(Medicare Claims Processing Manual)

 The basis for believing that the deficiencies that led to termination of the provider agreement have (or have not) been corrected.    If corrected, a description of:   o When and how this was done;   o The evidence showing compliance has existed for a sufficient period of time; and   o The FIs reasons for concluding that the deficiencies will not recur.    A description of any other fiscal and reimbursement problems and the basis of believing these should (or should not) affect certification of the facility.  40.4 - Payment for Services Furnished After Termination, Expiration, or Cancellation of Provider Agreement  (Rev. 980, Issued: 06-14-06, Effective: 10-01-06, Implementation: 10-02-06)  The CMS RO will inform the FI upon termination, expiration or cancellation of a provider agreement.  Effective with the date a provider agreement under 1866 of the Act (or swing bed approval) terminates, expires, or is cancelled, no payment is made to the provider under such agreement for:  A  Termination of Hospital Agreement   Inpatient hospital services (including inpatient psychiatric hospital services) and swing bed extended care services furnished on or after the effective date of the hospitals termination, except that payment can continue to be made for up to 30 days of inpatient hospital services and/or swing bed extended care services (total of no more than 30 days) furnished on or after the termination date to beneficiaries who were admitted (at either the acute or extended care level) prior to the termination date.   B  Termination of Swing Bed Approval  Swing bed extended care services furnished on or after the effective date of the termination of the hospitals swing bed approval, except that payment can continue for up to 30 days of extended care services furnished on or after the termination date to beneficiaries who were admitted (at either the acute or extended care level) prior to the termination date.   C  Skilled Nursing Facility Termination   Posthospital extended care services furnished on or after the effective date of termination of the agreement, where such agreement has been voluntarily terminated by the provider (40.1) or involuntarily terminated by the Secretary for cause ( 40.2). However, payment can continue to be made for up to 30 days of posthospital extended care services furnished on and after the termination date to beneficiaries who were admitted prior to the termination date.   D  Expiration SNF  Posthospital extended care services furnished on or after the date which follows the last day of the specified term of the agreement, where such agreement has expired at the close of the last day of its specified term ( 40.3), except that where the agreement has not been renewed, payment can be made for up to 30 days of posthospital extended care services furnished on and after the date which follows the last day of the specified term of such agreement to beneficiaries who were admitted on or before such last day.   E  HHA and Hospice   Home health and hospice services furnished under a plan which is established on or after the termination date, except that if the plan was established before the termination date, payment is made for services for up to 30 days following the effective date of termination.   F  Other  Other items and services, including outpatient physical therapy or speech- language pathology and diagnostic services, furnished on or after the effective date of termination or, in the case of an expiration or cancellation of an SNF agreement, on or after the day following the close of such agreement.   40.4.1 - Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions  (Rev. 1, 10- 01-03) A3-3600.3   See 40.4 for provisions for payment following a termination or expiration of a provider agreement.  A SNF may be denied payment for new admissions, but not readmissions, as an option to termination of its provider agreement for noncompliance with one or more requi rements of participation.  The SNF may only be reimbursed for covered services furnished on or after the effective date of denial of payments  if such services were furnished to beneficiaries who were admitted to the SNF before the effective date of termination or expiration.   EXAMPLE:   Effective date of denial of payment -  9-30  Beneficiary admitted before 9 -30 - pay for covered Part A or B services   Beneficiary admitted on or after 9 -30 - deny payment under Part A or B   NOTE:  An inpatient who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.   The contractor is notified of SNF payment denials through the Form CMS -2007.  It must install appropriate edits or other safeguards to prevent incorrect payments to the provider.   The contractor obtains a list of Medicare inpatients when a SNF or hospital agreement is terminated, or after a SNF is denied payment for new admissions to assure that nonpayment spell of illness bills are filed.   40.4.2 - Status of Hospital or SNF After Termination, Expiration, or Cancellation of Its Agreement  (Rev. 1, 10- 01-03) A3-3699.3.C   Following termination, expiration, or cancellation of its agreement, a hospital or SNF is considered to be a nonparticipating provider.  An inpatient of such an institution who has Part B coverage, but for whom Part A benefits have been exhausted or othe rwise not available, is entitled to reimbursement only for services that are covered in a nonparticipating institution.  A patient admitted to the SNF on or after the effective date of denial of payment who has Part B coverage is entitled to reimbursement for services covered in a nonparticipating institution.  Such services furnished on or after the effective date of termination, or in the case of expiration or cancellation of an SNF agreement, on or after the day following the close of such agreement, are  billed on Form CMS -1500, Health Insurance Claim Form, and sent to the carrier.   A terminated hospital may be certified to provide emergency services.  If it meets the criteria, it is assigned an emergency provider number (E suffix).  This procedure is not automatic, and hospitals terminated for Life Safety Code violations may not be a ble to qualify.  If a terminated hospital qualifies, the designated emergency FI handles billings as follows:   Region I  Associated Hospital Services of Maine (dba, Maine Blue Cross and Blue Shield  Region III  Veritus  Region IV  First Coast Services  Region VI  Trailblazers  Region VII  Blue Cross and Blue Shield of Nebraska  Region IX  United Government Services  Regions II, V, VIII, and X have no designated FI.   Claims for services provided in a Religious Nonmedical Healthcare Institutions (domestic and foreign) are sent to Riverbend Government Benefits Administrator (GBA) in Tennessee.   The following CMS Web address provides a complete list of addresses and phone numbers for FIs and carriers:  http://cms.hhs.gov/contacts/incardir.asp.   In a no- payment situation, where the entire billing period represents charges for which no Part A payment can be made, it is not necessary for the provider to submit two bills.  The provider submits only a final no- payment bill, with a discharge date, unde r the former provider number.   Services furnished during the no- payment period may subsequently be determined to be covered. Where such covered services were furnished before the date of change in provider number, the provider submits one corrected bill covering the entire period showing the former provider number. Where the services were furnished after the date of change in provider number or both before and after the date of change, the provider submits a corrected discharge bill.   40.5 - FI/Carrier/DMERC Responsibilities for Informing Providers of Changes  (Rev. 1, 10- 01-03) A3-3600.7   Contractors must inform providers in writing of changes in policy and procedures and the effective date before making changes.  They must send these notices at least thirty days before changes are put into effect to give providers time to adjust.  When a s horter implementation schedule is unavoidable, the contractor must provide the notice as soon as it is available.   For electronic data interchange (EDI) instructions, the contractor must notify providers of changes at least 60 to 90 days in advance.   Contractors must conduct provider training on an as needed basis and initiate regular contact with the provider community through organizations that represent them.  It must develop continuing staff contacts with these organizations to resolve issues of mutual concern.   The contractor must provide adequate telephone service so that providers can receive prompt answers to claims status and processing questions.  It must implement procedures and training in telephone units to ensure that its employees furnish consistent and correct information and make appropriate referrals for specialized information.   50 - Filing a Request for Payment With the Carrier or FI  (Rev. 1, 10- 01-03) A3-3301   Except as provided in 50.1.2 and 50.1.6, payment may not be made for Medicare services furnished under Part A or Part B unless the beneficiary or a designated representative files a timely written request for payment and the provider files a timely claim.  (See 80 for an explanation of time limits.)   If the beneficiary does not file a request upon admission or start of care, it may be filed later with the provider or (less preferably) with an FI or carrier or CMS. The provider still must file a claim for payment (billing).   50.1 - Request for Payment From the Carrier or FI (Rev. 1, 10- 01-03) A3-3302   50.1.1 - Billing Form as Request for Payment  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  Each of the paper billing forms --CMS -1500-- Health Insurance Claim Form; and  CMS -1490S -- Patients Request for Medical Payment,) -- contains a patients signature line or reference to the patient signature incorporating the patients request for payment of  benefits, authorization to release information, and assignment of benefits. When the billing form is used as the request for payment, there must be a signature, except when the provisions in 50.1.2 apply.  The Medicare Uniform Institutional Provider Bill, Form CMS -1450, does not contain a line for the patients signature.  As a result, the billing form itself cannot be used as a request for payment.  Requests for payment must be obtained and retained in the providers records.  The institutional claim form contains a provider representative signature, which includes a certification that a request for payment has been obtained from the patient.  See 50.1.2 for requirements for providers.   Electronic billing is required except when an exception is possible under ASCA.  See 2 of this chapter for related information.  50.1.2 - Beneficiary Request for Payment on Provider Record - ASC X12 837 Institutional Claims  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A participating provider (hospital, critical access hospital, skilled nursing facility, home health agency, outpatient physical therapy provider, or comprehensive outpatient rehabilitation facility), ESRD facility, Independent rural health clinic, freestan ding Federally Qualified Health Clinic, Religious Nonmedical Health Care Institution, or Community Mental Health Centers must use a procedure under which the signature of the patient (or his representative) on its records will serve as a request for paymen t for services of the provider.   To implement this procedure the provider must incorporate language to the following effect in its records:   Request for Payment   _______________________  NAME OF BENEFICIARY _______________________  Medicare beneficiary identifier  I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in (name of provider).  I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed t o determine these benefits or benefits for related services.   For services furnished to inpatients of a hospital, or SNF, the request is effective for the period of confinement.  For services furnished by an HHA under a plan of treatment the request is effective for the plan of treatment. For other services the request is effective until revoked.  If a patient objects to part of the request for payment, the provider should annotate the statement accordingly.  In using this procedure, the provider undertakes to make the patient signature files available for A/B MAC (A and B) inspection on request.  The A/B MAC (A and B) must make periodic audits of signature files selected on a random basis. The A/B MAC (B) may arrange with the A/B MAC (A) for the latter to perform this function on its behalf for A/B MAC (B) claims submitted by providers.