(Medicare Claims Processing Manual)

Sanctioned/Excluded provider:  A sanctioned or excluded provider is an individual or business excluded from participation in the Medicare program for a stated period of time as a result of fraudulent activity, program abuse, or impermissible conduct as determined by OIG.  CMS will pay the first claim submitted by a beneficiary for the services of a sanctioned/excluded physician or practitioner and immediately notify the sanctioned/excluded physician or practitioner of the exclusion.   CMS will not pay a claim for sanctioned/excluded physician or practitioner services more than 15 days after the date on the notice to the physician or practitioner, or after the effective date of the exclusion, whichever is later.  Under no circumstance may Medicare payment be made to any entity, including beneficiaries, for services rendered by such providers after the first claim is paid.  An example of language that may be considered:  MSN Message 21.27  English Services provided by a Medicare sanctioned/excluded provider.  No Medicare payment may be made.   Spanish Los servicios fueron brindado por un proveedor excludo de Medicare, por lo tanto Medicare no pag por los servicios.  Opt-Out physicians and practitioners:  Medicare payment may be made for the claims submitted by a beneficiary for the services of an opt out physician or practitioner when the physician or practitioner did not privately contract with the beneficiary for services that were not emergency care services or urgent care services and that were furnished no later than 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare (see 42 C.F.R. 405.435(c)).  Therefore, if the beneficiary submits a claim for a service that was furnished by an opt out physician or practitioner, then the carrier must contact the opt out physician or practitioner in order to ascertain whether the beneficiary entered into a private contract with the opt out physician or practitioner. (Note: The carrier should obtain a copy of the private contract from the opt out physician/practitioner before denying the beneficiarys claim if the beneficiary did, in fact, enter into a private contract with the physician or practitioner.) If the beneficiary did not enter into a private contract with the physician or practitioner and the beneficiary did not receive notice from the carrier that the physician opted out of Medicare, then Medicare payment may be made to the beneficiary for the non -emer gency and/or non-urgent care services (assuming that the services would otherwise be payable).  On the other hand, if the beneficiary did enter into a private contract with the physician or practitioner for the services or received services from the physician/practitioner 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare, then no Medicare payment may be made. Medicare has instructed opt out physicians and practitioners that private contract language must include beneficiary instruction precluding the beneficiary from billing Medicare for these services.  An example of language that may be considered:  MSN Message 21.26  English Claim denied because services were provided by an Opt-Out physician or practitioner. No Medicare payment may be made.   Spanish La reclamacin fue denegada porque los servicios fueron brindados por un mdico  proveedor que decidi no participar en Medicare, por lo tanto, Medicare no pag por los servicios.   Contractors shall maintain documentation of beneficiary complaints involving violations of the mandatory claims submission policy and a list of the top 50 violators, by State, of the mandatory claim submission policy.  Contractors are encouraged to educate providers and suppliers that they must be enrolled in the Medicare program before they submit claims for services furnished or supplied to any Medicare beneficiary.   The above policy, including the NPI requirement, is not applicable for foreign beneficiary claims submitted for covered services.  These claims should be processed using guidelines for foreign claims.  The above policy, including the NPI requirement, is not applicable to beneficiary claims submitted to DMEMACs for durable medical equipment, prosthetics, orthotics, and supplies.  These claims should be processed by DMEMACs using current procedures.  C. Exception When Physician, Other Practitioner, or Supplier Is Excluded From Participating in Medicare Program   Section 1848(g)(4) of the Social Security Act requires physicians, other practitioners, or suppliers to submit claims to Medicare carriers for services furnished after September 1, 1990.  This does not  apply to physicians, other practitioners, or suppliers who have been excluded from participating in the Medicare program.  Physicians, other practitioners, and suppliers who have been excluded from the Medicare program are prohibited from submitting claims or causing claims to be submitted.  See the Medicare Program Integrity Manual for procedures concerning claims submitted by an excluded practitioner, his/her employer, or a beneficiary for services or items provided by an excluded physician, other practitioner, or supplier.  Carriers must maintain the systems capability to identify claims submitted by excluded physicians, other practitioners, or suppliers as well as items or services provided, ordered, prescribed, or referred by an excluded party.  When an excluded physician, other practitioner, or supplier has not submitted a claim on behalf of the beneficiary and/or the beneficiary has submitted the claim themselves, do not  send a notification letter to the physician, other practitioner, or supplier warning of civil monetary penalties due to noncompliance with 1848(g)(4)(A) of the Act.  Instead, follow the instructions in the Program Integrity Manual.  70.8.8.7  Notification Letters  (Rev. 1588; Issued:  09-05- 08; Effective/Implementation Date:  08 -18-08)  A. The letter sent to the beneficiary should explain why the claim is being returned including an explanation of the corrections needed in order to process the claim.  Also, include an explanation of the statutory requirement that providers and suppliers must  submit claims for all covered services provided to Medicare beneficiaries.  The letter should also provide the beneficiary with instructions on what should be done if the provider or supplier refuses to enroll with Medicare and/or submit the claim.  B. A letter shall also be sent to the provider or supplier explaining the statutory requirement for submitting claims for all services rendered to Medicare beneficiaries.  The letter should explain to the provider or supplier that they are required to enroll with the Medicare program before a claim can be submitted.  Finally the letter should include language explaining the penalties for failure to comply with the mandatory claims submission requirements.  70.8.8.8 - Violations That Are Not Developed For Referral  (Rev. 420, Issued:  12- 30-04, Effective:  01/31/05, Implementation:  01/31/05)   Claim submission violations need not be developed on beneficiary- submitted Form CMS -1490S claims that include approved charges for services performed on or after September 1, 1990 in the following situations:   o Used DME purchases from private sources;   o Cases in which a physician/supplier does not possess information essential for filing a MSP claim.  Assume this is the case if the beneficiary files a MSP claim and encloses the primary insurer's payment determination notice and there is no indication that the service provider was asked to file but refused to do so;   o Services paid under the indirect payment procedure;  o Foreign claims; and  o Other unusual or unique situations that you evaluate on a case -by-case basis.