(Medicare Claims Processing Manual)

The ASCA law allows for there to be exceptions for which a provider, or other claim submitter, is permitted to send his/her claims to Medicare on paper.  Refer to Chapter 24 90- 90.5.4 for more information regarding ASCA exceptions.   02.2.1 - Paper Formats for Institutional Claims  (Rev. 3086, Issued: 10- 03-14, Effective:  ICD -10: Upon Implementation of ICD -10, ASC X12: January 1, 2012, Implementation  ICD- 10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   The required format for submitting institutional claims to Medicare on paper is the CMS - 1450 form.  Refer to chapter 25 for more information, including how to complete this form.  In addition, where needed, additional instruction is provided throughout this manual for submitting paper claims.   02.2.2 - Paper Formats for Professional and Supplier Claims  (Rev. 3086, Issued: 10- 03-14, Effective:  ICD -10: Upon Implementation of ICD -10, ASC X12: January 1, 2012, Implementation  ICD- 10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   The required format for submitting professional and supplier claims to Medicare on paper is the CMS -1500 claim form.  Refer to chapter 26 for more information, including how to complete this form.  In addition, where needed, additional instruction is provi ded throughout this manual for submitting paper claims.  02.3 - Remittance Advices  (Rev. 3086, Issued: 10- 03-14, Effective:  ICD -10: Upon Implementation of ICD -10, ASC X12: January 1, 2012, Implementation  ICD- 10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   Another of the electronic health care transactions for which HIPAA requires the Secretary to adopt a standard is the remittance advice.  The standard adopted is the ASC X12 Health Care Claim Payment/Advice (835).  The current HIPAA version, including the implementation guide, is listed in Chapter 24.  Throughout this manual, you may see references to this standards short form, ASC X12 835 remittance advice.  More information about this transaction and its implementation guide can be found in chapters 22 and 24.  10 - Jurisdiction for Claims  (Rev. 1, 10- 01-03)  In general  FIs have jurisdiction for providers and institutional suppliers. Examples of institutional suppliers are renal dialysis facilities, comprehensive outpatient rehabilitation facilities, rural health clinics, and federally qualified health centers.  In gener al, carriers have jurisdiction for physicians and other individual practitioners, and for labs that are not a part of hospital, ambulance suppliers, ASCs, DME suppliers, and IDTFs.   See 10.1 -  10.2 for more detail.   10.1 - A/B MACs (Part B) and DME MAC Jurisdiction of Requests for Payment  (Rev. 10840; Issued: 06- 11-21; Effective: 07 -12-21; Implementation: 07 -12-21)  B3-3100  A/B MACs (Part B) have jurisdiction for all claims from the following:   Physicians;   Other individual practitioners;   Groups of physicians or practitioners;   Labs not part of a hospital;   Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the A/B MAC (Part A);   Ambulatory surgical centers (ASCs); and   Independent diagnostic testing facilities (IDTFs).   Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have jurisdiction for claims from the following:   Nonimplantable  durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) (including home use);    Suppliers of enteral and parenteral products other than to inpatients covered under Part A;    Oral drugs billed by pharmacies; and    Method II home dialysis (for dates of service prior to January 1, 2011).  Note:  Please refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis for dates of service on and after January 1, 2011.   The CMS maintains a list of which HCPCS codes are under DME MAC only jurisdiction or dual DME MAC/Part B MAC jurisdiction and issues updates to DME MACs and A/B MACs (Part B) as needed (Usually quarterly). Any other codes not listed as DME MAC only or dual DME MAC/Part B MAC jurisdiction shall be A/B MAC (Part B) only jurisdiction.    There are four DME MACs each of which is assigned specific States.   A/B MACs (Part B) typically process Part B fee-for- service claims for services furnished in specific geographic areas (e.g., a State). However, a single A/B MAC (Part B) processes all physician/supplier claims for railroad retirement beneficiaries. (See 1 0.1.3 for claims for Part B medical services performed outside the U.S. for individuals who reside in the U.S.).   The rules for determining jurisdiction are the same whether a claim is assigned or nonassigned (see 30.3 for assignment rules).   Further information on A/B MACs (Part B) and DME MACs for specific geographic areas is available on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Contracting/Medicare- Administrative -Contractors/Who- are-the- MACs  .  Most skilled nursing facilities submit claims to the A/B MACs (Part A). However, a nonparticipating skilled nursing facility (SNF) is considered a supplier and its claims are submitted to the appropriate A/B MACs (Part B) under its own Medicare supplier number.   10.1.1 - Payment Jurisdiction among A/B MACs (Part B)  for Services Paid Under the Physician Fee Schedule and Anesthesia Services   (Rev.  4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)  The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is governed by the payment locality where the service is furnished and will be based on the ZIP code. Though a number of additional services appear on the MPFS database, these payment jurisdiction rules apply only to those services actually paid under the MPFS and to anesthesia services.  (For example, it does not apply to clinical lab, ambulance or drug claims .)  Effective for claims received on or after April 1, 2004, A/B MACs (Part B) must use the ZIP code of the location where the service was rendered to determine A/B MACs (Part B) jurisdiction over the claim and the correct payment locality.  Effective for dates of service on or after October 1, 2007, except for services provided in POS Home, if they are not already doing so, A/B MACs (Part B) shall use the CMS ZIP code file along with the ZIP code submitted on the claim with the address that represents where the service was performed to determine the correct payment locality.  (See section 10.1.1B for instructions on processing services rendered in POS Home -12 and section 10.1.1.1 for instructions on when a 9-digit ZIP code is required.)  When a physician, practitioner, or supplier furnishes physician fee schedule or anesthesia services in payment localities that span more than one A/B MAC (Part B)s service area (e.g., provider has separate offices in multiple localities and/or multiple A/ B MACs (Part B)), separate claims must be submitted to the appropriate area A/B MACs (Part B) for processing. For example, when a physician with an office in Illinois furnishes services outside the office setting (e.g., home, hospital, SNF visits) and that  out-of-office service location is in another A/B MAC (Part B)s service area (e.g., Indiana), the A/B MAC (Part B) which processes claims for the payment locality where the out of office service was furnished has jurisdiction for that service.  It is the A/B MAC (Part B) with the correct physician fee schedule pricing data for the location where the service was furnished. In the majority of cases, the physician fee schedule or anesthesia services provided by physicians are within the same A/B MAC (Part B) jurisdiction that the physicians office(s) is/are located.   Although pricing rules for services paid under the MPFS remain in effect, effective for claims with dates of service on or after January 25, 2005, suppliers (including laboratories, physicians, and independent diagnostic testing facilities (IDTFs) must bil l their A/B MAC (Part B) for the technical component and professional component of diagnostic tests that are subject to the anti- markup payment limitation, regardless of the location where the service was furnished.  Beginning in 2005, and in each subseque nt calendar year (CY) through 2013, CMS provided A/B MACs (Part B) with a national abstract file containing Healthcare Common Procedural Coding System (HCPCS) codes that are payable under the MPFS as anti -markup tests for the year.  In addition, CMS made q uarterly updates to the abstract file to add and/or delete codes, as needed, in conjunction with the MPFSDB quarterly updates.   Beginning in 2014, CMS adopted a more streamlined approach to providing the A/B MACs with the HCPCS codes payable under the MPF S as anti -markup tests for the year.  The national abstract file was discontinued and an Anti -markup (formerly Purchased Diagnostic) Test Indicator, to identify HCPCS codes payable under the MPFS as anti -markup tests for the year, was added to the MPFS payment file.  Quarterly updates to the Anti -Markup Test Indicator are made directly to the MPFS Payment file. As with all other services payable under the MPFS, the ZIP code of the locality in which the service was furnished determines the payment amount.  R efer to 30.2.9 of this chapter for information on the anti -markup payment limitation as it applies to supplier billing requirements.   A. Multiple Offices   In states with multiple physician fee schedule pricing localities or where a provider has multiple offices located in two or more states, or there is more than one A/B MAC (Part B) servicing a particular state, physicians, suppliers and group practices wit h multiple offices in such areas must identify the specific location where office -based services were performed. This is to insure correct claim processing jurisdiction and/or correct pricing of MPFS and anesthesia services. The A/B MAC (Part B) must ensur e that multiple office situations are cross -referenced within its system. If a physician/group with offices in more than one MPFS pricing locality or a multi -contractor state fails to specify the location where an office- based service was furnished, the A/B MAC (Part B) will return/reject the claim as unprocessable.   Physicians, suppliers, and group practices that furnish physician fee schedule services at more than one office/practice location may submit their claims through one office to the A/B MAC (Part B) for processing. However, the specific location where the se rvices were furnished must be entered on the claim so the A/B MAC (Part B) has the ZIP code, can determine the correct claims processing jurisdiction, and can apply the correct physician fee schedule amount.  B. Service Provided at a Place of Service Other than Home- 12 or Office -11  For claims submitted prior to April 1, 2004, in order to determine claims jurisdiction, Medicare approved charges, Medicare payment amounts, Medicare limiting charges and beneficiary liability, Part B fee -for-service claims for services furnished in other than in an office setting or a beneficiarys home must include information specifying where the service was provided.   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.