(Medicare Claims Processing Manual)

Effective for claims received on or after April 1, 2004, claims for services furnished in all places of service other than a beneficiarys home must include information specifying where the service was provided.  A/B MACs (Part B) must use the address on t he beneficiary files when place of service (POS) is home -  12, or any other mechanism currently in place to determine pricing locality when POS is home  12.  A/B MACs (Part B) shall take this same action for any other POS codes they currently treat as POS  home.  Effective for claims processed on or after October 5, 2009, for services rendered in POS home - 12, or for any other POS the contractor currently treats as POS home, when alerted by the shared system that a 9- digit ZIP code is required according to the CMS ZIP Code file, and a 9 -digit ZIP code is not available on the beneficiary file, the contractor shall determine that ZIP code by using the United States Postal Service Web site.  They shall use that ZIP code to determine the correct payment locality for the  claim for pricing purposes.   A/B MACs (Part B) processing these claims shall take necessary steps to ensure that the claims for services rendered in the physical location for which they are the MAC are priced and processed correctly applying appropriate edits as necessary.   Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional claim format, submission of the complete address of where the service was performed is required regardless of where the serv ice was performed.  This information should be entered on the claim per the Implementation Guide for the current version.  Contractors shall use that ZIP code to determine correct payment locality.   Effective January 1, 2011 for claims processed on or after January 1, 2011 on paper claims submitted on the CMS -1500 form, submission of the ZIP code of where the service was provided will also be required for all POS code and contractors shall use that ZIP code to determine correct payment locality.   For paper and electronic claims, when a global diagnostic service code is billed (e.g. no modifier TC and no modifier 26), the address where the technical component was performed shall be reported on the claim (this only applies to global services with separat e technical component/professional component). Global billing does not apply to anti-markup tests because the technical and professional component must be billed separately when the anti -markup payment limitation applies.   Refer to Pub 100- 04, Chapter 35, Section 10.2.1 and 10.2.2 for more information on global billing and separate technical and professional billing.   Contractors shall make no changes for claims submitted on the 4010A1 format as they pertain to POS Home and determining pricing locality.  Contractors shall require the submission of the 9- digit ZIP code when required per the CMS ZIP Code file.   C. Outside A/B MAC (Part B) Jurisdiction   If A/B MACs (Part B) receive claims outside of their jurisdiction, they must follow resolution procedures in accordance with the instructions in 10.1.9. If they receive a significant volume or experiences repeated incidences of misdirected Medicare Physici an Fee Schedule or anesthesia services from a particular provider, an educational contact may be warranted.   D. HMO Claims   For services that HMOs are not required to furnish, A/B MACs (Part B) process claims for items or services provided to an HMO member over which they have jurisdiction in the same manner as they process other Part B claims for items or services provided by physicians or suppliers. Generally, the physician/supplier who provides in -plan services to its HMO members submits a bill directly to the HMO for payment and normally does not get involved in processing the claim. However, in some cases, claims for servic es to HMO members are also submitted to A/B MACs (Part B), e.g., where claims are received from physicians for dialysis and related services provided through a related dialysis facility.   10.1.1.1 - Claims Processing Instru ctions for Payment Jurisdiction  (Rev.  4473, Issued: 12- 6-19; Effective: 3 -9-20; Implementation: 3 -9-20)  A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)   Note that the following instructions do not apply to services rendered at POS home -12. For services rendered at POS home  12, use the address on the beneficiary file for the beneficiarys home (or wherever else the beneficiary information is currently being stored) to determine pricing locality.  ( See 10.1.1 for changes to processing for services rendered at POS home  12.)  For pricing purpose, contractors shall use the ZIP code of where the service was performed.  Contractors shall locate that information according to the Implementation Guide of the 4010/4010A1 version of the ASC X12 837 professional claim format.  EXCEPTION:   For DME MAC claims - Effective for claims received on or after 1/1/05, the Standard System shall not evaluate the 2010AA loop for a valid place of service. If there is no entry in the 2420C loop or the 2310D loop, the claim shall be returned as unprocessable.   If the Pay -To Provider Name and Address loop 2010AB is not the same as the Billing Provider, both will be entered. If the Service Facility Location loop 2310D is not the same as the Billing Provider or the Pay-To Provider, the Service Facility Location loop 2310D (claim level) will be entered. Price the service based on the ZIP code in Service Facility Location loop 2310D, unless the 2420C (line level) is also entered. In that case, price the service based on the ZIP code in the Service Facility Location lo op 2420C (line level) for that line.  If the POS code is the same for all services, but the services were provided at different addresses, each service shall be submitted with the appropriate address information for each service.  This will provide a ZIP code to price each service on the claim .  B. Entering the Address of Where a Service was Performed on the 5010 Version of the ASC X12 837 Professional Claim  Following the requirements of the implementation guide of the 5010 version of the ASC X12 837professional claim, the complete address of where a service was performed shall be entered.  Pay the service based on the ZIP code of the address of where the service was performed based on the appropriate entry on the claim.  See 30.2.9 and Chapter 12 for information on anti-markup tests.  C.  Paper Claims Submitted on the Form CMS -1500  Note that for claims processed on the Form CMS-1500 prior to January 1, 2011, the following instructions do not apply to services rendered at POS home  12 or any other places of service contractors consider to be home. (See 10.1.1.1)  It is acceptable for claims to contain POS home and an additional POS code. No service address for POS home needs to be entered for the service rendered at POS home in this situation as the address will be drawn from the beneficiary file (or wherever else the A/B MAC (Part B) is currently storing the beneficiary information) and the information on the claim will apply to the other POS.   Except for the situation described above, the provider shall submit separate claims for each POS.  The specific location where the services were furnished shall be entered on the claim.  Use the ZIP code of the address entered in Item 32 to price the claim .  If multiple POS codes are submitted on the same claim, treat the claim as unprocessable and follow the instructions in 80.3.1.  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 Two.  Group Code: CO  CARC: 16  RARC: M77  MSN: 9.2  Effective January 1, 2011, for claims processed on or after January 1, 2011, submitted on the Form CMS -1500 paper claim, i t will no longer be acceptable for the claim to have more than one POS.  Separate claims must be submitted for each POS.  Contractors shall treat claims submitted with more than one POS as unprocessable and follow the instructions in 80.3.2.1.1.  If the contractor receives a fee -for-service claim containing one or more services for which the MPFS payment locality is in another A/B MAC (Part B)s jurisdiction, handle in accordance with the instructions in 10.1.9.  If you receive a significant volume or experience repeated incidences of misdirected Medicare Physician Fee Schedule claims/services from a particular provider, an educational contact may be warranted. Handle misdirected claims/services for HMO enrollees in accordance with 10.1.1.C and D.  D. Determining the Correct Payment Locality for Services Paid Under the Medicare Physician Fee Schedule (MPFS) and Anesthesia Services When Rendered in a Payment Locality that Crosses ZIP Code Areas   Per the instructions above, Medicare A/B MACs (Part B) have been directed to determine the payment locality for services paid under the MPFS and anesthesia services by using the ZIP code on the claim of where the service was performed.  It has come to the attention of CMS that some ZIP codes fall into more tha n one payment locality.  The CMS ZIP Code file uses the convention of the United States Postal Service, which assigns these ZIP codes into dominant counties.  In some cases, though the service may actually be rendered in one county, per the ZIP code it is assigned into a different county.  This causes a payment issue when each of the counties has a different payment locality and therefore a different payment amount.  Note that as the for services which have the Anti-markup Test Indicator on the MPFS, the 9-digit ZIP code requirements will also apply to those codes.  Effective for dates of service on or after October 1, 2007, CMS shall provide a list of the ZIP codes that cross localities as well as provide quarterly updates when necessary.  The CMS ZIP Code file shall be revised to two files:  one for 5-digit ZIP code s (ZIP5) and one for 9-digit ZIP codes (ZIP9).  Providers performing services paid under the MPFS, anesthesia services, or any other services as described above, in those ZIP codes that cross payment localities shall be required to submit the 9- digit ZIP c odes on the claim for where the service was rendered.  Claims for services payable under the MPFS and anesthesia services that are NOT performed in one of the ZIP code areas that cross localities may continue to be submitted with 5 -digit ZIP codes.  Claims  for services other than those payable under the MPFS or anesthesia services may continue to be submitted with 5 -digit ZIP codes.  Beginning in 2009, contractors shall maintain separate ZIP code files for each year which will be updated on a quarterly basis.  Claims shall be processed using the correct ZIP code file based on the date of service submitted on the claim.  It should be noted that though some states consist of a single pricing locality, ZIP codes can overlap states thus necessitating the submission of the 9-digit ZIP code in order to allow the process to identify the correct pricing locality.  Claims received with a 5 -digit ZIP code that is one of the ZIP codes that cross localities and therefore requires a 9 -digit ZIP code to be processed shall be treated as unprocessable.  For claims received that require a 9 -digit ZIP code with a 4 -digit extension that does not match a 4 -digit extension on file, manually verify the 4-digit extension to identify a potential coding error on the claim or a new 4-digit extension established by the U.S. Postal Service (USPS).  ZIP code and county information may be found at the USPS Web site at http://www.usps.com/, or other commercially available sources of ZIP code information may be consulted.  If this process validates the ZIP code, the claim may be processed.  The Revision to Payment Policies under the Physician Fee Schedule that is published annually in the Federal Register , or any other available resource, may be used to determine the appropriate payment locality for the ZIP code with the new 4- digit extension.  If this process does not validate the ZIP code, the claim shall be treated as unprocessable.  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 Two.  Group Code: CO CARC: 16  RARC: MA114  MSN: N/A   Should a service be performed in a ZIP code area that does not require the submission of the 9 -digit ZIP code, but the 4-digit extension has been included anyway, A/B MACs (Part B) shall price the claim using the A/B MAC (Part B) locality on the ZIP5 file and ignore the 4-digit extension.  Effective for claims processed on or after July 6, 2009, the standard system shall make revisions to allow contractors to add valid 4-digit extensions not included on the current quarter s 9-digit ZIP Code file until they  appear on  a quarterly file.