(Medicare Claims Processing Manual)

NOTE : Tribally operated ambulatory care clinics, including those that are participating as FQHCs, are entitled to enroll their physicians and non- physician practitioners with the applicable A/B MAC (B) like any other Medicare provider.  Although FQHCs are paid on a cost basis for the professional services of physicians and practitioners, the FQHC benefit does not cover and pay for clinical laboratory and diagnostic tests. Consequently, the tribal health center can remain an FQHC and still bill their A/B MAC (B) for laboratory and diagnostic tests.  40.1.2 - Individual Practitioners  (Rev. 1643, Issued: 12- 05-08, Effective: 01- 01-07, Implementation: 03- 09-09)  For those eligible practitioners already working in or for hospitals or freestanding ambulatory care clinics, whether operated by the Indian Health Service (IHS) or by an Indian tribe or tribal organization, enroll and process requests for reassignment of benefits following the current individual practitioner enrollment and verification instructions. For practitioners enrolling to work in or reassign benefits to hospitals or freestanding ambulatory care clinics, whether operated by the IHS or by an Indian t ribe or tribal organization, it is necessary only to verify licensure in one State even if it is not the State in which the practitioners practice. This only applies to federal employees and does not apply if the practitioner/physician is enrolling to work in or to reassign to an Indian tribe or tribal organization. For those disciplines that must be legally authorized to perform services in a State, the practitioner must be legally authorized to perform the services in at least one State, even if it is not the State where the practitioner practices with the IHS. An exception to the reassignment rules was made for physical therapist/occupational therapist, for details see 40.1.4, Reassignment.   For those practitioners who are already enrolled in Medicare Part B with the designated A/B MAC (B), process requests to reassign benefits in accordance with current instructions. All other physicians and practitioners must enroll in the Medicare program with the designated A/B MAC (B).   For those individual practitioners who are employees of an IHS, tribe, or tribal facility that provides offsite care to the IHS, tribe, or tribal Medicare Part B beneficiaries, the facility can bill if the employee reassigns his right to payment. However, the IHS, tribe, or tribal faci lity cannot bill for offsite services of a contract practitioner, unless the IHS, tribe, or tribal facility owns or leases the space where that contract practitioner provides the services.   However, when an IHS provider contracts with non- IHS physicians to  perform interpretations of radiological services, the physicians may be paid by the IHS facility regardless of the location of the offsite practitioner, if services are contracted in accordance with the requirements listed in 120 of this Chapter.  See 120 in this Chapter for further information.   40.1.3 - Multiple Sites  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Multiple clinics utilizing the same TIN can be enrolled as practice locations under the owner of the TIN (i .e., the hospital). Each clinic will be assigned a separate PIN.  If the clinic has a separate TIN, then the clinic would have to enroll separately. Payment is made to the name associated with the TIN. The legal business name must be shown on the Form CMS -855 exactly as it appears on the Internal Revenue Service documentation. However, the doing business as name can be listed as the practice location.   40.1.4 - Reassignment  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  For those individual practitioners who are employees of the IHS, tribe or tribal facility that provides offsite care to the IHS, tribe or tribal Medicare Part B beneficiary, the facility can bill under reassignment from the employee. With regard to contract practitioners, the IHS, tribe, or tribal facility can accept reassignment and bill for offsite services if the space where the contract practitioner provides the service is owned or leased, by the IHS, tribe, or tribal facility.   The physical therapists/occu pational therapists that are employees of the IHS, tribe or tribal group practice will enroll in Medicare Part B and receive a PIN. The physical therapists/occupational therapists will reassign their benefits to the facility. The facility will then bill Me dicare for their services.   40.1.5 - Mobile Units (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The entity providing the service must bill for the service unless the service is provided under contractual arrangements. If the  contracted entity performs services on space that the IHS facility owns or leases, the IHS facility can bill under arrangements.   In order to purchase a professional test interpretation, the IHS physician or practitioner must have performed the technical component of the test. In order to purchase a technical component of a test, the IHS physician or practitioner must perform the professional component of the test. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1 for more information on purcha sed tests.   40.1.5.1 - Mobile Mammography Units  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  With respect to mobile mammography units, the law provides specific standards regarding those qualified to perform mammograms and how they should be certified. The Mammography Quality Standards Act (MQSA) requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all facilities providing screening  and diagnostic mammography services (except Veterans Affairs) must have a certificate issued by the Food and Drug Administration (FDA) to operate.   All IHS providers billing for services rendered by a mobile mammography unit under reassignment must compl ete 1, 4, and 14 of Form CMS -855B. The certification number for the mammography equipment must be entered in 4.1.5 of Form CMS -855B. For more information on the MQSA file, see Chapter 18, 20.1.2 of Pub. 100- 04, Medicare Claims Processing Manual.   40.1. 6 - Clinical Laboratory, Ambulance and Medicare Part B Drugs  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Enrollment of IHS, tribe and tribal organization facilities providing clinical laboratory, ambulance services and Med icare Part B drugs must be provided through the designated A/B MAC (B). These IHS, tribe and tribal organization facilities must meet all the usual enrollment requirements for the designated A/B MAC (B). The designated A/B MAC (B) started accepting enrollm ent applications from IHS, tribe and tribal organization facilities providing clinical laboratory and ambulance services beginning September 1, 2004.  These instructions apply to freestanding or independent clinical labs and independent ambulance suppliers , but not to hospital -based ambulance providers or hospital lab services.    40.2 - Provider Enrollment with A/B MAC (A)  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  New IHS providers, including Critical Access Hospitals (CA Hs) follow the same application process as any other provider enrolling in Medicare with the designated A/B MAC (A). Instructions for completing the Form CMS-855A, Application for Health Care Providers that will bill Medicare A/B MACs (A) are found in Pub. 100- 08, Medicare Program Integrity Manual, Chapter 10.  Section 1865 of the Social Security Act and pursuant regulations provide that IHS owned/tribally operated and IHS owned/operated facilities accredited by the Joint Commission of Accreditation of Heal thcare Organization (JCAHO) or the American Osteopathic Accreditation (AOA) are deemed to meet the Medicare Conditions of Participation (COPS). A Federal survey is required for facilities without JCAHO or AOA accreditation.   Tribally owned and operated fac ilities are generally under the state survey agency jurisdiction. However, the state or the tribe may request that the survey be conducted by a Federal surveyor.   Freestanding FQHCs enroll with the designated FQHC A/B MAC (A).   40.2.1 - Provider Enrollment with A/B MAC (A)  - Ambulatory Surgical Services  (Rev. 1325; Issued:  08-29-07; Effective:  01-01- 08; Implementation:  01 -07-08)  For dates of service prior to January 1, 2008, IHS providers that want to bill for surgeries on the ambulatory surgical center (ASC) list and receive the ASC rate must contact their designated A/B MAC (A). IHS providers are certified by one of several national accrediting organizations recognized by the Centers for Medicare and Medicaid Services (CMS) and meet the conditions for performing ASC procedures.  The IHS hospital outpatient departments are not certified as separate ASC entities. The ASC indication merely means that CMS approved them to bill for ASC services and be paid based on the ASC rates for services on the ASC list.  In order to bill for ASC services, the hospital outpatient department must meet the conditions of participation for hospitals defined in 42 CFR, Part 482.  Authority for Medicare to pay IHS hospital outpatient departments using the freestanding ASC rates was incorporated into Public Health Service regulations on December 27, 1989. The first IHS hospital requested to bill separately for ASC procedures at the appropriate ASC group payment amounts in March 1987.  HCFA (now CMS) approved payment of the ASC group payment amounts for dates of service on or after October 1, 1987. Previously, the hospital was reimbursed for ASC procedures at the Off ice of Management and Budget (OMB) negotiated all inclusive rate (AIR) for outpatient hospital services.  The rationale for approving this request was that the hospital was already JCAHO certified, encompassing the ability to perform outpatient surgical procedures, and that acute care hospitals providing surgical inpatient or outpatient services can perform any surgical procedures within their capacity and capability.   For dates of service prior to January 1, 2008, in order for IHS providers to bill for ASC  procedures and receive payment based on the ASC rates published in the Federal Register, the designated A/B MAC (A) must update the IHS/ASC cert indicator on the provider file to Y. A Y in this field indicates that the IHS provider or ASC is certified  under IHS and their claims should be processed through ASC Pricer, ensuring the IHS provider is paid based on the ASC price rather than the AIR. Reimbursement is made based on the AIR until the A/B MAC (A) updates the IHS/ASC cert indicator to a Y.   See 100.6 and 100.6.1 of this chapter for information on the payment policy and claims processing for ASC services.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs.  All IHS ASC providers, including hospital outpatient departments requesting payment based on freestanding ASC rates and ASCs affiliated with a hospital but operating as a distinct entity for the purpose of performing outpatient surgical services must enroll with and subm it their claims to the designated A/B MAC (B).   40.2.2 - Provider Enrollment with A/B MAC (A) - Services Under Arrangements  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  If an IHS provider is unable to provide all the servic es a beneficiary that is a registered outpatient of the provider needs, the provider may provide those services under arrangements, via a contract with another entity.  Section 1862(a)(14) of the Social Security Act prohibits payment for nonphysician ser vices furnished to hospital inpatients and outpatients unless the services are furnished by the hospital either directly or under an arrangement.  All services that are furnished by a hospital, either directly or under arrangement, to a registered hospital  outpatient during a hospital encounter are subject to the hospital bundling requirements.  42 CFR 482.12(e) spells out the criteria for contracted services as they apply to a hospitals COPS in the Medicare program.  The IHS providers governing body must  be responsible for services furnished in the provider whether or not they are furnished under contracts.  The governing body must ensure that the services performed under a contract are provided in a safe and effective manner.  The IHS provider must maint ain a list of all contracted services, including the scope and nature of the services provided.  Chapter 5, 10.3 of Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual sets forth general Under Arrangement guidelines.  The provider must exercise professional responsibility over the arranged -for services rather than merely serving as a billing conduit.