Medicare Advantage and Other Managed Care Organizations
Medicare Advantage (MA) and other managed care organizations (MCOs) are allowed to bill Part B fee-for-service under certain situations. Such fee-for-service claims include services provided to a beneficiary under the following situations: (1) the beneficiary has enrolled, but his or her enrollment is not yet effective; (2) services provided by an attending physician or services unrelated to a terminal illness furnished to an enrollee who has elected hospice benefits; and (3) services furnished to an enrollee, but which are excluded under section 1852(a)(5) of the Social Security Act from the MA/MCO contract.
The MA/MCO must submit a Form CMS-855B to its local Medicare contractor as a prerequisite for enrolling in Medicare to bill for these services. The entity shall check the “Other” box in section 2A of the Form CMS-855B. The contractor shall use specialty code 88 when enrolling these organizations.
15.4.4 - Individual Practitioners
This section provides background information on physicians and non-physician practitioners (NPPs). While Medicare has established Federal standards governing these supplier types, these practitioners must also comply with all applicable state and local laws as a precondition of enrollment.
It is important that contractors review Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 for specific information regarding the required qualifications of the suppliers listed in this section 15.4.4 et seq.
Standards for Initial Applications
applications” also includes:
1. Form CMS-855 change of ownership, acquisition/merger, and consolidation applications submitted by the new owner.
2. “Complete” Form CMS-855 applications submitted by enrolled providers: (a) voluntarily, (b) as part of any change request if the provider does not have an established enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS), (c) as a Form CMS-855 reactivation, or (d) as a revalidation.
3. Reactivation certification packages (as described in sections 15.27.1.2.1 and 15.27.1.2.2 of this chapter).
Paper Applications - Timeliness
For purposes of sections 15.6.1.1.2 though 15.6.1.1.4 below, the term “development” means that the contractor needs to contact the supplier for additional information. (A prescreening letter to the provider is considered to be the first developmental request.)
Form CMS-855 Applications That Require a Site Visit
The contractor shall process 80 percent of all Form CMS-855 initial applications that require a site visit within 80 calendar days of receipt, process 90 percent of all Form CMS-855 initial applications that require a site visit within 150 calendar days of receipt, and process 95 percent of all Form CMS-855 initial applications that require a site visit within 210 calendar days of receipt.
Form CMS-855 Applications That Do Not Require a Site Visit
The contractor shall process 80 percent of all Form CMS-855 initial applications that do not require a site visit within 60 calendar days of receipt, process 90 percent of all Form CMS-855 initial applications that do not require a site visit within 120 calendar days of receipt, and process 95 percent of all Form CMS-855 initial applications that do not require a site visit within 180 calendar days of receipt.
Web-Based Applications That Require A Site Visit
The contractor shall process 80 percent of all Form CMS-855 Web-based initial applications that require a site visit within 80 calendar days of receipt, process 90 percent of all Form CMS-855 Web-based initial applications that require a site visit within 90 calendar days of receipt, and process 95 percent of all Form CMS-855 Web-based initial applications that require a site visit within 120 calendar days of receipt. This process generally includes, but is not limited to:
• Receipt of the provider’s certification statement in the contractor’s mailroom and forwarding it to the appropriate office for review.
• Verification of the application in accordance with existing instructions.
• Requesting and receiving clarifying information in accordance with existing instructions.
• Supplier site visit.
• Formal notification of the contractor’s decision or recommendation (and providing the appropriate appeal rights, as necessary).
Medicare Advantage (MA) and other managed care organizations (MCOs) are allowed to bill Part B fee-for-service under certain situations. Such fee-for-service claims include services provided to a beneficiary under the following situations: (1) the beneficiary has enrolled, but his or her enrollment is not yet effective; (2) services provided by an attending physician or services unrelated to a terminal illness furnished to an enrollee who has elected hospice benefits; and (3) services furnished to an enrollee, but which are excluded under section 1852(a)(5) of the Social Security Act from the MA/MCO contract.
The MA/MCO must submit a Form CMS-855B to its local Medicare contractor as a prerequisite for enrolling in Medicare to bill for these services. The entity shall check the “Other” box in section 2A of the Form CMS-855B. The contractor shall use specialty code 88 when enrolling these organizations.
15.4.4 - Individual Practitioners
This section provides background information on physicians and non-physician practitioners (NPPs). While Medicare has established Federal standards governing these supplier types, these practitioners must also comply with all applicable state and local laws as a precondition of enrollment.
It is important that contractors review Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 for specific information regarding the required qualifications of the suppliers listed in this section 15.4.4 et seq.
Standards for Initial Applications
applications” also includes:
1. Form CMS-855 change of ownership, acquisition/merger, and consolidation applications submitted by the new owner.
2. “Complete” Form CMS-855 applications submitted by enrolled providers: (a) voluntarily, (b) as part of any change request if the provider does not have an established enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS), (c) as a Form CMS-855 reactivation, or (d) as a revalidation.
3. Reactivation certification packages (as described in sections 15.27.1.2.1 and 15.27.1.2.2 of this chapter).
Paper Applications - Timeliness
For purposes of sections 15.6.1.1.2 though 15.6.1.1.4 below, the term “development” means that the contractor needs to contact the supplier for additional information. (A prescreening letter to the provider is considered to be the first developmental request.)
Form CMS-855 Applications That Require a Site Visit
The contractor shall process 80 percent of all Form CMS-855 initial applications that require a site visit within 80 calendar days of receipt, process 90 percent of all Form CMS-855 initial applications that require a site visit within 150 calendar days of receipt, and process 95 percent of all Form CMS-855 initial applications that require a site visit within 210 calendar days of receipt.
Form CMS-855 Applications That Do Not Require a Site Visit
The contractor shall process 80 percent of all Form CMS-855 initial applications that do not require a site visit within 60 calendar days of receipt, process 90 percent of all Form CMS-855 initial applications that do not require a site visit within 120 calendar days of receipt, and process 95 percent of all Form CMS-855 initial applications that do not require a site visit within 180 calendar days of receipt.
Web-Based Applications That Require A Site Visit
The contractor shall process 80 percent of all Form CMS-855 Web-based initial applications that require a site visit within 80 calendar days of receipt, process 90 percent of all Form CMS-855 Web-based initial applications that require a site visit within 90 calendar days of receipt, and process 95 percent of all Form CMS-855 Web-based initial applications that require a site visit within 120 calendar days of receipt. This process generally includes, but is not limited to:
• Receipt of the provider’s certification statement in the contractor’s mailroom and forwarding it to the appropriate office for review.
• Verification of the application in accordance with existing instructions.
• Requesting and receiving clarifying information in accordance with existing instructions.
• Supplier site visit.
• Formal notification of the contractor’s decision or recommendation (and providing the appropriate appeal rights, as necessary).
No comments:
Post a Comment