Radiation Therapy Centers
Under 42 CFR § 410.35, Medicare Part B pays for X-ray therapy and other radiation therapy services, including radium therapy and radioactive isotope therapy, and materials and the services of technicians administering the treatment.
Radiation therapy centers (RTCs) may receive reassigned benefits. An RTC need not separately enroll as a group practice in order to receive them.
For additional background on radiation therapy services, see:
• 42 CFR § 410.35
• Pub. 100-04, Claims Processing Manual, chapter 13
• Pub. 100-02, Benefit Policy Manual, chapter 15, section 90
Paper Applications - Accuracy
The contractor shall process 98 percent of paper Form CMS-855 changes of information in full accordance with all of the instructions in this chapter (with the exception of the timeliness standards identified in section 15.6.2.1 above) and all other applicable CMS directives.
Web-Based Applications - Timeliness
The contractor shall process 90 percent of all Form CMS-855 Web-based change of information applications within 45 calendar days of receipt, and process 95 percent of all such changes of information within 90 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. (This obviously does not apply to applications submitted with an electronic signature.)
• Ensuring that the changed information has been verified
• Requesting and receiving clarifying information
• Supplier site visit (if necessary)
• Formal notification to the SA and/or RO of the contractor’s approval, denial or recommendation for approval of the application.
Web-Based Applications – Accuracy
The contractor shall process 98 percent of Form CMS-855 Web-based change of information applications in full accordance with all of the instructions in this chapter (with the exception of the timeliness standards identified in section 6.2.3 above) and all other applicable CMS directives.
General Timeliness Principles
Unless stated otherwise in this chapter or in another CMS directive, the principles discussed below apply to all applications discussed in sections 15.6.1 through 15.6.2.3 of this chapter (e.g., change of ownership (CHOW) applications submitted by old and new owners, CMS-588 forms).
A. Clock Stoppages
The processing time clocks identified in sections 15.6.1 and 15.6.2.3 of this chapter cannot be stopped or suspended for any reason. This includes, but is not limited to, the following situations:
• Referring an application to the Office of Inspector General (OIG) or the Zone Program Integrity Contractor.
• Waiting for a final sales agreement (e.g., CHOW, acquisition/merger).
• Waiting for the regional office (RO) to make a provider-based or CHOW determination.
• Referring a provider to the Social Security Administration to resolve a discrepancy involving a social security number.
• Contacting CMS’ Provider Enrollment & Oversight Group (PEOG) or an RO’s survey/certification staff with a question regarding the application or CMS policy.
Notwithstanding the prohibition on clock stoppages and suspensions, the contractor should always document any delays by identifying when the referral to CMS, the OIG, etc., was made, the reason for the referral, and when a response was received. By doing so, the contractor will be able to furnish explanatory documentation to CMS should applicable time limits be exceeded. To illustrate, assume that a contractor received an initial Form CMS-855I application on March 1. On March 30, the contractor sent a question to CMS, and received a reply on April 7. The processing time clock did not stop from March 31 to April 7. However, the contractor should document its files to explain that it forwarded the question to CMS, the dates involved, and the reason for the referral.
by ambulatory surgical centers (ASCs) or portable x-ray suppliers, the processing cycle ends on the date that the contractor:
• Sends its recommendation of approval to the State agency
• Denies the application
In situations involving a change request that does not require a recommendation (i.e., it need not be forwarded to and approved by the State or RO), the cycle ends on the date that the contractor sends notification to the provider that the change has been processed. If notification to the provider is made via telephone, the cycle ends on the date that the telephone call is made (e.g., the date the voice mail message is left).
For (1) Form CMS-855I applications, (2) Form CMS-855R applications, and (3) Form CMS-855B applications from suppliers other than ASCs and portable x-ray suppliers, the processing cycle ends on the date that the contractor sends its approval/denial letter to the supplier. For change request approval/denial notifications made via telephone, the cycle ends on the date that the telephone call is made (e.g., the date the voice mail message is left).
For any application that is rejected per existing instructions, the processing time clock ends on the date that the contractor sends notification to the provider that the application has been rejected.
E. PECOS
Unless stated otherwise in this chapter or in another CMS directive, the contractor must create a logging & tracking (L & T) record in PECOS:
• For applications that do not require an application fee, no later than 20 calendar days after its receipt of the provider’s application in the contractor’s mailroom.
• For applications that require an application fee, no later than 20 calendar days after:
• The date on which the provider paid the fee – as confirmed by either the Fee Submitter List or the provider’s submission of a receipt of payment from Pay.gov, or
• The date on which PEOG approved the provider’s hardship exception request (or, for suppliers of durable medical requirement, prosthetics, orthotics and supplies, the date on which the NSC approved the hardship exception request).
Moreover, the contractor must establish a complete enrollment record in PECOS – if applicable - prior to its approval, recommendation of approval, or denial of the provider’s application. To the maximum extent possible, the contractor shall establish the enrollment record at one time, rather than on a piecemeal basis.
The L & T and enrollment record requirements in the previous paragraph apply to all applications identified in sections 15.6.1 through 15.6.2.4 of this chapter (e.g., reassignments, CHOW applications submitted by old and new owners).
In situations where the contractor cannot create an L & T record within 20 days due to missing information (e.g., no NPI was furnished), the contractor shall document the provider file accordingly.
Under 42 CFR § 410.35, Medicare Part B pays for X-ray therapy and other radiation therapy services, including radium therapy and radioactive isotope therapy, and materials and the services of technicians administering the treatment.
Radiation therapy centers (RTCs) may receive reassigned benefits. An RTC need not separately enroll as a group practice in order to receive them.
For additional background on radiation therapy services, see:
• 42 CFR § 410.35
• Pub. 100-04, Claims Processing Manual, chapter 13
• Pub. 100-02, Benefit Policy Manual, chapter 15, section 90
Paper Applications - Accuracy
The contractor shall process 98 percent of paper Form CMS-855 changes of information in full accordance with all of the instructions in this chapter (with the exception of the timeliness standards identified in section 15.6.2.1 above) and all other applicable CMS directives.
Web-Based Applications - Timeliness
The contractor shall process 90 percent of all Form CMS-855 Web-based change of information applications within 45 calendar days of receipt, and process 95 percent of all such changes of information within 90 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. (This obviously does not apply to applications submitted with an electronic signature.)
• Ensuring that the changed information has been verified
• Requesting and receiving clarifying information
• Supplier site visit (if necessary)
• Formal notification to the SA and/or RO of the contractor’s approval, denial or recommendation for approval of the application.
Web-Based Applications – Accuracy
The contractor shall process 98 percent of Form CMS-855 Web-based change of information applications in full accordance with all of the instructions in this chapter (with the exception of the timeliness standards identified in section 6.2.3 above) and all other applicable CMS directives.
General Timeliness Principles
Unless stated otherwise in this chapter or in another CMS directive, the principles discussed below apply to all applications discussed in sections 15.6.1 through 15.6.2.3 of this chapter (e.g., change of ownership (CHOW) applications submitted by old and new owners, CMS-588 forms).
A. Clock Stoppages
The processing time clocks identified in sections 15.6.1 and 15.6.2.3 of this chapter cannot be stopped or suspended for any reason. This includes, but is not limited to, the following situations:
• Referring an application to the Office of Inspector General (OIG) or the Zone Program Integrity Contractor.
• Waiting for a final sales agreement (e.g., CHOW, acquisition/merger).
• Waiting for the regional office (RO) to make a provider-based or CHOW determination.
• Referring a provider to the Social Security Administration to resolve a discrepancy involving a social security number.
• Contacting CMS’ Provider Enrollment & Oversight Group (PEOG) or an RO’s survey/certification staff with a question regarding the application or CMS policy.
Notwithstanding the prohibition on clock stoppages and suspensions, the contractor should always document any delays by identifying when the referral to CMS, the OIG, etc., was made, the reason for the referral, and when a response was received. By doing so, the contractor will be able to furnish explanatory documentation to CMS should applicable time limits be exceeded. To illustrate, assume that a contractor received an initial Form CMS-855I application on March 1. On March 30, the contractor sent a question to CMS, and received a reply on April 7. The processing time clock did not stop from March 31 to April 7. However, the contractor should document its files to explain that it forwarded the question to CMS, the dates involved, and the reason for the referral.
by ambulatory surgical centers (ASCs) or portable x-ray suppliers, the processing cycle ends on the date that the contractor:
• Sends its recommendation of approval to the State agency
• Denies the application
In situations involving a change request that does not require a recommendation (i.e., it need not be forwarded to and approved by the State or RO), the cycle ends on the date that the contractor sends notification to the provider that the change has been processed. If notification to the provider is made via telephone, the cycle ends on the date that the telephone call is made (e.g., the date the voice mail message is left).
For (1) Form CMS-855I applications, (2) Form CMS-855R applications, and (3) Form CMS-855B applications from suppliers other than ASCs and portable x-ray suppliers, the processing cycle ends on the date that the contractor sends its approval/denial letter to the supplier. For change request approval/denial notifications made via telephone, the cycle ends on the date that the telephone call is made (e.g., the date the voice mail message is left).
For any application that is rejected per existing instructions, the processing time clock ends on the date that the contractor sends notification to the provider that the application has been rejected.
E. PECOS
Unless stated otherwise in this chapter or in another CMS directive, the contractor must create a logging & tracking (L & T) record in PECOS:
• For applications that do not require an application fee, no later than 20 calendar days after its receipt of the provider’s application in the contractor’s mailroom.
• For applications that require an application fee, no later than 20 calendar days after:
• The date on which the provider paid the fee – as confirmed by either the Fee Submitter List or the provider’s submission of a receipt of payment from Pay.gov, or
• The date on which PEOG approved the provider’s hardship exception request (or, for suppliers of durable medical requirement, prosthetics, orthotics and supplies, the date on which the NSC approved the hardship exception request).
Moreover, the contractor must establish a complete enrollment record in PECOS – if applicable - prior to its approval, recommendation of approval, or denial of the provider’s application. To the maximum extent possible, the contractor shall establish the enrollment record at one time, rather than on a piecemeal basis.
The L & T and enrollment record requirements in the previous paragraph apply to all applications identified in sections 15.6.1 through 15.6.2.4 of this chapter (e.g., reassignments, CHOW applications submitted by old and new owners).
In situations where the contractor cannot create an L & T record within 20 days due to missing information (e.g., no NPI was furnished), the contractor shall document the provider file accordingly.
No comments:
Post a Comment