End Stage Renal Disease (ESRD) Radiology

Transcription

1 March 2016 This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Bulletins are available at no cost from our Website at Cahaba News Please Route.. 3 General Medicare Questions for Medicare Recipients Holiday Closure Schedule Provider Contact Center (PCC), Clerical Error Reopenings (CER) and EDI Training Schedule Provider Contact Center (PCC) Telephone Number... 5 Using the Interactive Voice Response (IVR) System for Claim Status and Eligibility Requests Medicare Health Insurance Claim (HIC) Number 7 Join Our Mailing List InSite Connecting and Exchanging Information 9 Top EDI Claim Rejections 10 Claim Specific CERT Errors- January Local Coverage Determination (LCD) Updates Comment Period for Proposed /Draft Local Coverage Determinations.. 12 Widespread Pre Pay Targeted Review Notification- Notice to Providers of Widespread Pre Pay Targeted Review of CPT CMS News National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers- Revised New Non-Physician Specialty Code for Dentist Update to Pub , Chapter 15 of the Medicare Program Integrity Manual Accredited Standards Committee (ASC) X12 Healthcare Claims Acknowledgement (277CA) Flat File Update.. 20 CMS News cont d Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits 21 New Waived Tests.. 27 April 2016 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program- Revised Documentation Requirements for Home Health Prospective Payment System (HH PPS) Face-to-Face Encounter- Rescinded. 37 Implementation of Fingerprint-Based Background Checks- Revised.. 38 CMS MLN Connects Provider enews.. 43 Medicare B Newsline Quality Survey. 44 Online Web Portal Check Claims Check Eligibility See Financials Enroll Today! Key For Icons All Providers Claims End Stage Renal Disease (ESRD) Radiology Skilled Nursing Facility (SNF) The Medicare B Newsline provides information for those providers who submit claims to Cahaba Government Benefit Administrators, LLC. The CPT codes, descriptors and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

2 This educational material was prepared as a tool to assist Medicare providers and other interested parties and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within this module, the ultimate responsibility for the correct submission of claims lies with the provider of services. Cahaba Government Benefit Administrators, LLC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of these materials. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. We encourage users to review the specific statues, regulations and other interpretive materials for a full and accurate statement of their contents. Although this material is not copyrighted, CMS prohibits reproduction for profit making purposes. American Medical Association Notice and CPT codes, descriptors and other data only are Copyright 2015 American Medical Association. All rights reserved. ICD-10 Notice The ICD-10-CM codes and descriptors used in this material are copyright 2015 under uniform copyright convention. All rights reserved. Page 2

3 Cahaba News Please Route Remember that this newsletter, and all other Medicare publications, serves as your official notice of Medicare coverage and billing information. If you have any questions about the information included in this newsletter, please call your Provider Contact Center. This bulletin shall be shared with all health care practitioners and managerial members of your provider staff. Bulletins are available at no cost from our website at Routing List Provider/Supplier Administrator Office/Clinic Manager Medical Personnel Billing/Insurance Staff Other Additional Staff General Medicare Questions for Medicare Recipients Do some of your patients have questions regarding their Medicare benefits and you are not sure how to answer? Medicare recipients should call MEDICARE ( ) for all questions related to Medicare services. Questions regarding specific claims will be automatically routed to the appropriate Medicare contractor s call center for response. Please do not ask your patients to contact Medicare on a claim that you accepted assignment on. Page 3

4 Holiday Closure Schedule-2016 Cahaba Medicare offices in Birmingham, Alabama and Douglasville, Georgia are closed on the following days in In addition, the Medicare Provider Contact Center (PCC), Clerical Error Reopenings (CER), and the Electronic Data Interchange (EDI) Help Desk close on federal holidays for continuing education training; therefore, these representatives will not be available on those days to receive your calls. New Year s Day January 1, 2016 Friday Holiday / Date Martin Luther King Jr Day January 18, 2016 Monday President s Day February 15, 2016 Monday Good Friday March 25, 2016 Friday Memorial Day May 30, 2016 Monday Independence Day July 4, 2016 Monday Labor Day September 5, 2016 Monday Columbus Day October 10, 2016 Monday Veterans Day November 11, 2016 Friday Thanksgiving November 24 & 25, 2016 Thursday/Friday Christmas December 23 & 26, 2016 Friday/Monday New Year s Day January 2, 2017 Monday Closure Schedule All Offices Closed All Offices Closed PCC/CER/EDI Closed for Training All Offices Closed All Offices Closed All Offices Closed All Offices Closed PCC/CER/EDI Closed for Training PCC/CER/EDI Closed for Training All Offices Closed All Offices Closed All Offices Closed Page 4

5 Provider Contact Center, Clerical Error Reopening, and EDI Training Schedule Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the Provider Contact Center (PCC), Clerical Error Reopenings (CERs), and the Electronic Data Interchange (EDI) Help Desk the opportunity to offer training to their representatives. Listed below are the closed training dates and times. PCC, CER, & EDI Training Dates Friday, March 4, 2016 Friday, March 11, 2016 Friday, March 18, 2016 Time 9:30-11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 9:30-11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET 9:30-11:30 a.m. CT/10:30 a.m.- 12:30 p.m. ET Provider Contact Center Telephone Number / TDD The Provider Contact Center (PCC) hours of operation are from 7:00 a.m. to 4:00 p.m. Central Time (8:00 a.m. 5:00 p.m. Eastern Time). This allows us to serve our providers located in different geographical areas and removes the time zone restriction. Our Interactive Voice Response (IVR) System is designed to assist providers in obtaining answers to numerous issues through self-service options. Options on our IVR include information regarding patient eligibility, checks, claims, deductible and other general information. Please note that our Customer Service Representatives (CSRs) are available to answer questions that cannot be answered by the IVR. CSRs are physically located in Birmingham, Alabama and Douglasville, Georgia. When your call is received, it is routed to the next available representative. Page 5

6 Using the Interactive Voice Response (IVR) System for Claim Status and Eligibility Requests Some providers opt out of the Interactive Voice Response (IVR) System to speak to a Customer Service Representative (CSR) for information that can be accessed through the IVR. The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Chapter 6 Section 50.1 states: Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR. CSRs may provide claims status and/or eligibility information if it is clear that the provider cannot access the information through the IVR because the IVR is not functioning. If you are requesting whether Cahaba has received a claim or if a claim has finalized, this is considered a claim status request. DDR Section 3.3 ( kb) states: If a CSR or written inquiry correspondent receives an inquiry about information that can be found on a Remittance Advice (RA), the CSR/correspondent should take the opportunity to educate the inquirer on how to read the RA, in an effort to encourage the use of self-service. The CSR/correspondent should advise the inquirer that the RA is needed in order to answer any questions for which answers are available on the RA. Providers should also be advised that any billing staff or representatives that make inquiries on his/her behalf will need a copy of the RA. Cahaba CSRs have visibility as to the path the provider takes in the IVR and/or whether they opt out to speak with a representative up front. The CSR will instruct the provider to call back and utilize the IVR if they did not attempt to use this self service option as required by CMS. Page 6

7 Medicare Health Insurance Claim (HIC) Number A Medicare card is issued to every person who is eligible for Medicare benefits and may be identified by its red, white and blue coloring. This card identifies the Medicare beneficiary and includes the following information: Name (exactly as it appears on the Social Security records); Medicare Health Insurance Claim (HIC) number; Beginning date of Medicare entitlement for hospital and/or medical insurance; Sex and Beneficiary's signature. Three of the top five reasons for claim rejection in any given month are for: The last name submitted for the beneficiary does not match the last name we have on record for the HIC number on the claim. The beneficiary's last name must include apostrophes, spaces, hyphens, etc., if they appear in the beneficiary's last name on his or her Medicare card. The first name submitted for the beneficiary does not match the first name we have on record for the HIC number on the claim. The beneficiary's first name must appear as it does on the beneficiary's Medicare card. This includes spaces, hyphens, apostrophes, etc. The HIC number not matching the name we have on record. The Medicare Claim Number must appear on the claim exactly as it does on the beneficiary s card, without the dashes and with no spaces. It is extremely important that you submit the patient s complete name and HIC number to Medicare or any other health care provider you use (i.e. clinical laboratories, radiology imaging groups, or outpatient therapy providers, etc.). This will ensure that those providers have the correct patient information to file their claims as well. Social Security Number Removal Initiative from Medicare Cards In 2015, Congress passed a law that directs Medicare to remove Social Security numbers from Medicare cards. This will help protect beneficiaries (patients) against identity fraud and help protect the Medicare program. Beneficiaries do not need to do anything. Starting in 2018, they will get information letting them know about the new Medicare card with a randomly-generated Medicare number. This information will explain how to use the new Medicare card, and what to do with their old card. Page 7

8 Join Our Mailing List Located on the homepage of the Cahaba website, you will find a selection in the top gray toolbar entitled Join Mailing List. By clicking here and enrolling in our mailing list (known to many as a listserv), you will receive timely CMS and Cahaba news including policies, benefits, event announcements, claims submission, processing updates and more. This service is FREE and all you need to subscribe is a valid address. Having the most current information will help you avoid costly and time-consuming interruptions. We encourage all Medicare Part A and Part B providers to enroll at Once you are a member, you can edit your profile to: Unsubscribe from all lists Subscribe to additional lists Update your address Change your name or address information Change what Cahaba lists you are subscribed to In order to ensure that you receive your subscription s and announcements from Cahaba, please add us to your contact lists, adjust your spam settings, or follow the instructions from your provider on how to prevent our s from being marked Spam or Junk Mail. Page 8

9 InSite - Connecting and Exchanging Information InSite allows providers and suppliers to conduct business via a web portal instead of calling into an Interactive Voice Response (IVR) system or contact center. You can use this system to find beneficiary eligibility and entitlement information, query for your claims status, see financials and view your provider/supplier demographic information. This system operates in a secure, protected environment to ensure your billing information is never compromised. Each provider will select a Local Security Officer (LSO) to be authorized by Cahaba. Your LSO will manage your InSite user access. InSite provides educational material to assist with enrollment and navigation, such as: Quick Steps Job Aid Training Material Frequently Asked Question (FAQs) InSite is a free and secure online portal to help you manage your Medicare billing. It s easy to use and available 24 hours a day. Located in the top gray toolbar on the Cahaba website at we encourage you to begin the enrollment process today. Page 9

10 Top Electronic Data Interchange (EDI) Claim Rejections The Electronic Data Interchange (EDI) Department publishes information on the Top EDI Claim Rejections for HIPAA 5010 on our website. The rejections are updated monthly and can be viewed at The information published has been extracted from the 277CA transactions created for the month indicated. The 277CA indicates files, batch, and claim level rejections. Information about the 277CA transactions can be found on the Washington Publishing Company's website at For more information about specific edits, visit the CMS website at Referring to these reports will allow you to correct and resubmit claims quickly, reducing delay of payment. Claim Specific CERT Errors January 2016 The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like Cahaba. Contractors are then notified by CERT of the errors and findings. We would like to remind you that should you receive an Additional Documentation Request (ADR), such as a request for records to support services that are involved in a CERT review, you should submit the appropriate documentation to support the services billed, including but not limited to progress note(s) to match the DOS billed, lab results, operative reports, diagnostic tests, physician orders, etc. Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes. Providers may appeal unfavorable decisions with additional supporting documentation. For detailed information regarding the Appeals Process, refer to the following link: Please contact the Provider Contact Center for individual questions concerning CERT errors at This summary provides examples of Cahaba GBA's errors identified by CERT. We encourage all providers to review this listing to educate you on common errors. This information will be updated periodically. The intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and reduce future denials by Medicare. Page 10

11 Local Coverage Determination (LCD) Updates Revisions made to Local Coverage Determinations (LCDs) as the result of the CPT/HCPCS Update for 2016 are described below. The code revisions reflect services which are currently addressed in these LCDs and do not further restrict the current coverage. Please make note of these revisions, which became effective January 1, L Pathology and Laboratory: Qualitative Drug Testing CPT code G6058 was invalid after December 31, 2015 and was removed from this LCD. CPT codes G0477, G0478 and G0479 were added to the 'CPT/HCPCS Codes' section of the LCD. L35920 Pathology and Laboratory: Quantitative Drug Testing CPT codes G G6034, G6036, G6037, G6040 G6046, G6048, G6051 G6054, G6056 and G6057 were invalid after December 31, 2015 and were removed from the 'CPT/HCPCS Codes' section of the LCD. CPT codes G0480, G0481, G0482 and G0483 were added to the 'CPT/HCPCS Codes' section of the LCD. LCDs are located on the Medicare Coverage Database (MCD) which can be accessed from the Local Coverage Determinations (LCDs) & Articles page of the Medical Review section on the Cahaba website. (Select LCDs for your state). Providers are encouraged to review this information to ensure compliance. Page 11

12 Comment Period for Proposed /Draft Local Coverage Determinations The Comment Period for the Proposed/Draft Local Coverage Determinations (LCDs) listed below is from March 4, 2016 through April 18, 2016: (DL36582) Pathology and Laboratory: K-ras Testing prior to Treatment of Colorectal Cancer (CRC) (DL36584) Surgery: Implantable Pacemakers with Leads for Cardiac Rate, Dysrhythmia, Resynchronization, and Cardioversion/ Defibrillation (PM CRT AICD) The Proposed/Draft LCDs are located on the Medicare Coverage Database (MCD), which can be accessed from the Local Coverage Determinations (LCDs) & Articles page of the Part B Medical Review section of the Cahaba website (select LCDs for your state, and choose Proposed/Draft LCDs not released to final LCDs ). Comments on the Proposed/Draft LCDs may be submitted via to LCDComment@Cahabagba.com or in writing to the Medical Director at the address below: Cahaba GBA Comments for Draft LCDs Attention: Contractor Medical Director Post Office Box Birmingham, AL Page 12

13 Widespread Pre Pay Targeted Review Notification- Part B- Notice to Providers of Widespread Pre Pay Targeted Review of CPT As a result of data analysis, Cahaba Medical Review Part B has been conducting a prepayment widespread targeted review of CPT Office or other outpatient visit for the evaluation and management of an established patient. Claims will be randomly selected across the provider community for billing services that meet the parameters of the edit. This notice to all providers is to inform of low sampling and has not provided an accurate analysis; therefore the counter is being reset Office or other outpatient visit for the evaluation and management of an established patient To ensure timely submission of records the provider may mail to the following address: Cahaba Medicare Part B Medical Review/ADS Post Office Box 6169 Indianapolis, IN Office or other outpatient visit for the evaluation and management of an established patient is defined as requiring at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. E/M services health care professionals may use either version of the 1995 or 1997 documentation guidelines, not a combination of the two for a patient encounter. For detailed documentation and coding information on Office or other outpatient visit for the evaluation and management of an established patient (CPT 99214) refer to the following references: American Medical Association Current Procedural Terminology (CPT ) Standard Edition Medicare Claims Processing Manual, Chapter 12, Section /1997 Documentation Guidelines for Evaluation and Management Services Page 13

14 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services NEW product from the Medicare Learning Network (MLN) Provider Compliance Tips for Computed Tomography (CT) Scans Podcast, ICN , downloadable only MLN Matters Number: MM9078 Revised Related Change Request (CR) #: CR 9078 Related CR Release Date: December 10, 2015 Effective Date: August 13, 2013 Related CR Transmittal #: R3421CP and R187NCD Implementation Date: July 6, 2015 National Coverage Determination (NCD) for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers Note: This article was revised on January 27, 2016, to note that the NCD for Cardiac Pacemakers, Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (NCD20.8.3) was effective on August 13, 2013, and remains in effect. In order to address claims processing issues, the Centers for Medicare & Medicaid Services has instructed Medicare Administrative Contractors (MACs) to implement this NCD at the local level until CMS is able to revise the formal claims processing instructions. All aspects of the NCD policy in the NCD Manual, Section , remain in effect. Additionally, CMS is temporarily removing the corresponding Medicare Claims Processing Manual, Chapter 32, Section 320, and all but two business requirements, to avoid confusion and better clarify that the MACs will use their discretionary authority to process these claims. Provider Types Affected This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to MACs for single chamber and dual chamber permanent cardiac pacemaker services provided to Medicare beneficiaries. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. Page 14 Page 1 of 2

15 MLN Matters Number: MM9078 Related Change Request Number: 9078 Additional Information The official instruction, CR 9078, was issued to your MAC via two transmittals. The first transmittal updates the Medicare Claims Processing Manual and it is available at Guidance/Guidance/Transmittals/Downloads/R3421CP.pdf on the CMS website. The second updates the Medicare National Coverage Determination Manual and it is available at Guidance/Guidance/Transmittals/Downloads/R187NCD.pdf on the CMS website. If you have questions, please contact your MAC at their toll-free number. The number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work? Document History Date January 27, 2016 November 13, 2015 October 28, 2015 May 26, 2015 Description This article was revised to reflect the revised CR9078 issued on December 10, The CR was revised to further clarify that the MACs are to implement the NCD at the local level until Medicare system instructions are revised and Medicare system changes are implemented. The CR also included a specific implementation date of January 13, 2016 for local implementation. All references to the old claims processing instructions were removed from the article. This article was revised to reflect the revised CR9078 issued on October 26. The CR was revised to direct the MACs to implement the NCD at the local level until Medicare system instructions are revised and Medicare system changes are implemented. This article was revised to add a reference to MLN Matters Article MM8525 which allows payment for nationally covered implanted permanent cardiac pacemakers, single chamber or dual chamber, for the indications outlined in the Medicare National Coverage Determinations Manual. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. Page 15 Page 2 of 2

16 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9355 Related Change Request (CR) #: CR 9355 Related CR Release Date: January 29, 2016 Effective Date: July 1, 2016 Related CR Transmittal #: R3447CP and R262FM Implementation Date: July 5, 2016 New Non-Physician Specialty Code for Dentist Provider Types Affected This MLN Matters Article is intended for Dentists and certain suppliers submitting claims to Medicare Administrative Contractors (MACs) for dental services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9355 announces that the Centers for Medicare & Medicaid Services (CMS) has created a new non-physician specialty code (C5) for Dentist. Background Physicians self-designate their Medicare physician specialty on the Medicare enrollment application ((CMS-855B, CMS-855I or CMS-855O) or Internet-based Provider Enrollment, Chain and Ownership System (PECOS) when they enroll in the Medicare program. Nonphysician practitioners are assigned a Medicare specialty code when they enroll. The specialty code becomes associated with the claims that the physician or non-physician practitioner submits, and describes the specific/unique types of medicine that they (and certain other suppliers) practice. CMS uses specialty codes for programmatic and claims processing purposes. Additional Information The official instruction, CR9355, issued to your MAC regarding this change consists of two transmittals. The first revises the Medicare Claims Processing Manual and it is available This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 16 Page 1 of 2

17 MLN Matters Number: MM9355 Related Change Request Number: 9355 at Guidance/Guidance/Transmittals/Downloads/R3447CP.pdf on the CMS website. The second transmittal updates the Medicare Financial Management Manual and it is available at Guidance/Guidance/Transmittals/Downloads/R262FM.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 17 Page 2 of 2

18 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9390 Related Change Request (CR) #: CR 9390 Related CR Release Date: February 4, 2016 Effective Date: March 4, 2016 Related CR Transmittal #: R636PI Implementation Date: March 4, 2016 Update to Pub , Chapter 15 Provider Types Affected This MLN Matters Article is intended for providers, including Home Health Agencies (HHAs), submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9390, from which this article was developed, makes several minor revisions to Chapter 15 of the Medicare Program Integrity Manual. These changes include, but are not limited to: 1. Clarifying the process for verifying correspondence telephone numbers; 2. Clarifying the process for validating the credentials of technicians of Independent Diagnostic Testing Facilities (IDTFs); and 3. Identifying the timeframe by which approval letters must be sent and to whom they must be sent. Make sure that your billing staffs are aware of these revisions. Background Chapter 15 of the Medicare Program Integrity Manual contains instructions regarding the processing of Form CMS-855 applications. CR9390 makes the following key changes: 1. If online verification of an IDTF technician's credentials is not available or cannot be made, the MAC will request a copy of the technician s certification card. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 18 Page 1 of 2

19 MLN Matters Number: MM9390 Related Change Request Number: The MAC will not request a social security card to verify an individual s identity or social security number. 3. Absent a CMS instruction or directive to the contrary, the MAC will send enrollment approval letters within 5 business days of approving the enrollment application. 4. For all applications other than the Form CMS-855S, the MAC will send development/approval letters/revocation letters, etc., to the contact person if one is listed; otherwise, the contractor may send the letter to the provider or supplier at the provider s/supplier s correspondence address or special payments address. Note: CR9390 does not involve any legislative or regulatory policies and is restricted to changes in operational procedures. Many of the other Chapter 15 revisions are small, such as inserting single words or short sentences, etc. Others are more significant and those revisions are in the revised Chapter 15, which is attached to CR9390. Additional Information The official instruction, CR9390, issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/Downloads/R636PI.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 19 Page 2 of 2

20 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9454 Related Change Request (CR) #: CR 9454 Related CR Release Date: February 4, 2016 Effective Date: July 1, 2016 Related CR Transmittal #: R1609OTN Implementation Date: July 5, 2016 Accredited Standards Committee (ASC) X12 Healthcare Claims Acknowledgement (277CA) Flat File Update Provider Types Affected This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. What You Need to Know Change Request (CR) 9454 updates the Accredited Standards Committee (ASC) X12 Healthcare Claims Acknowledgement (277CA) flat file to allow for larger monetary amounts to meet Medicare's needs. The 277CA amount fields are currently the same size as the size used for the input files. Additional Information The official instruction, CR 9454, issued to your MAC regarding this change is available at Items/R1609OTN.html?DLPage=1&DLEntries=10&DLFilter=9454&DLSort=1&DLSortDir=ascendi ng on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 20 Page 1 of 1

21 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9502 Related Change Request (CR) #: CR 9502 Related CR Release Date: January 15, 2016 Effective Date: January 1, 2016 Related CR Transmittal #: R3439CP Implementation Date: April 4, 2016 Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits Provider Types Affected This MLN Matters Article is intended for clinical diagnostic laboratories submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9502 informs MACs about the Healthcare Common Procedure Coding System (HCPCS) codes for 2016 that are both subject to, and excluded from, CLIA edits; and also includes the HCPCS codes discontinued as of December 31, Make sure that your billing staffs are aware of these CLIA-related changes for Background The Clinical Laboratory Improvement Amendments (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for laboratory tests performed in certified facilities, each claim for a HCPCS code that is considered a CLIA laboratory test is currently edited at the CLIA certificate level. The HCPCS codes that are considered a laboratory test under CLIA change each year. Contractors need to be informed about the new HCPCS codes that are both subject to CLIA edits and excluded from CLIA edits. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 21 Page 1 of 6

22 MLN Matters Number: MM9502 Related Change Request Number: 9502 Discontinued HCPCS Codes The HCPCS codes listed in table 1 below were discontinued on December 31, 2015 Table 1: HCPCS Codes Discontinued on December 31, 2015 HCPCS Code Descriptor G0431 G0434 G6030 G6031 G6032 G6034 G6035 G6036 G6037 G6038 G6039 G6040 G6041 G6042 G6043 G6044 G6045 G6046 G6047 G6048 G6049 G6050 G6051 G6052 G6053 G6054 G6055 G6056 G6057 Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter Drug screen, other than chromatographic; any number of drug classes, by clia waived test or moderate complexity test, per patient encounter Amitriptyline Benzodiazepines Desipramine Doxepin Gold Assay of imipramine Nortriptyline Salicylate Acetaminophen Alcohol (ethanol); any specimen except breath Alkaloids, urine, quantitative Amphetamine or methamphetamine Barbiturates, not elsewhere specified Cocaine or metabolite Dihydrocodeinone Dihydromorphinone Dihydrotestosterone Dimethadione Epiandrosterone Ethchlorvynol Flurazepam Meprobamate Methadone Methsuximide Nicotine Opiate(s), drug and metabolites, each procedure Phenothiazine This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 22 Page 2 of 6

23 MLN Matters Number: MM9502 Related Change Request Number: 9502 HCPCS Code G6058 Drug confirmation, each procedure Chemical analysis Chemical analysis Chemical analysis Chemical analysis Chemical analysis Chemical analysis Descriptor Chemical analysis using chromatography technique Chemical analysis using chromatography technique Chemical analysis using chromatography technique Mass spectrometry (laboratory testing method Antibody evaluation 0103T New HCPCS Codes for 2016 Measurement of vitamin B-12 deficiency marker The HCPCS codes listed in table 2, below, are new for 2016 and are subject to CLIA edits. The list does not include new HCPCS codes for waived tests or provider-performed procedures. The HCPCS codes listed below require a facility to have either a: 1. CLIA certificate of registration (certificate type code 9); 2. CLIA certificate of compliance (certificate type code 1); or 3. CLIA certificate of accreditation (certificate type code 3). The following facilities are not permitted to be paid for these tests: 1. A facility without a valid, current, CLIA certificate; 2. A facility with a current CLIA certificate of waiver (certificate type code 2); or 3. A facility with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4). Table 2: New HCPCS Codes Subject to CLIA Edits for 2016 HCPCS Code Descriptor G0477 G0478 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 23 Page 3 of 6

24 MLN Matters Number: MM9502 Related Change Request Number: 9502 HCPCS Code G0479 G0480 G0481 G0482 G Descriptor Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures by instrumented chemistry analyzers utilizing immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when performed, per date of service Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, drug class(es), including metabolite(s) if performed Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed Blood test panel for obstetrics ( cbc, differential wbc count, hepatitis b, hiv, rubella, syphilis, antibody screening, rbc, blood typing) Gene analysis (breast cancer 1 and 2) full sequence and duplication or deletion variants Gene analysis (ABL proto-oncogene 1, non-receptor tyrosine kinase) Gene analysis (ccaat/enhancer binding protein [c/ebp], alpha) full gene sequence Gene analysis (calreticulin), common variants Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 24 Page 4 of 6

25 MLN Matters Number: MM9502 Related Change Request Number: 9502 HCPCS Code Descriptor Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants; Gene analysis for cancer (neuroblastoma) Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence Test for detecting genes for disorders related to Ashkenazi Jews Gene analysis (breast and related cancers), genomic sequence Gene analysis (breast and related cancers), duplication or deletion variants Gene analysis (retinal disorders), genomic sequence Gene analysis (neuroendocrine tumors), genomic sequence Gene analysis (neuroendocrine tumors), duplication and deletion variants Gene analysis (noonan syndrome) genomic sequence analysis Test for detecting genes associated with rheumatoid arthritis using immunoassay technique Test for detecting genes associated with heart vessels diseases Gene analysis (colon related cancer) Gene analysis (colorectal cancer) Culture of live tumor cells and chemotherapy drug response by staining Culture of live tumor cells and chemotherapy drug response by staining Testing of lung tumor cells for prediction of survival Gene analysis (cancer) Gene analysis (thyroid cancer) Test for detecting genes associated with heart diseases Antibody evaluation 0009M 0010M Fetal aneuploidy (trisomy 21, and 18) dna sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy Oncology (high-grade prostate cancer), biochemical assay of four proteins (total psa, free psa, intact psa and human kallidrein 2 (hk2)) plus patient age, digital rectal examination status, and no history of positive prostate biopsy, utilizing plasma, prognostic algorithm reported as a probability score MACs will not search their files to either retract payment for claims already paid or retroactively pay claims, but will adjust claims that brought to their attention. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 25 Page 5 of 6

26 MLN Matters Number: MM9502 Related Change Request Number: 9502 Additional Information The official instruction, CR 9502 issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/Downloads/R3439CP.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 26 Page 6 of 6

27 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM 9515 Related Change Request (CR) #: CR 9515 Related CR Release Date: January 15, 2016 Effective Date: April 1, 2016 Related CR Transmittal #: R3440CP Implementation Date: April 4, 2016 New Waived Tests Provider Types Affected This MLN Matters Article is intended for clinical diagnostic laboratory providers submitting clinical diagnostic laboratory claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare & Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA certificate level. The Current Procedural Terminology (CPT) codes that the Centers for Medicare & Medicaid Services (CMS) consider to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 9515 informs the MACs about the latest new CPT codes that are subject to CLIA edits. Make sure your billing staffs are aware of the latest CLIA-related changes. Background Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the tests with CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and do not require a QW This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 27 Page 1 of 3

28 MLN Matters Number: MM9515 Related Change Request Number: 9515 modifier to be recognized as a waived test. The CPT code, effective date and description for the latest tests approved by the FDA as waived tests under CLIA are the following: 83036QW, August 10, 2015, PTS Diagnostics A1C + Professional Use; 82274QW, G0328QW, September 14, 2015, Tanner Scientific ifob One Step Rapid Test; 87502QW, September 18, 2015, Roche Molecular, cobas Liat System (cobas Liat Influenza A/B Assay; G0434QW [from October 27, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], Clarity Diagnostics LLC, Clarity Multi-Drug Urine Test Cup; G0434QW [from October 27, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], Clarity Diagnostics LLC, Clarity Multi-Drug Urine Test DipCard; G0434QW [from November 10, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], W.H.P.M., Inc. First Sign Drug of Abuse Butalbital Cup Test; G0434QW [from November 10, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], W.H.P.M., Inc. First Sign Drug of Abuse Butalbital Dip Card Test; G0434QW [from November 10, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], W.H.P.M., Inc. First Sign Drug of Abuse Morphine Dip Card Test; G0434QW [from November 13, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], UCP Biosciences, Inc. U-Cup Drug Test Cards; G0434QW [from November 13, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], UCP Biosciences, Inc. U-Card Drug Test Cups; and G0434QW [from December 14, 2015 to December 31, 2015] and G0477QW [on and after January 1, 2016], Tanner Scientific, Platinum Line Multi-Panel Drug Test Cup. The HCPS code G0434 [Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter] was discontinued on 12/31/2015. The new HCPCS code G0477 [Drug tests(s), presumptive, any This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 28 Page 2 of 3

29 MLN Matters Number: MM9515 Related Change Request Number: 9515 number of drug classes; any number of devices or procedures, (eg immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service] was effective 1/1/2016. HCPCS code G0477QW describes the waived testing previously assigned code G0434QW. All tests in the attachment to CR9515 that previously had HCPCS G0434QW are now assigned G0477QW. You should be aware that your MAC will not search their files, to either retract payment or retroactively pay claims; however, they should adjust such claims that you bring to their attention. Additional Information The official instruction, CR 9515 issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/Downloads/R3440CP.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 29 Page 3 of 3

30 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: MM9536 Related Change Request (CR) #: CR 9536 Related CR Release Date: February 4, 2016 Effective Date: April 1, 2016 Related CR Transmittal #: R3450CP Implementation Date: April 4, 2016 April 2016 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files Provider Types Affected This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment MACs (DME MACs) and Home Health & Hospice MACs (HH&H MACs), for Part B drugs provided to Medicare beneficiaries. Provider Action Needed Medicare will use the April 2016 quarterly Average Sales Price (ASP) and Not Otherwise Classified (NOC) pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after April 4, 2016, with dates of services from April 1, 2016, through June 30, Change Request (CR) 9536 instructs MACs to implement the April 2016 ASP Medicare Part B drug pricing file for Medicare Part B drugs, and if they are released by the Centers for Medicare & Medicaid Services (CMS), to also implement the revised January 2016, October 2015, July 2015, and April 2015 files. Make sure your billing personnel are aware of these changes. Background The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 30 Page 1 of 2

31 MLN Matters Number: MM9536 Related Change Request Number: 9536 System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are in the Medicare Claims Processing Manual, Chapter 4, Section 50. The following table shows how the files will be applied. Files Effective Date for Dates of Service April 2016 ASP and ASP NOC April 1, 2016, through June 30, 2016 January 2016 ASP and ASP NOC January 1, 2016, through March 31, 2016 October 2015 ASP and ASP NOC October 1, 2015, through December 31, 2015 July 2015 ASP and ASP NOC July 1, 2015, through September 30, 2015 April 2015 ASP and ASP NOC April 1, 2015, through June 30, 2015 Additional Information The official instruction, CR9536 issued to your MAC regarding this change is available at Guidance/Guidance/Transmittals/Downloads/R3450CP.pdf on the CMS website. If you have any questions, please contact your MAC at their toll-free number. That number is available at Network-MLN/MLNMattersArticles/index.html under - How Does It Work. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2014 American Medical Association. All rights reserved. Page 31 Page 2 of 2

32 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: SE1128 Revised Related CR Release Date: N/A Related CR Transmittal #: N/A Related Change Request (CR) #: N/A Effective Date: N/A Implementation Date: N/A Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program Note: This article was revised on February 4, 2016, to include updated information for 2016 and a correction to the second sentence in paragraph 2 under Important Clarifications Concerning QMB Balance Billing Law on page 3. All other information is the same. Provider Types Affected This article pertains to all Medicare physicians, providers and suppliers, including those serving beneficiaries enrolled in original Medicare or a Medicare Advantage plan. What you Need to Know STOP Impact to You This Special Edition MLN Matters Article from the Centers for Medicare & Medicaid Services (CMS) reminds all Medicare providers that they may not bill beneficiaries enrolled in the QMB program for Medicare cost-sharing (such charges are known as balance billing ). QMB is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability. CAUTION What You Need to Know The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. Page 32 Page 1 of 5

33 MLN Matters Number: SE1128 Related Change Request Number: N/A circumstances.) Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers --not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions. GO What You Need to Do Refer to the Background and Additional Information Sections of this article for further details and resources about this guidance. Please ensure that you and your staffs are aware of the federal balance billing law and policies regarding QMB individuals. Contact the Medicaid Agency in the States in which you practice to learn about ways to identify QMB patients in your State and procedures applicable to Medicaid reimbursement for their Medicare cost-sharing. If you are a Medicare Advantage provider, you may also contact the MA plan for more information. Finally, all Medicare providers should ensure that their billing software and administrative staff exempt QMB individuals from Medicare costsharing billing and related collection efforts. Background This article provides CMS guidance to Medicare providers to help them avoid inappropriately billing QMBs for Medicare cost-sharing, including deductibles, coinsurance, and copayments. This practice is known as balance billing. Balance Billing of QMBs Is Prohibited by Federal Law Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances. See Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of (Please note, this section of the Act is available at on the Internet.) QMB is a Medicaid program for Medicare beneficiaries that exempts them from liability for Medicare cost-sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. However, as permitted by federal law, States can limit provider reimbursement for Medicare cost-sharing under certain circumstances. See the chart at the end of this article for more information about the QMB benefit. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB beneficiary. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.) Inappropriate Balance Billing Persists Despite federal law, erroneous balance billing of QMB individuals persists. Many beneficiaries are unaware of the billing restrictions (or concerned about undermining This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. Page 33 Page 2 of 5

34 MLN Matters Number: SE1128 Related Change Request Number: N/A provider relationships) and simply pay the cost-sharing amounts. Others may experience undue distress when unpaid bills are referred to collection agencies. See Access to Care Issues Among Qualified Medicare Beneficiaries (QMB), Centers for Medicare & Medicaid Services July 2015 at Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/Downloads/Access_to_Care_Issues_Among_Qualified_Medicare_Beneficiaries.pdf on the CMS website. Important Clarifications Concerning QMB Balance Billing Law Be aware of the following policy clarifications to ensure compliance with QMB balance billing requirements. First, know that all original Medicare and MA providers-- not only those that accept Medicaid-- must abide by the balance billing prohibitions. In addition, QMB individuals retain their protection from balance billing when they cross state lines to receive care. Providers cannot charge QMB individuals even if the patient s QMB benefit is provided by a different State than the State in which care is rendered. Finally, note that QMBs cannot choose to waive their QMB status and pay Medicare costsharing. The federal statute referenced above supersedes Section of the State Medicaid Manual, which is no longer in effect. Ways to Improve Processes Related to QMBs Proactive steps to identify QMB individuals you serve and to communicate with State Medicaid Agencies (and Medicare Advantage plans if applicable), can promote compliance with QMB balance billing prohibitions. 1. Determine effective means to identify QMB individuals among your patients. Find out what cards are issued to QMB individuals so you can in turn ask all your patients if they have them. Learn if you can query state systems to verify QMB enrollment among your patients. If you are a Medicare Advantage provider contact the plan to determine how to identify the plan s QMB enrollees. 2. Discern what billing processes apply to seek reimbursement for Medicare cost-sharing from the States in which you operate. Different processes may apply to original Medicare and MA services provided to QMB beneficiaries. For original Medicare claims, nearly all states have electronic crossover processes through the Medicare Benefits Coordination & Recovery Center (BCRC) to automatically receive Medicareadjudicated claims. If a claim is automatically crossed over to another payer, such as Medicaid, it is customarily noted on the Medicare Remittance Advice. Understand the processes you need to follow to request reimbursement for Medicare cost-sharing amounts if they are owed by your State. You may need to complete a State Provider Registration Process and be entered into the State payment system to bill the State. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. Page 34 Page 3 of 5

35 MLN Matters Number: SE1128 Related Change Request Number: N/A 3. Make sure that your billing software and administrative staff exempt QMB individuals from Medicare cost-sharing billing and related collection efforts. QMB Eligibility and Benefits Dual Eligibility Eligibility Criteria Benefits Qualified Medicare Beneficiary (QMB only) Resources cannot exceed $7,280 for a single individual or $10,930 in 2015 for an individual living with a spouse and no other dependents. Income cannot exceed 100% of the Federal Poverty Level (FPL) +$20 ($1,001/month Individual $1,348/month Couple in 2015). Note: These guidelines are a federal floor. Under Section 1902 (r)(2) of the Social Security Act, states can effectively raise these limits above these baseline federal standards. QMB Plus Meets all of the standards for QMB eligibility as described above, but also meets the financial criteria for full Medicaid coverage Additional Information Medicaid Pays Medicare Part A and B premiums, deductibles, co-insurance and co-pays to the extent required by the State Medicaid Plan. Exempts beneficiaries from Medicare costsharing charges The State may choose to pay the Medicare Advantage (Part C) premium. Provides all benefits available to QMBs, as well as all benefits available under the State Plan to a fully eligible Medicaid recipient For more information about dual eligible categories and benefits, please visit on the Internet. Also, for more information about QMBs and other individuals who are dually eligible to receive Medicare and Medicaid benefits, please refer to the Medicare Learning Network publication titled Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles), which is available on the CMS website. For general Medicaid information, please visit the Medicaid webpage at on the CMS website. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. Page 35 Page 4 of 5

36 MLN Matters Number: SE1128 Related Change Request Number: N/A Document History Date of Change February 4, 2016 February 1, 2016 March 28, 2014 Description The article was revised on February 4, 2016, to include updated information for 2016 and a correction to the second sentence in paragraph 2 under Important Clarifications Concerning QMB Balance Billing Law on page 3. The article was revised to include updated information for 2016 and a clarifying note regarding eligibility criteria in the table on page 4. The article was revised on to change the name of the Coordination of Benefits Contractor (COBC) to Benefits Coordination & Recovery Center (BCRC). This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2010 American Medical Association. All rights reserved. Page 36 Page 5 of 5

37 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters Number: SE1405 Rescinded Related CR Release Date: N/A Related CR Transmittal #: N/A Related Change Request (CR) #: N/A Effective Date: N/A Implementation Date: N/A Documentation Requirements for Home Health Prospective Payment System (HH PPS) Face-to-Face Encounter Note: This article was rescinded on January 15, 2016, to reflect changes regarding the documentation requirements for HH face-to face encounters, which were updated in the CY 2015 HH PPS Final Rule. Those changes eliminated the narrative requirement for face-to-face encounter as part of the certification of eligibility, for episodes on or after January 1, For information regarding Certifying Patients for the Medicare Home Health Benefit, please review SE1436. Document History Date of Change January 15, 2016 Description The article was rescinded due to changes regarding the documentation changes to HH face-to face encounters, which were updated in the CY 2015 HH PPS Final Rule. Those changes eliminated the narrative requirement for face-to-face encounter as part of the certification of eligibility for episodes on or after January 1, This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association. Page 37 Page 1 of 1

38 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Revised products from the Medicare Learning Network (MLN) The Quick Reference Information: Home Health Services Educational Tool (ICN ) in downloadable format. MLN Matters Number: SE1417 Revised Related CR Release Date: N/A Related CR Transmittal #: N/A Related Change Request (CR) #: N/A Effective Date: N/A Implementation Date: N/A Implementation of Fingerprint-Based Background Checks Note: This article was revised on January 27, 2016, to update language in the article and to emphasize affected providers and suppliers in the Caution Section. Provider Types Affected This MLN Matters Special Edition article is intended for all providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed STOP Impact to You This Special Edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to announce the implementation of fingerprint-based background checks as part of enhanced enrollment screening provisions contained in Section 6401 of the Affordable Care Act. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association. Page 38 Page 1 of 5

39 MLN Matters Number: SE1417 Related Change Request Number: N/A CAUTION What You Need to Know Fingerprint-based background checks are generally completed on individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category. A 5 percent or greater owner includes any individual that has any partnership (general or limited) in a high risk provider or supplier. Note that the high level of risk category applies to providers and suppliers who are newly enrolling Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers or Home Health Agencies (HHA). It also applies to providers and suppliers who have been elevated to the high risk category. CMS may adjust a particular provider or supplier s screening level from limited to high or moderate to high if any of the following occur: CMS has imposed a payment suspension within the last 10 years; Has been excluded from Medicare by the OIG; Has had billing privileges revoked by CMS within the previous 10 years; Has been excluded from any Federal Health Care program; Has been subject to any final adverse action, in the previous 10 years; Has been terminated or is otherwise precluded from billing Medicaid; or CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted. GO What You Need to Do See the Background and Additional Information Sections of this article for further details. Background As part of the enhanced enrollment screening provisions contained in the Affordable Care Act (see enr.pdf), the Centers for Medicare & Medicaid Services (CMS) implemented fingerprintbased background checks. The fingerprint-based background checks will be used to detect bad actors who are attempting to enroll in the Medicare program and to remove those currently enrolled. Once fully implemented, the fingerprint-based background check will be completed on all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category. A 5 percent or greater owner includes any individual that has any partnership (general or limited) in a provider or supplier. Fingerprint- based background checks are also required for any provider or supplier who has been elevated to the high risk category for any of the following reasons: CMS has imposed a payment suspension within the last 10 years; This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association. Page 39 Page 2 of 5

40 MLN Matters Number: SE1417 Related Change Request Number: N/A Has been excluded from Medicare by the OIG; Has had billing privileges revoked by CMS within the previous 10 years; Has been excluded from any Federal Health Care program; Has been subject to any final adverse action, in the previous 10 years; Has been terminated or is otherwise precluded from billing Medicaid; or CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted. Please refer to 42 CFR (c)(3) at d82b5ae6413ba550e&node=42: &rgn=div8 on the Internet and the "Medicare Program Integrity Manual" (Chapter 15 (Medicare Enrollment), Section C (Screening Categories-Background-High)) at -and-guidance/guidance/manuals/downloads/pim83c15.pdf on the CMS website. Note: The fingerprint-based background checks will be applied to providers and suppliers in the high level of risk category, which includes newly enrolling Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, Home Health Agencies (HHA) and providers and suppliers who have been elevated to the high risk category in accordance with enrollment screening regulations. The fingerprint-based background check implementation has been phased in beginning in Affected providers and suppliers will receive notification of the fingerprint requirements from their MAC. The MAC will send a notification letter to the affected providers or suppliers listing all 5 percent or greater owners who are required to be fingerprinted. The notification letter will be mailed to the provider or supplier s correspondence address and the special payments address on file with Medicare. Generally, an individual will be required to be fingerprinted only once, but CMS reserves the right to request additional fingerprints if needed. The relevant individuals will have 30 days from the date of the notification letter to be fingerprinted. If the provider or supplier finds a discrepancy in the ownership listing, the provider or supplier should contact their MAC immediately to communicate the discrepancy and take the appropriate action to update the enrollment record to correctly reflect the ownership information. The notification letter will identify contact information for the Fingerprint-Based Background Check Contractor (FBBC). The relevant individual(s) are required to contact the FBBC prior to being fingerprinted to ensure the fingerprints are accurately submitted to the Federal Bureau of Investigation (FBI) and results are properly returned to CMS. Providers/suppliers may contact the FBBC by telephone or by accessing the FBBC s This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association. Page 40 Page 3 of 5

41 MLN Matters Number: SE1417 Related Change Request Number: N/A website. Contact information for the FBBC will be provided in the notification letter received from the MAC. Once contacted, the FBBC will provide at least three fingerprint locations convenient to the relevant individual s location. One of these locations will be a local, state, or federal law enforcement facility. The relevant individuals who are required to undergo the fingerprint-based background check will incur the cost of having their fingerprints taken, and the cost may vary depending on location. Once an individual has submitted his/her fingerprints, if that individual is subsequently required to undergo a fingerprint-based background check in accordance with 42 CFR (c), CMS will, to the extent possible, rerun the fingerprint-based background check rather than requiring resubmission of fingerprints. You can review 42 CFR (c) at on the Internet. Fingerprinting can be completed on the FD-258 form or electronically at certain locations. CMS strongly encourages all required applicants to provide electronic fingerprints, but CMS will accept the FD-258 card instead. If the FD-258 form is submitted, the FBBC will convert the paper form to electronic submission to the FBI. You can review the FD-258 form at on the Internet. Once the fingerprint process is complete, the fingerprints will be forwarded to the FBI for processing. Within 24 hours of receipt, the FBI will compile the background history based on the fingerprints and will share the results with the FBBC. CMS, through the FBBC, will assess the law enforcement data provided for the fingerprinted individuals. The FBBC will review each record and provide a fitness recommendation to CMS. CMS will assess the recommendation and make a final determination. All fingerprint data will be stored according to: Federal requirements; FBI Security and Management Control Outsourcing Standards for Channelers and Non-Channelers; and The FBI Criminal Justice Information Services (CJIS) Security Policy. The FBBC will maintain Federal Information Systems Management Act (FISMA) certification and comply with the FBI (CJIS) Security Policy. All data will be secured in accordance with the Privacy Act of 1974 and the FBI CJIS Security Policy. CMS will rely on existing authority to deny enrollment applications and revoke existing Medicare billing privileges per 42 CFR (a) and (a) ( cgi-bin/text-idx?sid=f14b263d1175a355d736e9f38f3a6baf&node=42: &rgn=div8) if an individual who maintains a 5 percent or greater direct or indirect ownership interest in a provider or supplier has submitted an enrollment application that contains false or misleading information. Providers or suppliers will be notified by CMS if This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association. Page 41 Page 4 of 5

42 MLN Matters Number: SE1417 Related Change Request Number: N/A the assessment of the fingerprint based background check results in the denial of its enrollment application or revocation of its existing Medicare billing privileges. Additional Information If you have any questions, please contact your MAC at their toll-free number, which may be found at Programs/provider-compliance-interactive-map/index.html on the CMS website. Document History Date of Change January 27, 2016, Description The article was revised to update language in the article and to emphasize affected providers and suppliers in the Caution Section. This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association. Page 42 Page 5 of 5

43 CMS MLN Connects Provider enews The Centers for Medicare & Medicaid Services (CMS) MLN Connects Provider enews is an official Medicare Learning Network (MLN) branded CMS product that contains a week s worth of news for Medicare Fee-for-Service (FFS) providers. It delivers planned, coordinated messages on Medicare-related topics. Below are the latest editions: February 25, 2016 February 18, 2016 February 11, 2016 February 4, 2016 Archived editions are available on the CMS website. Page 43