A/B MAC (A) Payment Policy and Claims Processing

100 - A/B MAC (A) Payment Policy and Claims Processing (Rev. 3049, Issued; 08-25-14, Effective: ICD-10 - Upon Implementation of ICD-10; ASC-X12-01-01-12, Implementation: ICD-10 - Upon Implementation of ICD-10; ASC-X12 - 09-23-14) Bills are submitted to the A/B MAC (A) by IHS providers (including CAHs) using the ASC-X12 837 institutional claim format. In exceptional circumstances, a hardcopy Form CMS-1450 may be accepted by the designated A/B MAC (A). The IHS providers are identified by Provider Type 08 in the Provider Specific File in the FISS claims processing system. The A/B MAC (A) uses specific IHS related edits, current outpatient edits for non-outpatient prospective payment system (non-OPPS) providers, and current inpatient prospective payment system (IPPS) edits on IPPS bills, as well as other edits applicable to CAHs. Medical review is done in accordance with current procedures. IHS provider bills are processed subject to existing CWF edits. International Classification of Diseases-9- Clinical Modification (ICD-9-CM) codes are required on all bill types for services before implementation of ICD-10. Upon implementation of ICD-10, ICD-10-CM diagnosis codes are required on inpatient and outpatient claims, and ICD-10-PCS procedure codes are required on inpatient claims. For services provided to AI/AN individuals in IHS providers (including CAHs) deductible and coinsurance amounts are applied by Medicare, but are waived by the IHS, and the MSN is suppressed. Third party payers may be billed for applicable deductible and coinsurance amounts.