(Medicare Claims Processing Manual)

B.  More Than One Vehicle Used   If more than one vehicle is used in transporting the patient to their destination, jurisdiction of the claim lies with:  The carrier serving the home base of the ambulance taking the patient on the first leg of the trip , on a trip to  a distant institution more remote than the nearest appropriate facility; or    The carrier serving the home base of the ambulance taking the patient on the final leg of the trip home, on a trip from  an institution more remote than the nearest appropriate facility.    If there is no  claim for the final leg of the trip, the carrier serving the patients home area handles any resulting claims or disallowance actions.   EXAMPLE:  A patient is transported by ambulance from a hospital in Miami Beach, Florida to Miami International Airport and from there by air ambulance to LaGuardia Airport in Queens, New York City. At the airport he is picked up by an ambulance (based in Yonkers, Ne w York) and taken to his home in Yonkers, New York. The carrier that handles the adjudication is the carrier whose area of responsibility includes Yonkers, New York, since partial reimbursement is based upon the nearest appropriate facility to his residence when he is being returned home from a distant institution.  In rules A and B above, the principle followed is that the carrier having the information to determine the nearest appropriate facility is the one to adjudicate the claim. In any event, before any partial reimbursement can be made, the carriers as designated in rules A and B, must have all the information concerning the patients transportation, from initial pickup to final destination .  10.1.5.4 - Independent Laboratories  (Rev. 1, 10- 01-03)  Jurisdiction of claims for laboratory services furnished by an independent laboratory normally lies with the carrier serving the area in which the laboratory test is performed. However, there are some situations where a regional or national lab chain juris diction is with a single carrier.   10.1.5.4.1 - Cases Involving Referral Laboratory Services  (Rev. 1, 10- 01-03)  If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by the other laboratory.   Examples of Independent Laboratory Jurisdiction   EXAMPLE 1:   An independent laboratory located in Oregon performs laboratory services for physicians whose offices are located in several neighboring States.  A physician from Nevada sends specimens to the Oregon laboratory.  If the laboratory sends the results to the physician and accepts assignment, the carrier in Oregon has jurisdiction.  EXAMPLE 2:   American Laboratories, Inc., is an independent laboratory company with branch laboratories located in Philadelphia, Pennsylvania, and Wilmington, Delaware, as well as regional laboratories located in Millville, New Jersey, and Boston, Massachusetts.  The Philadelphia laboratory receives a blood sample from a patient whose physician ordered a complete blood count, an SMAC T -4, and a B12 and folate. The Philadelphia lab performs the complete blood count, but the SMAC T -4 is performed at the Millville lab, while the B12 and folate is performed at the Boston Lab. The Pennsylvania carrier retains jurisdiction for processing the claims if they have certification information and the appropriate fee schedule allowance in house . Otherwise, the local carrier serv icing Boston and/or Millville has jurisdiction for processing their claims.   The Wilmington laboratory draws a blood specimen from a patient whose physician has ordered a blood culture. The Wilmington lab then sends the specimen to the Boston laboratory, which performs the required test. American Laboratories accepts an assignment for the service.   If the Delaware carrier has the capability of comparing the Wilmington labs charge for the blood culture against the appropriate reasonable charge screens for the Boston lab, the Delaware carrier will retain jurisdiction for processing the claim. If the D elaware carrier does not have this capability, the claim should be transferred to the Massachusetts carrier for processing.  10.1.6 - Railroad Retirement Beneficiary Carrier  (Rev. 142, 04- 16-04) B3-3103  Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:    The services are furnished by a M+C organization which deals directly with CMS on a cost basis;    The QRRB is enrolled under a buy- in agreement involving a State  agency that has entered into an agreement to act as a carrier with respect to such individuals; or;    The medical services were provided outside the United States, in which case the RRB handles the claim.  (See 10.1.4.6 for handling claims for services in Mexico.)   If a claim involves medical services provided both within and outside the United States, Palmetto GBA processes the claim for the medical services provided within the United States.  If the claimant raises a question as to why the medical services provided  outside the United States were not paid, Palmetto GBA directs the claimant to contact the RRB and forwards the claims to them at:   Railroad Retirement Board  Division of Disability and Health Insurance  844 Rush St.  Chicago, IL 60611   10.1.7 - Welfare Carriers  (Rev. 1, 10- 01-03) B3-3104, B3- 3060 for buy- in definition   Section 1843(f)  of Title XVIII permits a State agency that administers a plan under Titles I, XVI, or XIX to become the carrier for individuals enrolled in the States Buy In agreement. Currently there are no State agencies that are serving as carriers.   10.1.9 - Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  A misdirected claim is a claim that has been submitted to the wrong place.  This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.   Each fee- for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing.   Physicians and other suppliers are required to submit claims to the contractor having the appropriate jurisdiction.  Jurisdictional rules are specified in this Chapter at Section 10.   A contractor may not knowingly adjudicate a misdirected claim and, as such, upon receipt of such a claim, must dispose of the claim in accordance with the specifications of this section or other relevant instructions.  This section addresses the following types of misdirected claims:   1. a CMS -1500 or electronic claim submitted to the wrong local contractor (Part B MAC or carrier);   2. a CMS -1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to a DME MAC;   3. a CMS -1500 or electronic claim submitted to a DME MAC that should have been submitted to a local contractor (Part B MAC or carrier);   4. a CMS -1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to the Railroad Retirement Board (RRB);   5. a CMS -1500 or electronic claim submitted to a DME MAC or a local contractor (Part B MAC or carrier) that should have been submitted the United Mine Workers of America (UMWA);   6. a CMS -1500 claim that should be submitted to a DME MAC that is submitted to the wrong DME MAC, and  This subsection does not apply to:   1. misdirected beneficiary -submitted claims.  See Section 80.3.2 of this Chapter regarding handling of such claims;   2. electronic claims for durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) that are submitted to the incorrect DME MAC (misdirected DMEPOS claims are automatically routed to the appropriate DME MAC jurisdiction for processing);   3. a claim submitted to the wrong Part A MAC or fiscal intermediary (FI), including a regional home health intermediary (RHHI).   10.1.9.1  An A/B MAC (B) Receives a Claim for Services that are in Another A/B MAC (B)s Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a CMS -1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.   NOTE:  This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, but are billed to the wrong B MAC/carrier payment jurisdiction.  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 Three.   Group Code: CO  CARC: 109  RARC: N104  MSN: N/A  10.1.9.2 - An A/B MAC (B) Receives a Claim for Services that are in a DME MACs Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a CMS -1500 or electronic claim for Medicare payment for items/services that are in a DME MACs payment jurisdiction, the claim shall be returned 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 Three.   Group Code: CO  CARC: 109  RARC: N104   MSN: N/A  10.1.9.3 - A DME MAC Receives a Claim for Services that are in an A/B MAC (B)s Payment Jurisdiction   (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local DME MAC receives a CMS -1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carriers payment jurisdiction, the claim shall be returned 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 Three.   Group Code: CO  CARC: 109  RARC: N104  MSN: N/A  10.1.9.4 - An A/B MAC (B) Receives a Claim for an RRB Beneficiary  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier) receives a Form CMS -1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned 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 Three.   Group Code: CO  CARC: 109  RARC: N105  MSN: N/A  NOTE :  CMS requests that when RRB receives a claim that is not for an RRB beneficiary that they return the claim to the sender and notify them that the claim must be submitted to the local contractor (Part B MAC or carrier) or DME MAC for processing.   10.1.9.5 - An A/B MAC (B) or DME MAC Receives a Claim for a UMWA Beneficiary  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS -1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned 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 Three.   Group Code: CO  CARC: 109  RARC: N127  MSN: N/A  10.1.9.6 - Medicare Carrier or RRB -Named Carrier to Welfare Carrier  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)