(Medicare Claims Processing Manual)

a. During the enrollment period provided near the end of any calendar year, the participant notifies in writing every MAC/carrier  with whom the participant has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the end of the current term. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calendar year, the agreement shall end on December 31 of that year.   b. The Centers for Medicare & Medicaid Services may find, after notice to and opportunity for a hearing for the participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is made, the Centers for Medicare & Medicaid Services will notify the participant in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement.    __________________________  Signature of participant  (or authorized representative  of participating organization)  _________________________  Title  (if signer is authorized  representative of organization)  _________  Date  Office phone number (including area code)_____________________  Received by    (name of carrier)  Effective date _____________   30.3.12.3 - Carrier Rules for Limiting Charge  (Rev. 1, 10- 01-03) B3-17002  Effective January 1, 1991, the maximum allowable actual charge (MAAC) for non-participating physicians is replaced by the limiting charge. The limiting charge is the maximum that the non -participating provider may charge the beneficiary.  It also effectively replaces  the special charge limits for overpriced procedure, anesthesia associated with cataract and iridectomy surgery, A -mode ophthalmic ultrasound and intraocular lenses (IOLs, and designated specialty, because the limiting charge is always less than  or equal to the special charge limits.   The limiting charge applies to all of the following services/supplies, regardless of who provides or bills for them, if the services/supplies are covered by the Medicare program and are provided:    Physicians services;    Services and supplies furnished incident to a physicians services that are commonly furnished in a physicians office;    Outpatient physical therapy services furnished by an independently practicing physical therapist;    Outpatient occupational therapy services furnished by an independently practicing occupational therapist;    Diagnostic tests; and    Radiation therapy services (including x- ray, radium, and radioactive isotope therapy, and materials and services of technicians).   NOTE:  This means that, effective for services/supplies provided on or after January 1, 1994, the limiting charge applies to drugs and biologicals provided incident to Initials of carrier official__________   According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 -0373. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate( s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244 -1850.  physicians services, to physical therapy services provided by independently practicing physical therapists, and to occupational therapy services provided by independently practicing occupational therapists. These changes are made because of provisions in OBRA 1993. OBRA 1993 expanded the limiting charge to apply to services/supplies which the law permits Medicare to pay for under the physician fee schedule methodology but which Medicare has chosen to pay for under some other method. Incident to drugs and biologicals, previously excluded from the limiting charge because of their exclusion from physician fee schedule payment, are, effective January  1, 1994, still excluded from physician fee schedule payment but subject to the limiting charge. Also, OBRA 1993 applies the limiting charge to all of the above listed services/supplies, regardless of who provides or bills for the services/supplies. No longer are services of suppliers and other nonphysicians, such as physician assistants, nurse midwives, and indepe ndently practicing physical and occupational therapists, excluded from the limiting charge.   Physicians, non- physician practitioners, and suppliers must take assignment on claims for drugs and biologicals furnished on or after February 1, 2001, under 114 of the Benefits Improvement and Protection Act (BIPA).   Effective January  1, 1993, the limiting charge is 115 percent of the fee schedule amount for nonparticipating physicians.  EXAMPLE:   Participating fee schedule amount  $2000 Nonparticipating fee schedule amount  $1900  (95% of $2000)  Limiting charge  $2185  ($1900 times 1.15)   Charges to either a payer for whom Medicare is secondary or to a payer under the indirect payment procedure are not subject to the limiting charge if the physician accepts the payment received as full payment (i.e., if there is no payment by the beneficiar y).  The provider may round the limiting charge to the nearest dollar if they do so consistently for all services.   30.3.13  Charges for Missed Appointments  Charges for Missed Appointments  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non- Medicare patients for missed appointments.  The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity.  Therefore, if a physician's or supplier's missed appointment policy applie s equally to all patients (Medicare and non- Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.   The amount that the physician or supplier charges for the missed appointment must apply equally to all patients (Medicare and non- Medicare), in other words, the amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non -Medicare patients (whatever amount that may be).  With respect to Part A providers, in most instances a hospital outpatient department can charge a beneficiary a missed appointment charge without violating its provider agreement and 42 CFR 489.22.  Because 42 CFR 489.22 applies only to inpatient services,  it does not restrict a hospital outpatient department from imposing charges for missed appointments by outpatients.  In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.   Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.  Charges to beneficiaries for missed appointments should not be billed to Medicare.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 204  RARC: N/A  MSN: 16.59  40 - Termination of Provider Agreement  (Rev. 1, 10- 01-03) A3-3008, A2- 2800   A provider as defined in Chapter 5 of the Medicare General Information, Eligibility, and Entitlement Manual, may voluntarily terminate its participation in the program or have it terminated by the Secretary for cause.   40.1 - Voluntary Termination  (Rev. 1, 10- 01-03) A3-3008.1, A2- 2800.1, RHC -330, Pub 9- 124  According to 42 CFR  489.52, a provider that wishes to terminate its agreement to participate in the Medicare program may do so by:  (1) filing with CMS a written notice stating its intention to terminate its agreement; and (2) informing CMS of the date upon which it wishes the termination to take effect.  The CMS may approve the date proposed by the provider or set a different date no later than six months after the date of the providers notice.   The effective date of termination may be less than six months following CMS receipt of the providers notice of its intention to terminate if CMS determines that termination on that date would not:    Unduly disrupt the furnishing of services to the community; or    Otherwise interfere with the effective and efficient administration of the Medicare program.   If a provider sends the FI a written notice of its intention to terminate its agreement, the FI should forward the notice to the CMS RO.  The date of receipt of the notice by the FI will be considered the date of filing in determining the date of termination.  The RO promptly notifies the FI when it learns from other sources that a provider wishes to terminate its participation in the program, and keeps the FI informed of the status of the providers request. It is the responsibility of the FI, as necessary, to make preliminary arrangements for filing of the cost report, and to adjust any interim payments, accelerated payments, of current financing payments to avoid overpayments. Final notice of termination of the providers agreement is formally given to the FI by the RO via Form CMS -2007.  As soon as the termination date is established, the RO instructs the provider to notify the public that it is voluntarily terminating its provider agreement. The public notice should be published in the local newspapers with the largest circulation, as soon as possible, but not less than l5 days before the effective termination date.  A provider that wishes to terminate its provider agreement should also file a Form CMS -855A with the FI requesting a voluntary termination of its Medicare billing number.  40.1.1 - Close of Business (Rev. 1, 10- 01-03) A2-2800.2, RHC -330  A provider may temporarily or permanently cease all business (Medicare and non-Medicare), and not timely notify the RO that it is ceasing operations. The FI may be made aware very early of an impending closure due to its fiscal relationship with the provider. Where the FI learns that a provider is ceasing operations, the FI should immediately notify the RO and also take necessary action to avert an overpayment.   A provider is considered to have voluntarily terminated its agreement if it ceases to furnish services to the community.  The termination is effective after the last day of business of the provider.   40.1.2 - Change of Ownership  (Rev. 1, 10- 01-03) HHA -145, HO -145, SNF -145, RHC -331, RHC -332  When an organization having a provider agreement undergoes a change of ownership in accordance with the principles articulated in 42 CFR  Part 489 and 3210 of the State Operations Manual, the agreement with the existing provider is automatically assigned to the new owner so that there is no interruption in service.  However, a new agreement with updated information must subsequently be signed and a  Form CMS -855A must be submitted by both the old and new owners.  Only if the provider, under the change of ownership, meets the applicable requirements for approval can the agreement be executed.  For FQHCs, these requirements include PHS approval.   An organization that plans to change ownership must give advance notice of its intention so that a new agreement can be negotiated or so that the public may be given sufficient notice in the event that the new owners do not wish to participate in the Medic are program.  A provider that plans to enter into a lease arrangement (in whole or in part) should also give advance notice of its intention.  A change of ownership occurs, for example, when:    A sole proprietor transfers title and property to another party;    In the case of a partnership, there is an addition, removal, or substitution of a partner unless the partners expressly agree otherwise;    An incorporated organization merges with an incorporated entity that is approved by the program and the latter entity is the surviving corporation.  It also occurs when two or more corporate providers consolidate and the consolidation results in the creati on of a new corporate entity;    An unincorporated organization (a sole proprietorship or partnership) becomes incorporated; or    The lease of all or part of an entity constitutes a change of ownership of the leased portion.  When an organizations agreement is terminated, whether by the entity or by CMS, no payment is available to the provider for services it furnishes to Medicare beneficiaries on or after the effective date of the termination.   40.1.3 - Expiration and Renewal- Nonrenewal of SNF Term Agreements  (Rev. 1, 10- 01-03) A3-3008.3, and Pub 100 -1, Chapter 5