(Medicare General Information, Eligibility, and Entitlement)

 The services are identifiable physicians' services, the nature of which requires performance by a physician in person and which contributes to the diagnosis or treatment of the patient's condition;   The intern or resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed; and    The services performed can be separately identified from those services that are required as part of the training program.  When these criteria are met, the services are considered to have been furnished by the individuals in their capacity as physicians and not in their capacity as interns and residents.   80 - Health Maintenance Organizations (HMOs) Defined  (Rev. 1, 09- 11-02)  An HMO for Medicare purposes is a public or private organization that provides, either directly or through arrangement with others, comprehensive health services to enrolled members.  An HMO must service those who live within a specified service area.  It must provide services based on a predetermined periodic rate or periodic per capita rate basis without regard to the frequency or extent of covered services it furnishes.  An HMO must also meet other statutory requirements.   An HMO's service area is a geographic area in which a full range of its services are offered to its members.  This geographic area differs from an HMO's enrollment area since it may include locations outside its service area where it offers less than its f ull range of services.  (For example, an HMO may cover house calls in emergencies in its service area but not for members who live outside the service area.)   Section 1876 of the Act allows a Medicare beneficiary eligible for Part A and Part B, or Part B only, to choose to have covered items and services furnished through a Medicare qualified HMO.  An HMO enters into a contract with the Secretary in order to par ticipate under Medicare.   90 - Other Definitions  (Rev. 1, 09- 11-02)  NOTE:  We anticipate adding to this section as we find the need to define other terms.   90.1 - Supplier Defined  (Rev. 1, 09- 11-02)  The term supplier means an entity that is qualified to furnish health services covered by Medicare, other than providers, physicians, and practitioners.   The following suppliers must meet the conditions in order to receive Medicare payment: ambulatory surgical centers (ASCs), independent physical therapists, mammography facilities, DMEPOS suppliers, independent occupational therapists, clinical laboratories , portable X -ray suppliers, dialysis facilities, rural health clinics, and Federally -qualified health centers.   An ASC is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. It enters into an agreement with CMS to do so.  An ASC is either independent (i.e., not a part of a provider of services or any ot her facility), or operated by a hospital (i.e., under the common ownership, licensure, or control of a hospital).   A DME supplier is an entity that furnishes DME and has a number assigned by the National Supplier Clearinghouse.  90.2 - Laboratory Defined  (Rev. 1, 09- 11-02)  Laboratory means a facility for the biological, microbiological, serological, chemical, immuno -hematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impa irment of, or the assessment of the health of, human beings.  These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body.  Facilities only collecting or pre paring specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories.  90.3 - Practitioners Defined  (Rev. 1, 09- 11-02)  Practitioners except for physicians are health professionals who may deliver covered Medicare services if the services are incident to a physician's service or if there is specific authorization in the law.  The following practitioners may deliver services  without direct physician supervision: nurse practitioners and physician assistants in rural health clinics, designated manpower shortage area or HMOs, qualified clinical psychologists, clinical social workers, certified nurse midwives, and certified regis tered nurse anesthetists.   90.4 - Group Practice Defined  (Rev. 1, 09-11-02)  A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not- for-profit corporation, faculty practice plan, or similar association:   In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, faci lities, equipment, and personnel;   For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;   In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and    Which meets such other standards as the Secretary may impose by regulation to implement 1877(h)(4) of the Social Security Act.  The group practice definition also applies to health care practitioners.   Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI   12/21/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update  01/01/2024 13496  R120GI  11/02/2018  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)  12/04/2018  11004  R114GI  03/16/2018  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512  R101GI  09/16/2016  Internet Only Manual Updates to Pub. 100-01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748  R58GI  03/06/2009  Disclosure of Physician Ownership in Hospitals  06/08/2009  6306  R42GI  11/09/2006  Swing bed Hospital Updates  12/11/2006  5114  R35GI  02/10/2006  Revisions to Instructions for Contractors Other Than the Religious Nonmedical Health Care Institution (RNHCI) Specialty Contractor Regarding Claims for Beneficiaries with RNHCI Elections  05/11/2006  4218  R28GI  08/12/2005  Conforming Changes for Change Request 3648 for Pub. 100 -01 09/12/2005  3912  R19GI  03/11/2005  Definition of Home Health Agency  N/A 3698  R18GI  03/04/2005  Billing for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2005  3681  R01MGI  09/11/2002  Initial Publication of Manual  NA NA  Back to top of Chapter