A/B MAC (B) - Claims Processing Requirements

80.2 - A/B MAC (B) - Claims Processing Requirements (Rev. 1040, Issued: 08-25-06, Effective: 09-11-06, Implementation: 09-11-06) 1. Claims will be submitted by IHS physicians and practitioners using either the ASC X12 837 professional format or Form CMS-1500. 2. The designated A/B MAC (B) shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non-physician practitioners. 3. The designated A/B MAC (B) shall place the demonstration code 40 on all IHS physician and practitioner claims. 4. The effective date (date service was provided) for covered services to be paid is on or after July 1, 2001. Timely claims filing requirements are not waived. Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §70 contains more information on timely claims filing requirements. 5. The designated A/B MAC (B) shall process IHS physician and practitioner claims using their LCD. Refer to Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.5.1.1 for more information on LCDs. The A/B MAC (B) has three options: • Develop LCDs specifically for IHS physician and practitioner claims; • Use existing LCDs for the State in which the A/B MAC (B) resides; or • Use existing LCDs for any State for which they process claims. The designated A/B MAC (B) shall specify which LCD they will use for processing IHS physician and practitioner claims. 6. Payment is to be made based on the Medicare locality in which the services are furnished in accordance with current jurisdictional pricing guidelines. 7. The designated A/B MAC (B) shall use the Medicare Part B Drug-Pricing File accessed at http://www.cms.gov/site-search/search-results.html?q=drug%20pricing%20files . However, if a drug or biological is not currently listed in the drug-pricing file, the designated A/B MAC (B) shall price the drug or biological utilizing current Medicare drug payment policy. (See Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, §20.) 8. The designated A/B MAC (B) shall train IHS physician and practitioner staff to complete correctly Form CMS-1500 and the electronic formats. • The designated A/B MAC (B) shall return as unprocessable any claim with missing or incomplete information in accordance with Chapter 1, Section 80.3.2, Handling Incomplete and Invalid Claims. 9. The IHS physicians and practitioners shall submit claims as if they were a group practice. • All IHS physicians and practitioners must apply for a group billing number via the normal processes. The designated A/B MAC (B) shall educate IHS physicians and practitioners on these processes. • All IHS physicians and practitioners who do not currently have Medicare billing numbers with the IHS, tribe, and tribal organization with the designated A/B MAC (B) shall apply for them via the normal processes described in §40.1 Provider Enrollment with A/B MAC (B) in this chapter. The designated A/B MAC (B) shall educate IHS physicians and practitioners on these processes. It is the IHS, tribes, and tribal organizations’ responsibility to notify their physicians and other practitioners of the need for enumeration. The IHS physicians and other practitioners must contact the designated A/B MAC (B) to initiate the enrollment process. 10. The designated A/B MAC (B) shall identify all IHS physicians and practitioners by their PINs. PINs shall be assigned in a manner that will allow the designated A/B MAC (B) to identify which facilities are IHS, tribes, or tribal organizations. All IHS physicians and practitioners will be assigned a UPIN in accordance with current practices. See §50 Reporting Requirements for more information about PINs and UPINs. 11. The designated A/B MAC (B) shall use all current edits (including current duplicate logic and Correct Coding Initiative edits) on claims from IHS physicians and practitioners. Medical review will be done in accordance with current procedures. The IHS physicians and practitioners need not submit line items for non-covered services. If non-covered services are billed, then the designated A/B MAC (B) shall process the line items for non-covered services and show on the remittance advice (RA) that Medicare did not cover the services. 12. The claim will post to history, update the deductible information, and update utilization. The deductible and coinsurance will apply. IHS physicians and practitioners shall not collect the deductible or coinsurance from the beneficiary. 13. The Common Working File (CWF) will subject IHS physician and practitioner claims to the working aged edit(s) using the Medicare Secondary Payer (MSP) Auxiliary (AUX) file. Where the beneficiary is shown as working aged but IHS physicians and practitioners have not submitted MSP information, the CWF will reject the claim to the designated A/B MAC (B), which will reject to IHS physicians and practitioners. 14. The IHS physician and practitioner claims will be processed through the CWF using existing edits. 15. A RA will be sent to IHS physicians and practitioners for each claim. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 2, Remittance Notice to Providers for more information on the RA. 16. Medicare summary notices (MSNs) will be suppressed. 17. Third party payer crossover claims will not be suppressed. See Chapter 28 of Pub- 100-04, Medicare Claims Processing Manual for more information on crossover claims. 18. Interest shall be calculated on IHS physician and practitioner claims that are not paid timely, in the same manner as any other claim. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §80 for more information on interest calculation. 19. Normal activities for fraud and abuse, MSP, and medical review will be required for IHS physician and practitioner claims. Aberrances that may indicate potential fraudulent behavior should be reported to the applicable regional office. 20. The contractor shall process claims for Medicare Railroad retiree beneficiaries. 21. The IHS physicians and practitioners are not included in the Medpar directory since these facilities treat only the AI/AN population, except in an emergency situation.