do I submit my provider enrollment documentation?
Medicare Provider Enrollment
First Coast Service Options Inc.
P.O. Box 44021
Jacksonville, FL 32231-4021
A: Any change in practice or facility location (e.g., establish new location, move existing location, close existing location) address must be reported to the provider/supplier’s Medicare administrative contractor (MAC) no later than 30 days after the “reportable event” occurred.
Providers and suppliers should utilize the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) external link to update their Medicare enrollment record. Registered users may use the system for initial enrollment as well as to change, reactivate, or voluntarily terminate an existing enrollment record.
When to complete a CMS-460
The CMS-460 may only be completed by new physicians, practitioners, and suppliers looking to become participating providers during initial enrollment and during annual participation open enrollment.
When to complete an EFT (CMS-588)
An EFT (CMS-588) is to be used to enroll in electronic payments. All providers enrolling in Medicare are required to submit an EFT in order to receive payments.
Where do I submit my provider enrollment documentation?
Medicare Provider Enrollment
First Coast Service Options Inc.
P.O. Box 44021
Jacksonville, FL 32231-4021
CMS855R - Medicare reassignment form download and tips to avoid mistakes
When to complete a CMS-855R
CMS-855R is to be used for Reassignment of Medicare Benefits -- Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments, or are terminating a reassignment of benefits.
Reassigning your Medicare benefits allows an eligible supplier to submit claims and receive payment for Medicare Part B services that you have provided. Such an eligible supplier may be an individual, a clinic/group practice or other organization.
Things to consider:
• Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner) in the Medicare program before the reassignment can take effect.
• Generally, this application is completed by a supplier, signed by the individual practitioner, and submitted by the supplier.
• When terminating a current reassignment, either the supplier or the individual practitioner may submit this application with the appropriate sections completed.
• The individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for service contractor of any future changes to the reassignment in accordance with 42 C.F.R. 424.516(d)(2).
• An individual will not need to reassign benefits to a corporation, limited liability company, professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for Physicians and Non-Physician Practitioners for more information.
• Physician assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported in Sections 2E through 2G of the CMS-855I
Download CMS-855R external pdf file
• Find step-by-step guidance to completing the CMS-855R form
• View a simulation flash file on how to avoid the No. 1 reason applications are denied
CMS-855R is to be used for Reassignment of Medicare Benefits -- Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments, or are terminating a reassignment of benefits.
Reassigning your Medicare benefits allows an eligible supplier to submit claims and receive payment for Medicare Part B services that you have provided. Such an eligible supplier may be an individual, a clinic/group practice or other organization.
Things to consider:
• Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner) in the Medicare program before the reassignment can take effect.
• Generally, this application is completed by a supplier, signed by the individual practitioner, and submitted by the supplier.
• When terminating a current reassignment, either the supplier or the individual practitioner may submit this application with the appropriate sections completed.
• The individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for service contractor of any future changes to the reassignment in accordance with 42 C.F.R. 424.516(d)(2).
• An individual will not need to reassign benefits to a corporation, limited liability company, professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for Physicians and Non-Physician Practitioners for more information.
• Physician assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported in Sections 2E through 2G of the CMS-855I
Download CMS-855R external pdf file
• Find step-by-step guidance to completing the CMS-855R form
• View a simulation flash file on how to avoid the No. 1 reason applications are denied
When to use a CMS-855I - Individual provider - tips to avoid error
CMS-855I is to be used by Physicians and non-physician practitioners (including clinical psychologists) -- Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17 of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for- service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner.
• If you provide services in a group/organization setting, you will also need to complete a separate application, the CMS-855R, to reassign your benefits to each organization. If you terminate your association with an organization, use the CMS-855R to submit that change.
All physicians, as well as all non-physician practitioners listed below, must complete this application to initiate the enrollment process:
• Anesthesiology Assistant
• Audiologist
• Certified nurse midwife
• Certified registered nurse anesthetist
• Clinical nurse specialist
• Clinical social worker
• Mass immunization roster biller
• Occupational therapist in private practice
• Physical therapist in private practice
• Physician assistant
• Psychologist, Clinical
• Psychologist billing independently
• Registered Dietitian or Nutrition Professional
• Speech Language Pathologist
Download CMS-855I external pdf file
Download CMS-855I
• Find step-by-step directions to completing the CMS-855I form.
• View how to avoid the errors flash file that result in the CMS-855I form not being processed, specifically missing signatures or other required information.
how to avoid the errors
Who shuould sign Medicare Enrollment form ? Can other than provider sign the form?
Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
When to use a CMS-855B form and tips to avoid error
CMS-855B is to be used by Clinics/group practices and certain other suppliers -- Complete this application if you are an organization/group that plans to bill Medicare and you are:
• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).
• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location).
The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (IDTF)
• Intensive Cardiac Rehabilitation Supplier
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Part B Drug Vendor
• Portable X-ray Supplier
• Radiation Therapy Center
• Pharmacy
Note: Are you a supplier looking for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) enrollment? Please visit CGS Medicare external link, the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.
Download CMS-855B external pdf file
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855b.pdf
• View how to avoid the errors flash file that result in the CMS-855B form not being processed, specifically missing signatures or dates in Section 15B and Section 16A.
http://medicare.fcso.com/pe_tips_and_tutorials/138139.asp
CMS-855 applications
When to complete a new CMS-855
Q: When do I need to complete a new CMS-855?
A. You need to complete a new CMS-855 when:
• An individual or entity is requesting initial enrollment into the Medicare program.
• Changes are being submitted to update enrollment information and the individual or entity does not have a completed enrollment application (CMS-855) on file.
• An individual or entity is submitting a request for Electronic Funds Transfer (EFT) and an enrollment application is not on file.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
How to complete a CMS-855 form
Q: How do I complete a CMS-855 form? How can I be sure that I have everything I need?
A: Medicare enrollment applications/forms (CMS-855A, CMS-855B, CMS-855I, and CMS-855R) must be completed with accurate information and include all supporting documentation.
First Coast Service Options Inc. (First Coast) offers several online resources to assist you during the provider enrollment process including:
• CMS-855 tutorials
• Institutional providers: CMS-855A flash file
• Clinics/group practices and certain other suppliers: CMS-855B flash file
• Physicians and non-physician practitioners: CMS-855I flash file
• Reassignment of benefits: CMS-855R flash file
• Provider enrollment tips, terms, and specialty codes:
• Tips to expedite your Medicare enrollment process
• Commonly used provider enrollment terms and their definitions
• Medicare provider/supplier specialty codes
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form and documentation for submission.
Determining the provider’s legal name
Q: What is the provider’s legal business name that should appear on CMS-855 Medicare enrollment applications?
A: A provider’s legal business name is the name that is registered with the Internal Revenue Service (IRS) and should appear on IRS documents, such as the CP-575, that contains a provider’s employee identification number (EIN) or tax identification number (TIN).
The provider’s legal business name with the IRS should identically match (including any or no punctuation) the business name registered with the National Plan & Provider Enumeration System (NPPES), which issues the national provider identifier (NPI). This is the information that will be loaded into the Provider Enrollment, Chain and Ownership System (PECOS). PECOS and NPPES must match exactly.
To validate that the legal business name the IRS has for you matches the business name registered with NPPES by visiting the NPPES website external link or contacting them at 1-800-465-3203 or 1-800-692-2326 for TTY services.
Certification statement of the CMS-855
Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
Delegating authority to sign CMS-855B applications
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
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Sole proprietor versus a sole owner
Q: What are the differences in completing Section 4 of a CMS-855I application for a sole proprietor versus a sole owner?
A: Sole Proprietorship - Section 4F of the CMS-855I is completed with the employer identification number (EIN). The instructions in this section state, “if you are a sole proprietor and you want Medicare payments to be reported under your EIN, list it below.” Only one national provider identifier (NPI) number is needed for the provider. Sole proprietors do not complete section 4A.
Sole Ownership - Section 4A of the CMS-855I is completed with the tax identification number (TIN). If anything is listed in section 4A, a separate NPI number must be obtained for the group number that will be assigned and listed in section 4A. The individual’s NPI number and information must be listed in section 4C.
CMS recently made available a document that will assist physicians and non-physician practitioners in completing the CMS-855I form titled Medicare Provider Enrollment of Individuals (Physicians and Non-Physician Practitioners) external pdf file. Scenarios 2a, 2b, 3 & 4 are very helpful in determining if you are a sole proprietor or sole owner.
Section 4 of the CMS-855R
Q: What information should be in Section 4 of the CMS-855R form?
A. The following information is required:
Initial Reassignment
Section 4A on page 6 is signed and dated by the person reassigning their benefits. Section 4B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, First Coast Service Options Inc. (First Coast) will request this information as part of the development process.
Terminating Reassignments
If the individual terminates a reassignment, the individual signs and dates section 4A.
If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 4B.
For terminations, both signatures are not required. However, if no signatures are present, First Coast will request this information as part of the development process.
Applicable to all CMS-855R applications
The authorized or delegated official who signs section 4B must be currently on file with First Coast. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.
If the application is not signed and dated appropriately, First Coast will send a developmenMiscellaneous forms and documentation.
Miscellaneous forms and documentation
CMS-460
Q: What is the purpose of the Medicare Participating Physician or Supplier Agreement (CMS-460)?
A: New physicians, practitioners, and suppliers may submit the CMS-460 form external pdf file at the time of their enrollment. Participants agree to accept assignment for all covered services provided to Medicare patients.
In addition, the CMS-460 may also be used for existing providers during the annual participation open enrollment. The annual physician and supplier participation period begins January 1 of each year, and runs through December 31. The annual participation enrollment is scheduled to begin on November 15 of each year. (Note: The dates listed for release of the participation enrollment/fee disclosure material are subject to publication of the annual Final Rule.)
During the annual enrollment period, for First Coast Service Options Inc. (First Coast), the MAC for jurisdiction N (JN), which includes Florida, Puerto Rico, and the U.S. Virgin Islands, submit your completed CMS-460 form (or disenrollment request) to:
Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849
• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).
• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location).
The following suppliers must complete this application to initiate the enrollment process:
• Ambulance Service Supplier
• Ambulatory Surgical Center
• Clinic/Group Practice
• Independent Clinical Laboratory
• Independent Diagnostic Testing Facility (IDTF)
• Intensive Cardiac Rehabilitation Supplier
• Mammography Center
• Mass Immunization (Roster Biller Only)
• Part B Drug Vendor
• Portable X-ray Supplier
• Radiation Therapy Center
• Pharmacy
Note: Are you a supplier looking for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) enrollment? Please visit CGS Medicare external link, the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.
Download CMS-855B external pdf file
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855b.pdf
• View how to avoid the errors flash file that result in the CMS-855B form not being processed, specifically missing signatures or dates in Section 15B and Section 16A.
http://medicare.fcso.com/pe_tips_and_tutorials/138139.asp
CMS-855 applications
When to complete a new CMS-855
Q: When do I need to complete a new CMS-855?
A. You need to complete a new CMS-855 when:
• An individual or entity is requesting initial enrollment into the Medicare program.
• Changes are being submitted to update enrollment information and the individual or entity does not have a completed enrollment application (CMS-855) on file.
• An individual or entity is submitting a request for Electronic Funds Transfer (EFT) and an enrollment application is not on file.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
How to complete a CMS-855 form
Q: How do I complete a CMS-855 form? How can I be sure that I have everything I need?
A: Medicare enrollment applications/forms (CMS-855A, CMS-855B, CMS-855I, and CMS-855R) must be completed with accurate information and include all supporting documentation.
First Coast Service Options Inc. (First Coast) offers several online resources to assist you during the provider enrollment process including:
• CMS-855 tutorials
• Institutional providers: CMS-855A flash file
• Clinics/group practices and certain other suppliers: CMS-855B flash file
• Physicians and non-physician practitioners: CMS-855I flash file
• Reassignment of benefits: CMS-855R flash file
• Provider enrollment tips, terms, and specialty codes:
• Tips to expedite your Medicare enrollment process
• Commonly used provider enrollment terms and their definitions
• Medicare provider/supplier specialty codes
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form and documentation for submission.
Determining the provider’s legal name
Q: What is the provider’s legal business name that should appear on CMS-855 Medicare enrollment applications?
A: A provider’s legal business name is the name that is registered with the Internal Revenue Service (IRS) and should appear on IRS documents, such as the CP-575, that contains a provider’s employee identification number (EIN) or tax identification number (TIN).
The provider’s legal business name with the IRS should identically match (including any or no punctuation) the business name registered with the National Plan & Provider Enumeration System (NPPES), which issues the national provider identifier (NPI). This is the information that will be loaded into the Provider Enrollment, Chain and Ownership System (PECOS). PECOS and NPPES must match exactly.
To validate that the legal business name the IRS has for you matches the business name registered with NPPES by visiting the NPPES website external link or contacting them at 1-800-465-3203 or 1-800-692-2326 for TTY services.
Certification statement of the CMS-855
Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:
CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.
CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.
CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.
CMS-855R
For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.
All CMS-855 applications
If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
Delegating authority to sign CMS-855B applications
Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.
An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.
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Sole proprietor versus a sole owner
Q: What are the differences in completing Section 4 of a CMS-855I application for a sole proprietor versus a sole owner?
A: Sole Proprietorship - Section 4F of the CMS-855I is completed with the employer identification number (EIN). The instructions in this section state, “if you are a sole proprietor and you want Medicare payments to be reported under your EIN, list it below.” Only one national provider identifier (NPI) number is needed for the provider. Sole proprietors do not complete section 4A.
Sole Ownership - Section 4A of the CMS-855I is completed with the tax identification number (TIN). If anything is listed in section 4A, a separate NPI number must be obtained for the group number that will be assigned and listed in section 4A. The individual’s NPI number and information must be listed in section 4C.
CMS recently made available a document that will assist physicians and non-physician practitioners in completing the CMS-855I form titled Medicare Provider Enrollment of Individuals (Physicians and Non-Physician Practitioners) external pdf file. Scenarios 2a, 2b, 3 & 4 are very helpful in determining if you are a sole proprietor or sole owner.
Section 4 of the CMS-855R
Q: What information should be in Section 4 of the CMS-855R form?
A. The following information is required:
Initial Reassignment
Section 4A on page 6 is signed and dated by the person reassigning their benefits. Section 4B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, First Coast Service Options Inc. (First Coast) will request this information as part of the development process.
Terminating Reassignments
If the individual terminates a reassignment, the individual signs and dates section 4A.
If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 4B.
For terminations, both signatures are not required. However, if no signatures are present, First Coast will request this information as part of the development process.
Applicable to all CMS-855R applications
The authorized or delegated official who signs section 4B must be currently on file with First Coast. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.
If the application is not signed and dated appropriately, First Coast will send a developmenMiscellaneous forms and documentation.
Miscellaneous forms and documentation
CMS-460
Q: What is the purpose of the Medicare Participating Physician or Supplier Agreement (CMS-460)?
A: New physicians, practitioners, and suppliers may submit the CMS-460 form external pdf file at the time of their enrollment. Participants agree to accept assignment for all covered services provided to Medicare patients.
In addition, the CMS-460 may also be used for existing providers during the annual participation open enrollment. The annual physician and supplier participation period begins January 1 of each year, and runs through December 31. The annual participation enrollment is scheduled to begin on November 15 of each year. (Note: The dates listed for release of the participation enrollment/fee disclosure material are subject to publication of the annual Final Rule.)
During the annual enrollment period, for First Coast Service Options Inc. (First Coast), the MAC for jurisdiction N (JN), which includes Florida, Puerto Rico, and the U.S. Virgin Islands, submit your completed CMS-460 form (or disenrollment request) to:
Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849
Medicare Participating Provider versus Non-Participating Provider
Key Points/Instruction/What you need to know
| Participating Provider | Non-Participating Provider |
| A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. | A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims. |
| Agrees to accept Medicare-approved amount as payment in full. | Can elect to accept assignment or not accept assignment on a claim-by-claim basis. |
| May not collect more than applicable deductible and coinsurance for covered services from patient. Payment for non-covered services may also be collected. | If the provider performs elective surgery costing more than $500, the beneficiary must be notified in writing of the expected financial responsibility. |
| Charges are not subject to limiting charge. | Cannot bill the patient more than the limiting charge on non-assigned claims. (DC, DE, MD, NJ, City of Alexandria, VA, Counties of Arlington and Fairfax in VA) |
| Medicare payment paid directly to the provider. | Pennsylvania’s Medicare Overcharge Measure prevents non-participating physicians from charging patients more than the Medicare allowance. Therefore, PA providers cannot bill the patient more than the Medicare approved amount on non-assigned claims. |
| Mandatory claims submission applies. | Beneficiary receives payment on non-assigned claims. |
| Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD). | Mandatory claims submission applies. |
| Reimbursement is 5 percent higher than the non-participating amount. | Clinical laboratory services and drugs and biologicals must be billed as assigned. |
| Medigap information is transferred. | Approved amount is 5 percent less than participating — even if assignment is accepted on the claim. |
| Patient referral service by hospital. | Medigap information is not transferred. |
To be a participating provider under Medicare, you must be in compliance with the applicable provisions of title VI of the Civil Rights Act of 1964 and must enter into an agreement under §1866 of the Act which provides that you: (1) will not charge any individual or other person for items and services covered by the health insurance program other than allowable charges and deductibles and coinsurance amounts; and (2) will return any money incorrectly collected from the beneficiary or other person on their behalf or make such other disposition that would cause a termination of your agreement.
Toward the end of each calendar year there is an open enrollment period. The open enrollment period generally is from mid-November through December 31. During this period, if you are enrolled in the Medicare Program, you can change your current participation status beginning the next calendar year on January 1. This is the only time you have the opportunity to change your participation status.
New physicians, practitioners, and suppliers can sign the participation agreement and become a Medicare participant at the time of enrollment into the Medicare Program. The participation agreement will become effective on the date of filing; i.e., the date the participant mails (post-mark date) the agreement to the Medicare Administrative Contractor (MAC) or delivers it to the MAC.
PHYSICIAN, PRACTITIONER OR SUPPLIER CURRENTLY ENROLLED:
If you choose to participate:
• Do nothing if you are currently participating, or
• If you are not currently a Medicare participant, complete the blank agreement (CMS-460) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)
If you decide not to participate:
• Do nothing if you are currently not participating, or
• If you are currently a participant, write to each MAC to which you submit claims, advising of your termination effective the first day of the next calendar year. This written notice must be postmarked prior to the end of the current calendar year.
NEW PHYSICIAN, PRACTITIONER OR SUPPLIER:
If you choose to participate:
• Complete the blank agreement (CMS-460) and submit it with your Medicare enrollment application.
• If you have already enrolled in the Medicare program, you have 90 days from when you are enrolled to decide if you want to participate. If you decide to participate within this 90-day timeframe, complete and submit the CMS-460.
If you decide not to participate:
• Do nothing. All new physicians, practitioners, and suppliers that are newly enrolled are automatically non-participating. You are not considered to be participating unless you submit the CMS-460 form.
2015 Annual Update for the Health Professional Shortage Area (HPSA) Bonus - Update from Medicare
Provider Action Needed:
Change Request (CR) 8942 alerts you that the annual
HPSA bonus payment file for 2015 will be made available by the Centers for
Medicare & Medicaid Services (CMS) to your MAC and will be used for HPSA
bonus payments on applicable claims with dates of service on or after January
1, 2015, through December 31, 2015. You should review Physican Bonuses below ,
whether you need to add modifer AQ to your claim in order to receive the bonus
payment, or to see if the ZIP code in which you rendered services will
automatically receive the HPSA bonus payment. Make sure that our billing staffs
are aware of thes changes.
HPSA
Designations
The Health Resources and Services
Administration (HRSA) published an updated Federal Register Notice on June 27,
2013, that contains important information about new and withdrawn HPSA
designations. For purposes of the Medicare Physician Bonus and the Medicare
Surgical Bonus programs, changes in designation status are effective for dates
of services on and after January 1 of the year following the designation date.
Therefore, areas whose designation is shown as “Withdrawn” on the June 27, 2013
Federal Register list, remain eligible for the HPSA bonuses through December
31, 2013.
MMA Section 413(b) required CMS to
revise some of the policies that address HPSA bonus payments. Section 1833(m)
of the Social Security Act provides bonus payments for physicians who furnish
medical care services in geographic areas that are designated by the HRSA as
primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health
Service (PHS) Act. In addition, for claims with dates of service on or after
July 1, 2004, psychiatrists (provider specialty 26) furnishing services in
mental health HPSAs are also eligible to receive bonus payments. If a zip code
falls within both a primary care and mental health HPSA, only one bonus will be
paid on the service.
MMA
Changes
Effective January 1, 2005, a
modifier no longer has to be included on claims to receive the HPSA bonus payment,
which will be paid automatically, if services are provided in ZIP code areas
that either:
- Fall entirely in a county designated as a full-county
HPSA; or
- Fall entirely within the county, through a USPS
determination of dominance; or
- Fall entirely within a partial county HPSA.
However, if services are provided in
ZIP code areas that do not fall entirely within a full county HPSA or partial
county HPSA, the AQ modifier must be entered on the claim to receive the bonus.
The following are the specific instances
in which a modifier must be entered:
- When services are provided in ZIP code areas that do
not fall entirely within a designated full county HPSA bonus area;
- When services are provided in a ZIP code area that
falls partially within a full county HPSA but is not considered to be in
that county based on the USPS dominance decision;
- When services are provided in a ZIP code area that
falls partially within a non-full county HPSA;
- When services are provided in a ZIP code area that was
not included in the automated file of HPSA areas based on the date of the
data run used to create the file.
To determine if a service will
automatically qualify to receive the bonus payment, review the information
provided on the CMS Web site. The HRSA website should be reviewed for the
most recent designations. Physicians may also use the HRSA website
designations when making the decision on whether or not to include the HPSA
modifier on their claims.
Some points to remember include the
following:
- Medicare contractors will base the bonus on the amount
actually paid (not the Medicare approved payment amount for each service)
and the ten-percent bonus will be paid on a quarterly basis.
- The HPSA bonus pertains only to physician's
professional services. Should a service be billed that has both a
professional and technical component, only the professional component will
receive the bonus payment.
- The key to eligibility is not that the beneficiary
lives in a HPSA nor that the physician's office or primary location is in
a HPSA, but rather that the services are actually rendered in a HPSA.
- To be considered for the bonus payment, the name,
address, and ZIP code of the location where the service was rendered must
be included on all electronic and paper claim submissions.
- Physicians should verify the eligibility of their area
for a bonus before submitting services with a HPSA modifier for areas they
think may still require the submission of a modifier to receive the bonus
payment.
- Services submitted with the AQ modifier will be subject
to validation by Medicare.
Affordable
Care Act of 2010 Changes (New for January 2011 for the HSIP Bonus)
The Affordable Care Act of 2010,
Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs.
Effective January 1, 2011 through December 31, 2015, physicians serving in
designated HPSAs will receive an additional 10% bonus for major surgical
procedures with a 10 or 90 day global period. This additional payment,
referred to as the HPSA Surgical Incentive Payment (HSIP) will be combined with
the original HPSA payment and will be paid on a quarterly basis. Modifier
AQ should be appended for these major surgical procedures similar to claims for
the Medicare original HPSA bonus when services are provided in ZIP code areas that
do not fall entirely within a full or partial county HPSA.
Some points to remember:
- The current HPSA physician bonus program
requirements will remain intact.
- Medicare contractors will identify and pay the
additional bonus on eligible services rendered in eligible ZIP code areas
based on the HPSA ZIP code file as of December 31st of the
prior year.
- Medicare contractors will calculate the bonus amount
based on the amount actually paid for the service, not the Medicare
approved amount
License Update Policy - From Molina Healthcare
Health care providers, who under the state plan and/or state statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with the West Virginia Bureau for Medical Services (BMS) Fiscal Agent, Molina. A provider’s participation in the WV Medicaid program may be terminated if Molina cannot verify the current status of a provider’s license.
Effective October 1, 2009, the Provider License Update Reminder Process is as follows:
*** 60 days prior to the license expiration date, an initial reminder letter will be sent to the provider’s correspondence address indicating their current license expiration date. If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.
*** If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards. If a provider’s license renewal date can be verified through the board listings, the pay hold will be re-moved. If Molina cannot verify an effective license renewal date via the board listing, the provider will remain on pay hold.
*** A letter will be sent 30 days after the provider’s license expiration date to providers who have failed to submit their updated license. Molina will not verify license renewal through the licensing boards. The provider will remain on pay hold until the updated license is sent to Molina.
*** 60 days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who have failed to send an updated license to Molina will remain on pay hold.
*** 90 days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license. Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.
*** If after 121 days from the initial license expiration date Molina has not received the provider’s updated license, the provider’s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid. A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services ren-dered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not pay-able. A listing of voided claims will accompany the letter.
*** Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expira-tion of the current license. Mailing address: Molina Provider Enrollment, PO Box 625, Charleston, WV 25322. Fax: Provid-er Enrollment 304-348-2763.
*** All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.
Effective October 1, 2009, the Provider License Update Reminder Process is as follows:
*** 60 days prior to the license expiration date, an initial reminder letter will be sent to the provider’s correspondence address indicating their current license expiration date. If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.
*** If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards. If a provider’s license renewal date can be verified through the board listings, the pay hold will be re-moved. If Molina cannot verify an effective license renewal date via the board listing, the provider will remain on pay hold.
*** A letter will be sent 30 days after the provider’s license expiration date to providers who have failed to submit their updated license. Molina will not verify license renewal through the licensing boards. The provider will remain on pay hold until the updated license is sent to Molina.
*** 60 days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who have failed to send an updated license to Molina will remain on pay hold.
*** 90 days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license. Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.
*** If after 121 days from the initial license expiration date Molina has not received the provider’s updated license, the provider’s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid. A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services ren-dered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not pay-able. A listing of voided claims will accompany the letter.
*** Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expira-tion of the current license. Mailing address: Molina Provider Enrollment, PO Box 625, Charleston, WV 25322. Fax: Provid-er Enrollment 304-348-2763.
*** All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.
Medicare physician signature - important rules
Physician (Supplier) Signature Requirement
The rules below apply to both assigned and unassigned claims unless otherwise indicated.
1. In a claim for services furnished by an individual physician (or supplier), the physician may:
a. In an unassigned claim, provide an itemized bill on his own letterhead - no physician signature required. A Form CMS-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physician’s own letterhead.
b. Sign item 31 of Form CMS-1500.
c. Sign one time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Authorize an employee (e.g., nurse, secretary) to enter the physician’s signature in item 31 of the Form CMS-1500.
i. Manually
ii. By stamp-facsimile or block letters
iii. By computer
e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physician’s signature in item 31 of the Form CMS-1500, followed by the agent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent may simply enter the physician’s signature.
2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for the services of the physician, the entity may:
a. In an unassigned claim, provide an itemized bill on its letterhead-no signature necessary. A Form CMS-1500 on which the name or identification code of the billing entity has been stamped or preprinted in item 8 is the equivalent of the reassignee’s own letterhead.
b. Have authorized official sign in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556).
c. Have authorized official sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Have authorized employee, e.g., a secretary, enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1d.
e. Have nonemployee agent enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1.e.
The rules below apply to both assigned and unassigned claims unless otherwise indicated.
1. In a claim for services furnished by an individual physician (or supplier), the physician may:
a. In an unassigned claim, provide an itemized bill on his own letterhead - no physician signature required. A Form CMS-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physician’s own letterhead.
b. Sign item 31 of Form CMS-1500.
c. Sign one time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Authorize an employee (e.g., nurse, secretary) to enter the physician’s signature in item 31 of the Form CMS-1500.
i. Manually
ii. By stamp-facsimile or block letters
iii. By computer
e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physician’s signature in item 31 of the Form CMS-1500, followed by the agent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent may simply enter the physician’s signature.
2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for the services of the physician, the entity may:
a. In an unassigned claim, provide an itemized bill on its letterhead-no signature necessary. A Form CMS-1500 on which the name or identification code of the billing entity has been stamped or preprinted in item 8 is the equivalent of the reassignee’s own letterhead.
b. Have authorized official sign in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556).
c. Have authorized official sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Have authorized employee, e.g., a secretary, enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1d.
e. Have nonemployee agent enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1.e.
When Beneficiary Statement is Not Required for Physician/Supplier Claim
A. Enrollee Signature Requirements
A request for payment signed by the enrollee must be filed on or with each claim for charge basis reimbursement except as provided below. All rules apply to both assigned and unassigned claims unless otherwise indicated.
1. When no enrollee signature required:
a. Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee.
b. Unassigned claim submitted by a public welfare agency on a bill which is paid.
c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.
2 When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.
3. When another person may sign on behalf of the enrollee:
a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.
b. Enrollee physically or mentally unable to transact business: The request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing the enrollee care or support, or of a governmental agency providing him/her assistance.
c. Enrollee physically or mentally unable to transact business and full documentation is supplied that the enrollee has no one else to sign on his behalf: The physician, supplier, or clinic may sign.
d. Enrollee deceased and bill paid or liability assumed: Person claiming payment should sign. If Form CMS-1500 was signed before the enrollee dies, claimant should sign separate request for underpayment.
4. When request retained in file may cover extended future period:
a. Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.
b. Authorization in files of organization approved under §30.2.8.3 covers all services paid for by that organization under that procedure.
c. Assignment in the files of group practice prepayment plan covers services furnished by the plan during the period of the enrollee’s membership.
d. Assignment in the files of a participating provider (hospital, SNF, home health agency, outpatient physical therapy or speech-language pathology provider or comprehensive rehabilitation facility) or ESRD facility covers physician services for which the provider or facility is authorized to bill, and may cover the physician services furnished in the provider or facility as follows:
• Inpatient services - effective for period of confinement.
• Outpatient services - effective indefinitely.
e. Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of durable medical equipment) or qualified reassignee under §30.2 is effective indefinitely
Would Medicare pay after provider termination
Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions
A SNF may be denied payment for new admissions, but not readmissions, as an option to termination of its provider agreement for noncompliance with one or more requirements of participation. The SNF may only be reimbursed for covered services furnished on or after the effective date of denial of payments if such services were furnished to beneficiaries who were admitted to the SNF before the effective date of termination or expiration.
EXAMPLE:
Effective date of denial of payment - 9-30
Beneficiary admitted before 9-30 - pay for covered Part A or B services
Beneficiary admitted on or after 9-30 - deny payment under Part A or B
NOTE: An inpatient who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.
The contractor is notified of SNF payment denials through the Form CMS-2007. It must install appropriate edits or other safeguards to prevent incorrect payments to the provider.
The contractor obtains a list of Medicare inpatients when a SNF or hospital agreement is terminated, or after a SNF is denied payment for new admissions to assure that nonpayment spell of illness bills are filed.
A SNF may be denied payment for new admissions, but not readmissions, as an option to termination of its provider agreement for noncompliance with one or more requirements of participation. The SNF may only be reimbursed for covered services furnished on or after the effective date of denial of payments if such services were furnished to beneficiaries who were admitted to the SNF before the effective date of termination or expiration.
EXAMPLE:
Effective date of denial of payment - 9-30
Beneficiary admitted before 9-30 - pay for covered Part A or B services
Beneficiary admitted on or after 9-30 - deny payment under Part A or B
NOTE: An inpatient who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.
The contractor is notified of SNF payment denials through the Form CMS-2007. It must install appropriate edits or other safeguards to prevent incorrect payments to the provider.
The contractor obtains a list of Medicare inpatients when a SNF or hospital agreement is terminated, or after a SNF is denied payment for new admissions to assure that nonpayment spell of illness bills are filed.
Effective Date of Provider Agreement in the Enrollment
Since one of the key issues is whether the facility has furnished “reasonable assurance” that the reasons for termination will not recur, the provider agreement cannot be effective before the date on which “reasonable assurance” is deemed to have been provided.
Generally, a facility will be required to operate for a period of 60 days without recurrence of the deficiencies that were the basis for the termination. The provider agreement will be effective with the end of the 60-day period. If corrections were made before filing the new request for participation, the period of compliance before filing the new request will be counted as part of the 60-day period; however, in no case can the effective date of the provider agreement be earlier than the date of the new request for participation.
Exceptions to the 60-day period of compliance will be made where:
• Structural changes have eliminated the reasons for termination. “Reasonable assurance” will be considered established as of the date such structural changes were completed. The effective date will be that date or the date of filing the new request to participate, whichever is later.
• "Reasonable assurance” is not established even after 60 days of compliance, because of the facility’s history of misrepresentation or of making temporary corrections and then relapsing into the old deficiencies that were the basis for termination. The effective date in such cases would be the earliest date after 60 days at which “reasonable assurance” is deemed to have been established, or the filing date of the new request to participate, whichever is later.
Generally, a facility will be required to operate for a period of 60 days without recurrence of the deficiencies that were the basis for the termination. The provider agreement will be effective with the end of the 60-day period. If corrections were made before filing the new request for participation, the period of compliance before filing the new request will be counted as part of the 60-day period; however, in no case can the effective date of the provider agreement be earlier than the date of the new request for participation.
Exceptions to the 60-day period of compliance will be made where:
• Structural changes have eliminated the reasons for termination. “Reasonable assurance” will be considered established as of the date such structural changes were completed. The effective date will be that date or the date of filing the new request to participate, whichever is later.
• "Reasonable assurance” is not established even after 60 days of compliance, because of the facility’s history of misrepresentation or of making temporary corrections and then relapsing into the old deficiencies that were the basis for termination. The effective date in such cases would be the earliest date after 60 days at which “reasonable assurance” is deemed to have been established, or the filing date of the new request to participate, whichever is later.
Billing provider - License updating policy
License Update Policy
Health care providers, who under the state plan and/or state statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with the West Virginia Bureau for Medical Services (BMS) Provider Enrollment Unit, Molina. A provider‟s participation in the WV Medicaid program may be terminated if Molina cannot verify the current status of a provider‟s license.
Effective, October 1, 2009 the Provider License Update Reminder Process is as follows:
• Sixty (60) days prior to the license expiration date, an initial reminder letter will be sent to the provider‟s correspondence address indicating their current license expiration date. If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.
• If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards. If a provider‟s license renewal date can be verified through the board listings, the pay hold will be removed. If Molina cannot verify an effective license renewal date
via the board listing, the provider will remain on pay hold.
• A letter will be sent 30 days after the provider‟s license expiration date to providers who have failed to submit their updated license and Molina was not able to verify license renewal through the licensing boards. The provider will remain on pay hold until the updated license is sent to Molina.
• Sixty (60) days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who
have failed to send an updated license to Molina will remain on pay hold.
• Ninety (90) days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license. Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.
• If after 121 days from the initial license expiration date Molina has not received the provider‟s updated license, the provider‟s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid. A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services rendered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not payable. A listing of voided claims will accompany the letter.
• Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expiration of the current license. Mailing address: Molina Provider Enrollment, PO Box 625, Charleston, WV 25322. Fax: Provider Enrollment 304-348-2763.
• All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.
Health care providers, who under the state plan and/or state statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with the West Virginia Bureau for Medical Services (BMS) Provider Enrollment Unit, Molina. A provider‟s participation in the WV Medicaid program may be terminated if Molina cannot verify the current status of a provider‟s license.
Effective, October 1, 2009 the Provider License Update Reminder Process is as follows:
• Sixty (60) days prior to the license expiration date, an initial reminder letter will be sent to the provider‟s correspondence address indicating their current license expiration date. If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.
• If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards. If a provider‟s license renewal date can be verified through the board listings, the pay hold will be removed. If Molina cannot verify an effective license renewal date
via the board listing, the provider will remain on pay hold.
• A letter will be sent 30 days after the provider‟s license expiration date to providers who have failed to submit their updated license and Molina was not able to verify license renewal through the licensing boards. The provider will remain on pay hold until the updated license is sent to Molina.
• Sixty (60) days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who
have failed to send an updated license to Molina will remain on pay hold.
• Ninety (90) days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license. Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.
• If after 121 days from the initial license expiration date Molina has not received the provider‟s updated license, the provider‟s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid. A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services rendered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not payable. A listing of voided claims will accompany the letter.
• Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expiration of the current license. Mailing address: Molina Provider Enrollment, PO Box 625, Charleston, WV 25322. Fax: Provider Enrollment 304-348-2763.
• All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.
Medicare rejection - Accident date is required and rendering provider required
An accident date is required for Federal program when an accident related diagnosis is present.
What this means: Some claims to this payer may reject for 'An accident date is required for Federal program when an accident related diagnosis is present.'
Provider action: Check the codes on the claims, are they considered accident codes? If so you will need to submit an accident indicator and and accident date on your claim.
Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.
Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.
An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain
What this means: Claims to this payer may reject for 'An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain a [OTER].'
Provider action: Verify that you are not sending the same insured and patient name on the claims, if so correct and resubmit.
Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.
Re-filing: Once this is corrected, you would want to re-file any
RENDERING PHYSICIAN IS REQUIRED
What this means: There are two possible reasons for this
rejection:
1. If the provider sends the claim with only the individual NPI in the billing loop and they are credentialed with a group NPI, then the claims will be rejected by the payer.
2. If the provider sends the claim with only the individual NPI in the billing loop and the entity type qualifier is 2 (non-person), then the claims will be rejected by the payer.
Resubmit with Group NPI (Box 33) information.
What this means: Some claims to this payer may reject for 'An accident date is required for Federal program when an accident related diagnosis is present.'
Provider action: Check the codes on the claims, are they considered accident codes? If so you will need to submit an accident indicator and and accident date on your claim.
Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.
Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.
An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain
What this means: Claims to this payer may reject for 'An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain a [OTER].'
Provider action: Verify that you are not sending the same insured and patient name on the claims, if so correct and resubmit.
Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.
Re-filing: Once this is corrected, you would want to re-file any
RENDERING PHYSICIAN IS REQUIRED
What this means: There are two possible reasons for this
rejection:
1. If the provider sends the claim with only the individual NPI in the billing loop and they are credentialed with a group NPI, then the claims will be rejected by the payer.
2. If the provider sends the claim with only the individual NPI in the billing loop and the entity type qualifier is 2 (non-person), then the claims will be rejected by the payer.
Resubmit with Group NPI (Box 33) information.
Medicare Enrollment denials when overpayment exists with example
What you need to know
This article, based on CR 8039, informs you that Medicare contractors may deny a Form CMS-855 enrollment application if the current owner of the enrolling provider or supplier or the enrolling physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time an application for new enrollment or change of ownership (CHOW) is filed.
Background
Under 42 Code of Federal Regulations (CFR) Section 424.530(a)(6), an enrollment application may be denied if the current owner (as that term is defined in 42 CFR Section 424.502) of the applying provider or supplier, or the applying physician or non-physician practitioner has an existing or delinquent overpayment that has not been repaid in full at the time the application was filed.(Under 42 CFR 424.502, the term “owner” means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in Sections 1124 and 1124A(A) of the Social Security Act) of the applying provider or supplier) Overpayments are Medicare payments that a provider or beneficiary has received in excess of amounts due and payable under the statute and regulations. Once a determination of an overpayment has been made, the amount is a debt owed by the debtor to the United States Government.
Upon receipt of a CMS-855A, CMS-855B, or CMS-855S application, the Medicare contractor will determine – whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment.
Upon receipt of a CMS-855I application, the Medicare contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment. (For purposes of this requirement, the term “non-physician practitioner” includes physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals.)
If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis.
Consider the following examples:
Example #1: Hospital X has a $200,000 overpayment. It terminates its Medicare enrollment. Three months later, it reopens as Hospital Y and submits a new CMS-855A application for enrollment as such. A denial is not warranted because §424.530 (a)(6) only applies to physicians, practitioners, and owners.
Example #2: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as a sole proprietorship; his practice is named “JS Medicine.” A denial is warranted because §424.530 (a)(6) applies to physicians and the $50,000 overpayment was attached to him as the sole proprietor.
Example #3: Dr. John Smith’s practice (“Smith Medicine”) is set up as a sole proprietorship. He incurs a $50,000 overpayment. He terminates his Medicare enrollment. Six months later, he tries to enroll as an LLC of which he is only a 30 percent owner; the practice is named “JS Medicine, LLC.” A denial is not warranted because the provision applies to “all” owners collectively and, again, the $50,000 overpayment was attached to him.
What is Medicare connection
About the Medicare B Connection
The Medicare B Connection is a comprehensive publication developed by First Coast Service Options Inc. (First Coast) for Part B providers in Florida, Puerto Rico, and the U.S. Virgin Islands and is distributed on a monthly basis.
Important notifications that require communication in between publications will be posted to the First Coast Medicare provider education website at http://medicare.fcso.com. In some cases, additional unscheduled special issues may be posted.
Who receives the Connection
Anyone may view, print, or download the Connection from our provider education website(s). Providers who cannot obtain the Connection from the Internet are required to register with us to receive a complimentary hardcopy.
Distribution of the Connection in hardcopy is limited to providers who have billed at least one Part B claim to First Coast Medicare during the twelve months prior to the release of each issue. Providers meeting these criteria are eligible to receive a complimentary copy of that issue, if a technical barrier exists that prevents
them from obtaining it from the Internet and they have returned a completed registration form to us.
Registration forms must be submitted annually or when you experience a change in circumstances that impacts your electronic access.
For additional copies, providers may purchase a separate annual subscription (see order form in the back of this issue). All issues published since 1997 may be downloaded from the Internet, free of charge.We use the same mailing address for all correspondence, and cannot designate that the Connection be sent to a
specific person/department within a provider’s office. To ensure continued receipt of all Medicare correspondence, providers must keep their addresses current with the Medicare Provider Enrollment department. Please remember that address changes must be done using the appropriate CMS-855.
Publication format
The Connection is arranged into distinct sections.
The Claims section provides claim submission requirements and tips.
The Coverage/Reimbursement section discusses specific CPT ® and HCPCS procedure codes. It is arranged by categories (not specialties). For example, “Mental Health” would present coverage information of interest to psychiatrists, clinical psychologists and clinical social workers, rather than listing articles separately under individual provider specialties. Also presented in this section are changes to the Medicare physician fee schedule, and other pricing issues.
The section pertaining to Electronic Data Interchange (EDI) submission also includes information pertaining to the Health Insurance Portability and Accountability Act (HIPAA).
The Local Coverage Determination section features summaries of new and revised local coverage determinations (LCDs) developed as a result of either local medical review or comprehensive data analysis initiatives.
The General Information section includes fraud and abuse, and national provider identifier topics, plus additional topics not included elsewhere.
In addition to the above, other sections include:
• Educational Resources, and
Contact information for Florida, Puerto Rico, and the U.S. Virgin Islands.
The Medicare B Connection represents formal notice of coverage policies Articles included in each edition represent formal notice that specific coverage policies either have or will take effect on the date given. Providers are expected to read, understand, and abide by the policies outlined in this document to ensure compliance with Medicare coverage and payment guidelines.
The Medicare B Connection is a comprehensive publication developed by First Coast Service Options Inc. (First Coast) for Part B providers in Florida, Puerto Rico, and the U.S. Virgin Islands and is distributed on a monthly basis.
Important notifications that require communication in between publications will be posted to the First Coast Medicare provider education website at http://medicare.fcso.com. In some cases, additional unscheduled special issues may be posted.
Who receives the Connection
Anyone may view, print, or download the Connection from our provider education website(s). Providers who cannot obtain the Connection from the Internet are required to register with us to receive a complimentary hardcopy.
Distribution of the Connection in hardcopy is limited to providers who have billed at least one Part B claim to First Coast Medicare during the twelve months prior to the release of each issue. Providers meeting these criteria are eligible to receive a complimentary copy of that issue, if a technical barrier exists that prevents
them from obtaining it from the Internet and they have returned a completed registration form to us.
Registration forms must be submitted annually or when you experience a change in circumstances that impacts your electronic access.
For additional copies, providers may purchase a separate annual subscription (see order form in the back of this issue). All issues published since 1997 may be downloaded from the Internet, free of charge.We use the same mailing address for all correspondence, and cannot designate that the Connection be sent to a
specific person/department within a provider’s office. To ensure continued receipt of all Medicare correspondence, providers must keep their addresses current with the Medicare Provider Enrollment department. Please remember that address changes must be done using the appropriate CMS-855.
Publication format
The Connection is arranged into distinct sections.
The Claims section provides claim submission requirements and tips.
The Coverage/Reimbursement section discusses specific CPT ® and HCPCS procedure codes. It is arranged by categories (not specialties). For example, “Mental Health” would present coverage information of interest to psychiatrists, clinical psychologists and clinical social workers, rather than listing articles separately under individual provider specialties. Also presented in this section are changes to the Medicare physician fee schedule, and other pricing issues.
The section pertaining to Electronic Data Interchange (EDI) submission also includes information pertaining to the Health Insurance Portability and Accountability Act (HIPAA).
The Local Coverage Determination section features summaries of new and revised local coverage determinations (LCDs) developed as a result of either local medical review or comprehensive data analysis initiatives.
The General Information section includes fraud and abuse, and national provider identifier topics, plus additional topics not included elsewhere.
In addition to the above, other sections include:
• Educational Resources, and
Contact information for Florida, Puerto Rico, and the U.S. Virgin Islands.
The Medicare B Connection represents formal notice of coverage policies Articles included in each edition represent formal notice that specific coverage policies either have or will take effect on the date given. Providers are expected to read, understand, and abide by the policies outlined in this document to ensure compliance with Medicare coverage and payment guidelines.
Change of Ownership - Procedure to follow
When an organization having a provider agreement undergoes a change of ownership in accordance with the principles articulated in 42 CFR Part 489 and §3210 of the State Operations Manual, the agreement with the existing provider is automatically assigned to the new owner so that there is no interruption in service. However, a new agreement with updated information must subsequently be signed and a Form CMS-855A must be submitted by both the old and new owners. Only if the provider, under the change of ownership, meets the applicable requirements for approval can the agreement be executed. For FQHCs, these requirements include PHS approval.
An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medicare program. A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention.
A change of ownership occurs, for example, when:
• A sole proprietor transfers title and property to another party;
• In the case of a partnership, there is an addition, removal, or substitution of a partner unless the partners expressly agree otherwise;
• An incorporated organization merges with an incorporated entity that is approved by the program and the latter entity is the surviving corporation. It also occurs when two or more corporate providers consolidate and the consolidation results in the creation of a new corporate entity;
• An unincorporated organization (a sole proprietorship or partnership) becomes incorporated; or
• The lease of all or part of an entity constitutes a change of ownership of the leased portion.
When an organization’s agreement is terminated, whether by the entity or by CMS, no payment is available to the provider for services it furnishes to Medicare beneficiaries on or after the effective date of the termination.
An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medicare program. A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention.
A change of ownership occurs, for example, when:
• A sole proprietor transfers title and property to another party;
• In the case of a partnership, there is an addition, removal, or substitution of a partner unless the partners expressly agree otherwise;
• An incorporated organization merges with an incorporated entity that is approved by the program and the latter entity is the surviving corporation. It also occurs when two or more corporate providers consolidate and the consolidation results in the creation of a new corporate entity;
• An unincorporated organization (a sole proprietorship or partnership) becomes incorporated; or
• The lease of all or part of an entity constitutes a change of ownership of the leased portion.
When an organization’s agreement is terminated, whether by the entity or by CMS, no payment is available to the provider for services it furnishes to Medicare beneficiaries on or after the effective date of the termination.
Mandatory Accept Assignment on Medicare and HMO Claims
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus the 20 percent coinsurance.
Assignment is mandated for the following claims:
• Clinical diagnostic laboratory services and physician lab services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians/nutritionists, anesthesiologist assistants, and mass immunization roster billers.
NOTE: The provider type Mass Immunization Roster Biller can only bill for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.
• Ambulatory surgical center services; (No deductible and 25% coinsurance for colorectal cancer screening colonoscopies {G0105 and G0121) and effective for dates of service on or after January 1, 2008 G0104 also applies);
• Home dialysis supplies and equipment paid under Method II for dates of service prior to January 1, 2011. Refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis for dates of service on and after January 1, 2011;
• Drugs and biologicals; and,
• Ambulance services
When these claims are inadvertently submitted as unassigned, carriers process them as assigned.
Note that, unlike physicians, practitioners, or suppliers bound by a participation agreement, practitioners/entities providing the services/supplies identified above are required to accept assignment only with respect to these services/supplies (unless they have signed participation agreements which blanket the full range of their services).
The carrier system must be able to identify (and update) the codes for those services subject to the assignment mandate.
For the practitioner services of physicians and independently practicing physical and occupational therapists, the acceptance of assignment is not mandatory. Nor is the acceptance of assignment mandatory for the suppliers of radiology services or diagnostic tests. However, these practitioners and suppliers may nevertheless voluntarily agree to participate to take advantage of the higher payment rate, in which case the participation status makes assignment mandatory for the term of the agreement. Such an agreement is known as the Medicare Participating Physician or Supplier Agreement. (See §30.3.12.2 Carrier Participation Agreement.) Physicians, practitioners, and suppliers who sign this agreement to participate are agreeing to accept assignment on all Medicare claims. The Medicare Participation Agreement and general instructions are on the CMS Web site.
Future updates to this section will be communicated in a Recurring Update Notification.
Assignment is mandated for the following claims:
• Clinical diagnostic laboratory services and physician lab services;
• Physician services to individuals dually entitled to Medicare and Medicaid;
Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians/nutritionists, anesthesiologist assistants, and mass immunization roster billers.
NOTE: The provider type Mass Immunization Roster Biller can only bill for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.
• Ambulatory surgical center services; (No deductible and 25% coinsurance for colorectal cancer screening colonoscopies {G0105 and G0121) and effective for dates of service on or after January 1, 2008 G0104 also applies);
• Home dialysis supplies and equipment paid under Method II for dates of service prior to January 1, 2011. Refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis for dates of service on and after January 1, 2011;
• Drugs and biologicals; and,
• Ambulance services
When these claims are inadvertently submitted as unassigned, carriers process them as assigned.
Note that, unlike physicians, practitioners, or suppliers bound by a participation agreement, practitioners/entities providing the services/supplies identified above are required to accept assignment only with respect to these services/supplies (unless they have signed participation agreements which blanket the full range of their services).
The carrier system must be able to identify (and update) the codes for those services subject to the assignment mandate.
For the practitioner services of physicians and independently practicing physical and occupational therapists, the acceptance of assignment is not mandatory. Nor is the acceptance of assignment mandatory for the suppliers of radiology services or diagnostic tests. However, these practitioners and suppliers may nevertheless voluntarily agree to participate to take advantage of the higher payment rate, in which case the participation status makes assignment mandatory for the term of the agreement. Such an agreement is known as the Medicare Participating Physician or Supplier Agreement. (See §30.3.12.2 Carrier Participation Agreement.) Physicians, practitioners, and suppliers who sign this agreement to participate are agreeing to accept assignment on all Medicare claims. The Medicare Participation Agreement and general instructions are on the CMS Web site.
Future updates to this section will be communicated in a Recurring Update Notification.
Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for Carrier Processed Claims
Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under §§30.2-30.2.8. They are used whether the charges are compensation related or non-compensation related.
A General
Chapter 26 contains general claims processing instructions. A medical group, or other entity entitled to bill and receive payment for physician services uses Form CMS-1500 or the current ANSI X12N billing format to submit claims to Medicare carriers. A single claim form may contain services furnished to the same patient by different physicians associated with the same entity. The name and address of the entity is entered in block 33 of Form CMS-1500 or in the corresponding ANSI X12N location. For paper claims an authorized official of the entity signs in block 31. This official need not be a physician. For EDI claims a certification can be maintained on file. (See CMS EDI Web page (http://www.cms.hhs.gov/providers/edi/edi3.asp) for electronic billing formats.)
B Provider Identification Numbers
The entity’s NPI, when required, is entered in block 33. Each physician who performs services for a patient must be identified on Form CMS-1500 in block 24J for the appropriate line item in accordance with instructions in the Medicare Program Integrity Manual. (When an entity bills for an independent substitute physician under a reciprocal or locum tenens billing arrangement, the performing physicians is the physician member of the entity for whom the substitute is providing services.)
C Payment Records
Where the charges by a hospital, medical group, or other entity differ depending on the individual treating physician, carriers transmit the performing physician’s UPIN or NPI when required on the Common Working File (CWF) claim record. Where the charges by a hospital, medical group, or other entity are uniform regardless of the individual performing physician, claims records are prepared by entity and entity identification numbers rather than by individual physician and individual physician identification numbers. Show code 70 as specialty code on claims records where such entity’s physicians have mixed (more than one) specialties. Where all the physicians associated with such entity have the same specialty, the code used reflects the specialty, e.g., code 30 for a group of radiologists, code 11 for a group of internists.
D Outpatient Physical Therapy or Speech-Language Pathology Claims
Clinics that have been certified to provide outpatient physical therapy or speech-language pathology services to outpatients also use Form CMS-1500 for billing the Part B carrier.
A General
Chapter 26 contains general claims processing instructions. A medical group, or other entity entitled to bill and receive payment for physician services uses Form CMS-1500 or the current ANSI X12N billing format to submit claims to Medicare carriers. A single claim form may contain services furnished to the same patient by different physicians associated with the same entity. The name and address of the entity is entered in block 33 of Form CMS-1500 or in the corresponding ANSI X12N location. For paper claims an authorized official of the entity signs in block 31. This official need not be a physician. For EDI claims a certification can be maintained on file. (See CMS EDI Web page (http://www.cms.hhs.gov/providers/edi/edi3.asp) for electronic billing formats.)
B Provider Identification Numbers
The entity’s NPI, when required, is entered in block 33. Each physician who performs services for a patient must be identified on Form CMS-1500 in block 24J for the appropriate line item in accordance with instructions in the Medicare Program Integrity Manual. (When an entity bills for an independent substitute physician under a reciprocal or locum tenens billing arrangement, the performing physicians is the physician member of the entity for whom the substitute is providing services.)
C Payment Records
Where the charges by a hospital, medical group, or other entity differ depending on the individual treating physician, carriers transmit the performing physician’s UPIN or NPI when required on the Common Working File (CWF) claim record. Where the charges by a hospital, medical group, or other entity are uniform regardless of the individual performing physician, claims records are prepared by entity and entity identification numbers rather than by individual physician and individual physician identification numbers. Show code 70 as specialty code on claims records where such entity’s physicians have mixed (more than one) specialties. Where all the physicians associated with such entity have the same specialty, the code used reflects the specialty, e.g., code 30 for a group of radiologists, code 11 for a group of internists.
D Outpatient Physical Therapy or Speech-Language Pathology Claims
Clinics that have been certified to provide outpatient physical therapy or speech-language pathology services to outpatients also use Form CMS-1500 for billing the Part B carrier.
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