(Medicare Claims Processing Manual)

The Form CMS -1556 (Prepayment Plan for Group Practices Dealing Through An A/B MAC (B)) is used by plans which, for Medicare purposes are, both Group Practice Prepayment Plans, and are paid on the basis of reasonable charges related to their costs for furni shing services to their subscribers.   70.8.5  Photocopies  (Rev. 170, 05- 07-04)  Some enrollees may want to keep the original itemized physician and supplier bills for income tax or complementary insurance purposes.  Photocopies of itemized bills are acceptable for Medicare deductible and payment purposes if there is no evidence of alteration.   70.8.6  Penalty for Filing Claims after One Year  (Rev. 2140, Issued: 01- 21-11, Effective: 01 -01-10, Implementation: 02- 22-11)  Section 1848(g)(4) of the Social Security Act (the Act) requires that physicians and suppliers complete and submit Part B claims for medical services, equipment and supplies (furnished on or after September 1, 1990) within 12 months of the service date.  Only assigned claims submitted more than 12 months after the service date will be subject to a 10 percent reduction of the amount that would otherwise have been paid.  Payment on an assigned claim submitted by a physician or other supplier 12 months or longer after the service is furnished, shall be reduced by 10 percent from the amount that would have otherwise been paid.  On March 23, 2010, Congress passed the Patient Protection and Affordable Care Act (the Affordable Care Act).  Section 6404 of the Affordable Care Act amended sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the  Act, by reducing the maximum time period for filing Medicare Part A and Part B claim s to no more than 12 months after the date of service.  Therefore, this nullifies the 10 percent reduction requirement on physician and supplier claims submitted after 12 months from the date of service, because the claim will be denied as untimely filed; unless, an exception for the late filing is granted.  And, if an exception for late filing is granted, then the 10 percent penalty is waived.   70.8.8  Penalty for Filing Claims after One Year  (Rev. 170, 05- 07-04)  Section 1848(g)(4) of the Social Security Act requires that physicians and suppliers complete and submit Part B claims for medical services, equipment and supplies (furnished on or after September 1, 1990) within 12 months of the service date.  Only assign ed claims submitted more than 12 months after the service date will be subject to a 10 percent reduction of the amount that would otherwise have been paid.  Payment on an assigned claim submitted by a physician or other supplier 12 months or longer after t he service is furnished, shall be reduced by 10 percent from the amount that would have otherwise been paid.   70.8.8.6  Monitoring Claims Submission Violations  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  A. General   Section 1848(g)(4) of the Social Security Act requires physicians and suppliers to submit claims to Medicare carriers for services furnished on or after September 1, 1990.  It also prohibits physicians and suppliers from imposing a charge for completing and submitting a claim.  Payment for assigned services not filed within 1 year (for services on or after 9/1/90) are reduced 10 percent.  Physicians and suppliers who f ail to submit a claim or who impose a charge for completing the claim are subject to sanctions. CMS is responsible for assessing sanctions and monetary penalties for noncompliance.   Physicians and suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Physician and Supplier Program or, in the case of physician services, the Medicare beneficiary is also a recipient of State medical assistance (Medicaid) or the service is otherwise s ubject to mandatory assignment.  B. Compliance Monitoring   To ensure that providers and suppliers are enrolled in the Medicare program and submit claims in compliance with the mandatory claims submission requirements found in 1848(g)(4) of the Social Security Act, contractors shall:  1) Process beneficiary claims submitted to A/B MACs or carriers for services that are not covered by Medicare (e.g., for hearing aids, cosmetic surgery, personal comfort services, etc.; see 42 CFR 411.15 for details), in accordance with its normal processing procedures;  2) Process beneficiary claims submitted to A/B MACs or carriers for services that are covered by Medicare and the beneficiary has submitted a complete and valid claim (Form CMS -1490S) and  all supporting documentation associated with the claim, including an itemized bill with the following information:    Date of service,   Place of service,   Description of illness or injury,   Description of each surgical or medical service or supply furnished,   Charge for each service,   The doctors or suppliers name and address,   The provider or suppliers National Provider Identifier (NPI)  The ordering & referring providers legal name and address and the National Provider Identifier (NPI) if known when the itemized bill is from: A Clinical laboratory for ordered tests An independent diagnostic imaging center for ordered imaging procedures A supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS  If the beneficiary furnishes all other information but fails to supply the provider or suppliers NPI the contractor shall not return the claim but rather look up the provider or suppliers NPI using the NPI registry.  If the contractor determines that the  provider or supplier was not a Medicare enrolled provider with a valid NPI, the contractor shall follow previously established procedures in order to process and adjudicate the claim.    3) Retain the Form -1490S and supporting documentation and manually return a copy to the beneficiary if it is for a Medicare -covered service and the claim is incomplete, does not include all required supporting documentation and/or contains invalid information.  Contractors shall also include an appropriate letter that specifically communicates all the items listed above which were missing or invalid.  In addition, the CMS-1490S and supporting documentation shall be maintained for purposes of the timely filing rules in the event that the beneficiary re-submits the claim.   If the Beneficiary submits a claim on the English or Spanish Form CMS-1490S (version 01/05) on or after April 1, 2019, manually return the Form CMS-1490S (version 01/05) claim to the beneficiary, and include a copy of the Form CMS-1490S (version 01/18), along with a letter instructing the beneficiary to complete and return the Form CMS-1490S (version 01/18) for processing within the time period prescribed in 70.5.    If a beneficiary submits a claim on the Form CMS -1500, manually return the Form CMS -1500 claim to the beneficiary, and include a copy of the Form CMS-1490S, along with a letter instructing the beneficiary to complete and return the Form CMS -1490S for processing within the time period prescribed in 70. 5, above.  Include in the letter a description of missing, invalid or incomplete items required for the Form CMS -1490S that were not included with the submitted Form CMS -1500 or were invalid.  4) Retain Medicare claims records using the following disposition rules.  DISPOSITION:   1. Carriers who Microform Claims   a)  Hardcopy Records - Cut off no later than the close of the calendar year (CY) in which paid. The hardcopy claim must be retained in accordance with the following:   (1)  If a corresponding master microfilm has been made and verified, transfer to a Federally -approved records storage facility or hold onsite. Destroy after a total retention of 3 years after the close of the CY in which paid.  (2)  If a corresponding master microform record has NOT been made and verified, transfer to a Federally -approved records storage facility or hold onsite. Destroy after a total retention of 6 years and 3 months after the close of the CY in which paid.  b)  Microform Records   The master microform record must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which paid.  2. Carriers Who Do Not Microfilm Claims Records   Cut off at the close of the calendar year (CY) in which paid, then transfer to a Federally -approved records storage facility. Destroy after a total retention of 6 years and 3 months. Earlier cutoff and transfer is authorized. However, the records must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which payment is made.   a)  Hardcopy Records - The hardcopy must be retained onsite until the microform has been verified. Cut off at the close of the calendar year in which paid; transfer hardcopy to a Federally -approved records storage facility only if there is a corresponding master microfilm record that can be retained for the period indicated in b. below; otherwise, the hardcopy shall be retained until the 6 years and 3 months period is reached. Earlier cutoff and transfer is authorized.  However, the hardcopy must be retained for a total retention of 3 years after the close of the calendar year in which paid.  b)  Microform Records - The master microform records must be retained for a total retention of 6 years and 3 months following the close of the calendar year in which payment is made.  When returning a beneficiary submitted claim, the contractor shall inform the beneficiary that the provider or supplier is required by law to submit a claim on behalf of the beneficiary (for services that would otherwise be payable), and that in order to s ubmit the claim, the provider must enroll in the Medicare program.  In addition, contractors shall encourage beneficiaries to always seek non -emergency care from a provider or supplier that is enrolled in the Medicare program.  If a beneficiary receives services from a provider or supplier that refuses to submit a claim to the A/B MAC or carrier, on the beneficiarys behalf, (for services that would otherwise be payable by Medicare), and/or refuses to enroll in the Medicare progr am, the beneficiary should:  (1) Notify the contractor in writing that the provider or supplier refused to submit a claim to Medicare and/or refused to enroll in Medicare, and   (2) Submit a complete Form CMS -1490S with all supporting documentation.  The contractor shall process and pay the beneficiarys claim if it is for a service that would be payable by Medicare were it not for the provider or suppliers refusal or inability to submit the claim and/or enroll in Medicare.  Claims shall be adjudicate d based on whether the service provided is covered or non-covered/excluded rather than on the providers enrollment status. If f or a covered service, the claim shall be processed and the allowed amount reimbursed to the beneficiary, if appropriate. If for a non -covered/excluded service, the claim shall be processed and denied with an appropriate MSN message.  For sanctioned/excluded and opt-out providers the following MSN messaging is recommended:   Sanctioned/Excluded provider:  A sanctioned or excluded provider is an individual or business excluded from participation in the Medicare program for a stated period of time as a result of fraudulent activity, program abuse, or impermissible conduct as determined by OIG.  CMS will pay the first claim submitted by a beneficiary for the services of a sanctioned/excluded physician or practitioner and immediately notify the sanctioned/excluded physician or practitioner of the exclusion.   CMS will not pay a claim for sanctioned/excluded physician or practitioner services more than 15 days after the date on the notice to the physician or practitioner, or after the effective date of the exclusion, whichever is later.  Under no circumstance may Medicare payment be made to any entity, including beneficiaries, for services rendered by such providers after the first claim is paid.  An example of language that may be considered:  MSN Message 21.27  English Services provided by a Medicare sanctioned/excluded provider.  No Medicare payment may be made.   Spanish Los servicios fueron brindado por un proveedor excludo de Medicare, por lo tanto Medicare no pag por los servicios.  Opt-Out physicians and practitioners: