(Medicare Claims Processing Manual)

A pair of cataract glasses is comprised of two distinct products:  a professional product (the prescribed lenses) and a retail commercial product (the frames). The frames serve not only as a holder of lenses but also as an article of personal apparel. As s uch, they are usually selected on the basis of personal taste and style.  Although Medicare will pay only for standard frames, most patients want deluxe frames. Participating physicians and suppliers cannot profitably furnish such deluxe frames unless they can make an extra (noncovered) charge for the frames even though they accept assignment.   Therefore, a participating physician or supplier (whether an ophthalmologist, optometrist, or optician) who accepts assignment on cataract glasses with deluxe frames may charge the Medicare patient the difference between his/her usual charge to private pay  patients for glasses with standard frames and his/her usual charge to such patients for glasses with deluxe frames, in addition to the applicable deductible and coinsurance on glasses with standard frames, if all of the following requirements are met:   A. The participating physician or supplier has standard frames available, offers them for sale to the patient, and issues and ABN to the patient that explains the price and other differences between standard and deluxe frames. Refer to Chapter 30.   B. The participating physician or supplier obtains from the patient (or his/her representative) and keeps on file the following signed and dated statement:   _____________________________________________  Name of Patient        Medicare beneficiary identifier  Having been informed that an extra charge is being made by the physician or supplier for deluxe frames, that this extra charge is not covered by Medicare, and that standard frames are available for purchase from the physician or supplier at no extra charge , I have chosen to purchase deluxe frames.   ___________________  Signature          Date   C. The participating physician or supplier itemizes on his/her claim his/her actual charge for the lenses, his/her actual charge for the standard frames, and his/her actual extra charge for the deluxe frames (charge differential).   Once the assigned claim for deluxe frames has been processed, the carrier will follow the ABN instructions as described in 60.  30.3.6 - Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3045.5  A.  General   No payment may be made for clinical diagnostic laboratory tests furnished by a physician or medical group unless the physician or medical group accepts assignment or claims payment under the indirect payment procedure.  Carrier direct payment to a physicia n or group after the death of the beneficiary is considered assigned payment.  Assignment may be accepted for the entire claim.  See subsections B and C if a physician wishes to accept assignment only for laboratory services.   B.  Submission of Non -EMC Claims   A nonparticipating physician or medical group who furnishes clinical diagnostic laboratory tests and other services to a beneficiary and accepts assignment only for the laboratory tests may either submit a separate (assigned) claim for them or a single cla im that includes both the assigned tests and the other unassigned services.  In the latter event, the claim must be annotated as unassigned in block 26 of the Form CMS -1500 and a special request for payment for the assigned tests written in block 25, as fo llows:  I accept assignment for the clinical laboratory tests.  C.  Submission of EMC Claims   A nonparticipating EMC physician or medical group who furnishes clinical diagnostic laboratory tests and other services and accepts assignment only for the laboratory tests may either submit a separate (assigned) data set for the tests or a single data set  that includes both the assigned tests and the unassigned other services.  In the latter event, the data set must include the unassigned indicator.  The physician or group must have filed a blanket statement agreeing to accept assignment on all clinical di agnostic laboratory tests, not withstanding the inclusion of the unassigned indicator on electronic data sets.  D.  Processing Claims   Carriers process as assigned all claims for clinical diagnostic laboratory tests as described above, including those submitted by a participating or non- participating physician or group either marked as unassigned or with no assignment option specified.  W here, however, evidence clearly shows that the beneficiary or provider refuses to assign the claim, carriers should deny it. They split a claim containing assigned laboratory tests and other unassigned services.  E.  Public Information   Carriers must inform all physicians and medical groups of this policy annually.  30.3.7 - Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti -Markup Payment Limitation - Claims Submitted to A/ B/MACs  (Rev. 10236, Issued: 07 -31-2020, Effective: 08 -31-2020, Implementation: 08- 31-2020)    A.  General   A physician or other supplier may bill and receive payment for the technical component (TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic laboratory test) that is performed by a physician or other supplier with whom the billing physician or other supplier does not share a practice.  Reimbursement for that service is subject to the anti -markup payment limitation.  If a physician or other suppliers bill or a request for payment includes a charge for a diagnostic test (ot her than a clinical diagnostic laboratory test) which the physician or other supplier did not personally perform or supervise, then payment for the test may not exceed the lesser of:    The performing physicians net charge to the billing physician or other supplier (net any discounts);    The billing physicians actual charge; or    The fee schedule amount that would be allowed for the test if the performing physician or other supplier billed directly.   (See 30.2.9 of this chapter for additional information.)   For payment to be made, the physician who acquires the TC or PC of a diagnostic test from an outside source must identify the performing physician or other supplier on the claim.  (The billing physician or other supplier should maintain a record of the performing physician or other suppliers NPI in the clinical record for auditing purposes.)   The billing physician or other supplier must also indicate on the claim that the test is subject to the anti -markup payment limitation.   See the guidelines at the official Washington Publishing Company website for how to show this on electronic claims.  If using the CMS -1500 paper claim form:   In item 20 check "yes" to indicate the test is subject to the anti- markup payment limitation and enter the amount the performing physician or other supplier charged.   In item 32 enter the name, address, and NPI of the performing physician or supplier.  If the performing physician provides the service outside the A/B MAC (B) jurisdiction where the billing physician is located, the billing physician must submit its own NP I with the name, address, and ZIP code of the performing physician or other supplier.   No payment may be made to the physician without this information unless the statement No anti -markup tests are included is annotated on the claim.  NOTE:  If the billing physician performs only the TC or the PC and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically or on separate claims if billing on paper (CMS -1500).  Gl obal billing is not allowed unless the billing physician or other supplier performs both components.  Effective for claims submitted with a receipt date on and after October 1, 2015, the billing physician or supplier must report the name, address, and NPI of the performing physician or supplier in Item 32a of the CMS- 1500 claim form (or its electronic equivalent) on anti-markup claims, even if the performing physician or supplier is enrolled in a different A/B MAC (B) jurisdiction.  (See 10.1.1.2 for more information regarding claims filing jurisdiction.)   B.  Unassigned Claims with Required Documentation  A physician or other supplier may not bill an individual an amount in excess of Medicares payment, except for any deductible and coinsurance, for the TC or PC of a diagnostic test that is subject to the anti- markup payment limitation.  A/B MACs (B) must notify physicians and other suppliers that they must indicate when a diagnostic test was acquired, identify the performing physician or other supplier, and show the amount the performing physician or other supplier charged.  The notification must inform physicians and other suppliers that they are prohibited by 1842(n)(3) of the Act from billing or collecting an amount in excess of Medicares payment, except for the deductible and coinsurance.  Excess amounts collected from the beneficiary must be repaid.   C.  Unassigned Claims without Required Documentation   A physician may not bill a beneficiary:   If the bill does not indicate who performed the test; and   If the bill indicates that a separate physician or other supplier performed the test, it does not identify the performing physician or other supplier or does not include the amount the performing physician or other supplier charged.  The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of a diagnostic test subject to the anti- markup payment limitation is received from either the physician or a beneficiary except when the physician submits an assigned claim and the beneficiary submits an unassigned duplicate claim.  They use the following sample letter.  Dear Doctor:   We have received an unassigned claim for diagnostic tests furnished to the patient (Beneficiary Name), on (Date of Service).  You are prohibited by 1842(n)(3) of the Social Security Act from billing or collecting any amount unless you indicate that No anti-markup tests are included or, if the diagnostic test was acquired, you indicate who performed the test and what the physician or other supplier charged you.  Some or all of the required information is missing from your patients claim.  If you have collected any amount from your patient, it must be refunded.  This claim may be resubmitted if the required information is included.   D.  Beneficiary Information Regarding Unassigned Claims   The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:    Billing the beneficiary when the necessary documentation is not supplied; and   Billing or collecting an amount in excess of Medicares payment, except for the deductible and coinsurance, when the required documentation is submitted.   (See chapter 21 of this manual, for MSN messages.)   30.3.8 - Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  B3-3045.7  For services furnished prior to January 1, 2011, the DME MACs pay only on an assignment basis for home dialysis supplies and equipment furnished to a beneficiary who had selected Method II.   Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims. All home dialysis claims must be billed by an ESRD facility and paid to  the ESRD facility under the ESRD PPS.   Refer to chapter 8 and chapter 20 for more information.  30.3.9 - Filing Claims to a Carrier for Nonassigned Services  (Rev. 702, Issued:  10- 07-05; Effective/Implementation Dates:  N/A)   A  General   Payment for Part B services furnished by a physician (or supplier) is made:    To the beneficiary on the basis of an itemized bill (nonassigned claims); or    To the physician (or supplier) who provided covered services on the basis of an assignment of benefit payments where the approved charge is the full charge for the services.   NOTE:  For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and nonassigned Part B claims for beneficiaries.   B  Conflicting Claims   Carriers must establish controls to detect and prevent payment for assigned and unassigned claims received for the same service (as well as duplicate assigned or duplicate unassigned claims.  If an appropriate assigned claim is received after an unassigned claim has been paid, carriers do not pay the subsequent claims.  Where an enrollees claim based on an unpaid bill is received and benefits are payable, carriers make payment to him/her unles s there is some definite basis for believing that payment has been assigned, e.g., the physician or supplier is a participating provider or the bill from a nonparticipating physician or supplier shows that assignment may have been made.  Carriers are instructed to inform physicians that, if they wish to be sure of receiving Part B benefits, they should accept assignment at the time services are furnished and that their submission of claims to the carrier should not be unduly delayed.   30.3.10 - Carrier Submitted Bills by Beneficiary  (Rev. 1, 10- 01-03) B3-3040.1  Carriers do not make payment for non- receipted itemized bills without a Form CMS -1490S claim form signed by either the patient or his/her representative.  Note that CMS does not accept beneficiary submitted claims for items subject to mandatory assignment.   They also do not accept them for blood glucose test strips effective April 1, 2002.  30.3.11 - Carrier Receipted Bill - Definition  (Rev. 1, 10- 01-03) B3-3040.2