(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 19  Indian Health Services   Table of Contents (Rev. 11427, 05-20-22)  Transmittals for Chapter 19  10 - General  20 - A/B MAC (B) and A/B MAC (A) Designation  20.1 - Durable Medical Equipment Me dicare Administrative Contractors (DME MAC) Designation  20.2 - Overview of Medicare Part B Services  30 - Medicare Part B Services  40 - Provider Enrollment  40.1 - Provider Enrollment with A/B MAC (B)  40.1.1 - Entities  40.1.2 - Individual Practitioners  40.1.3 - Multiple Sites  40.1.4 - Reassignment  40.1.5 - Mobile Units  40.1.5.1 - Mobile Mammography Units  40.1.6 - Clinical Laboratory, Ambulance and Medicare Part B Drugs  40.2 - Provider Enrollment with A/B MAC (A)  40.2.1 - Provider Enrollment with A/B MAC (A) - Ambulatory Surgical Services  40.2.2 - Provi der Enrollment with A/B MAC (A) - Services Under Arrangements  40.3 - Provider Enrollment with DME MAC  40.4 - NSC Supplier Number  50 - Reporting Requirements and Specifications  60 - Incentive Payments  70 - Covered Medicare Part B Services That May Be Paid to IHS Providers, Physicians and Practitioners  80 - A/B MAC (B) - Payment Policy and Claims Processing  80.1 - A/B MAC (B) - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy  80.2 - A/B MAC (B) - Claims Processing Requirements  80.3 - A/B MAC (B) - Ambulance Services - Payment Policy  80.3.1 - A/B MAC (B) - Ambulance Services - Claims  Processing  80.4 -  A/B MAC (B) - Vaccines and Vaccine Administration -  Payment Policy  80.4.1 -  A/B MAC (B) - Vaccines and Vaccine Administration -  Coverage Policy  80.5 -  A/B MAC (B) - Screening and Preventive Services  80.6 -  A/B MAC (B) - Clinical Laboratory Services - Payment Policy  80.6.1 -  A/B MAC (B) - Clinical Laboratory Services - Claims Pro cessing  80.7 -  A/B MAC (B) - Medical Nutrition Therapy (MNT) -  Payment Policy  80.7.1 -  A/B MAC (B) - MNT -  Claims Processing  80.8 -  Dual Eligibility  80.9 -  A/B MAC (B) Claims Processing and Payment for ASC Claims  90 - DME General Information  90.1-  Durable Medical Equioment, Prosthetics, Orthotics and Supplies (DMEPOS) Pa yment Policy  90.1.1 -  Licensure to Dispense Drugs  90.1.2 -  Payment  90.2 -  DMEPOS Claims Processing Rules  90.2.1 -  Services Billed to the DME MAC  90.2.1.1 -  Prosthetics, Orthotics and Supplies Billed to the A/B MAC  90.2.2 -  General Claims Processing Rules for DMEPOS  100 -  A/B MAC (A) Payment Policy and Claims Processing  100.1 -  A/B MAC (A) -  Medicare Part B Services Paid Under Various Fee Schedules  100.2 -  A/B MAC (A) -  Medicare Part B Services Included in the All In clusive Rate (AIR ) 100.3 -  A/B MAC (A) -  Inpatient Acute Care -  Medicare Part A -  Payment Policy  100.3.1 -  A/B MAC (A) - Inpatient Acute Care - Medicare Part A -  Claims Processing  100.3.2 -  A/B MAC (A) - Physician Acknowledgement Statement  100.3.3 -  A/B MAC (A) - Social Admissions  100.3.4 -  A/B MAC (A) - Inpatient Ancillary Services -  Medicare Pa rt B -  Payment Policy  100.3.4.1 -  A/B MAC (A) -  Inpatient Ancillary Services -  Medicare Part B - Claims Processing  100.4 -  A/B MAC (A) -  Swing -bed 100.4.1 -  A/B MAC (A) - Swing -bed -  Medicare Part A -  Payment Policy  100.4.1.1 -  A/B MAC (A) -  Swing -bed -  Medicare Part A -  Claims Processing  100.4.2 -  A/B MAC (A) - Swing -bed -  Inpatient Ancillary Claims -  Medicare Part B - Payment Policy  100.4.2.1 -  A/B MAC (A) -  Swing -bed -  Inpatient Ancillary Claims -  Medicare Part B -  Claims Processing  100.5 -  A/B MAC (A) -  Outpatient -  Medicare P art B -  Payment Policy  100.5.1 -  A/B MAC (A) - Outpatient -  Medicare Part B -  Claims Processing  100.6 -  A/B MAC (A) -  Ambulatory Surgical Center (ASC) -  Medicare Part B -  Payment Policy  100.6.1 -  A/B MAC (A) - ASC -  Medicare Part B - Claims Processing  100.7 -  A/B MAC (A) -  Critical Access Hospital (CAH) Inpatient - Medicare Part A - Payment Policy  100.7.1 -  A/B MAC (A) - CAH Inpatient - Medicare Part A -  Claims Processing  100.7.2 -  A/B MAC (A) - CAH Ancillary Services - Medicare Part B -  Payment Policy  100.7.2.1 -  A/B MAC (A) -  CAH Ancillary Services -  Medicare Part B -  Claims Processing  100.8-  A/B MAC (A) -  CAH Swing -bed -  Medicare Part A -  Payment Policy  100.8.1 -  A/B MAC (A) - CAH Swing -bed -  Medicare Part A -  Clai ms Processing  100.8.2-  A/B MAC (A) -  CAH Swing -bed - Inpatient Ancillary Claims -  Medicare Part B - Payment Policy  100.8.2.1 -  A/B MAC (A) -  CAH Swing -bed -  Inpatient Ancillary Claims -  Medi care Part B -  Claims Processing  100.9 -  A/B MAC (A) -  CAH Outpatient -  Medicare Part B -  Payment Policy  100.9.1 -  A/B MAC (A) - CAH Outpatient -  Medicare Part B - Claims Processing  100.9.1.1 -  A/B MAC (A) -  CAH Election of Method I or Method II 100.10-  A/B MAC (A) -  Vaccines and Vaccine Administration -  Payment Policy  100.10.1 - A/B MAC (A) - Vaccines and Vaccine Administration -  Claims Processing  100.11 -  A/B MAC (A) -   Pulmonary Rehabilitation, Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services - Payment Policy  100.11.1 -  A/B MAC (A) -  Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services -  Claims Processing  100.11.2 -  A/B MAC (A)  Pulmonary Rehabilitatio n Services -  Claims Processing  100.12 -  A/B MAC -  Ambulance Services  100.12.1 -  A/B MAC (A) -  Outpatient Hospital- Based Ambulance Services -  Medicare Part B -  Payment Policy  100.12.1.1 -  A/B MAC (A) -  Outpatient Hospital- Based Ambulance Services -  Medicare Part B - Claims Processing  100.12.2 -  A/B MAC -  CAH Ambulance Services - Medicare Part B -  Payment Policy  100.12.2.1 -  A/B MAC (A) -  CAH Ambulance Services -  Medicare Part B - Claims Processing  100.12.3 -  A/B MAC (A) - Ambulance Services -  Medicare Part A -  Payment Policy  100.13 -  A/B MAC (A) -  Other Screening and Preventive Services -  Payment Policy  100.13.1 -  A/B MAC (A) -  Other Screening and Preventive Services -  Claims Processing  100.13.2 -  A/B MAC (A) -  MNT -  Payment Policy  100.13.2.1 -  A/B MAC (A) -  MNT -  Claims Processing  100.14 -  A/B MAC (A) -  Laboratory Services  100.15 -  A/B MAC (A) -  Drugs  100.16 -  A/B MAC (A) -  Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners  100.16.1 -  A/B MAC (A) -  Telehealth Originating Site Facility Fee -  Medicare Part B - Payment Policy  100.16.2 -  A/B MAC (A) -  Telehealth Originating Site Facility Fee -  Medicare Part B - Claims Processing  100.16.3 -  A/B MAC (A) -  Payment for Distant Site Practitioner Services  110 -  Audit  110.1 -  Audit of IHS Cost Reports  110.2 -  Method E Cost Reports  110.3 -  Critical Access Hospitals  120 -  Payment to Non- Indian Health Service Physicians by Indian Health Service (IHS) Providers for Teleradiology Interpretations     10 - General  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  The Indian Health Service (IHS) is the primary health care provider to the American Indian/Alaska Native (AI/AN) Medicare population. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventi ve health services to its beneficiaries, via a network of hospitals, clinics, and other entities. While 1814(c) and 1835(d) of the Social Security Act (the Act), as amended, generally prohibit payment to any Federal agency, an exception is provided for I HS/Tribally owned and operated facilities under 1880. The enactment of Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA), expanded payment for Medicare services provided in IHS /tribally owned and operated facilities beyond services provided in hospitals, skilled nursing facilities (SNFs) and swing -bed facilities.   Effective January 1, 2005, 630 of the Medicare Modernization ACT (MMA), extended to IHS facilities the ability to b ill for all Medicare Part B covered services and items that were not covered under BIPA. This includes all screening and preventive services covered by Medicare.  Section 2902 of the Patient Protection and Affordable Care Act (ACA) indefinitely extends 630 of the MMA, retroactive to January 1, 2010.  Tribally owned and operated facilities may choose to bill the Medicare program in one of two ways. First, these tribally owned and operated facilities are authorized to enroll or become certified to participate in the Medicare program as any other provider/supplier of Medicare services. Depending upon the type of supplier/provider, these entities file claims with the MAC for the type of service and which serves the specific geographic region where the facility is located.  They follow the same coverage and claims filing requirements as any other regular Medicare provider/supplier. On the other hand, since tribally owned and operated facilities are covered under the Indian Self Determination and Education Assista nce Act (ISDEA), P.L.93- 638 [25 U.S.C. 450 et seq.] (commonly referred to as 638), this affords them the option of electing the same billing rights as facilities run by the IHS. Tribally owned and operated facilities choosing this option file claims with  the designated MAC used for processing IHS claims instead of with the MAC serving the specific geographic region where the facility is located. Because many tribally owned and operated facilities elect to file claims with the Medicare contractors designat ed for IHS, many tribal facilities not actually run by IHS are considered to be IHS for Medicare billing purposes. Unless otherwise specified, any references in this chapter to IHS providers, IHS suppliers or IHS physicians or practitioners includes:  (1) tribally owned and operated facilities electing to bill as IHS; (2) tribally operated IHS facilities; (3) IHS owned and operated facilities; (4) tribally owned and IHS operated facilities.  Tribally owned and operated facilities electing to bill the MAC serving their specific geographic location should look to other pertinent chapters of this manual for instructions that apply to regular Medicare providers/suppliers, not to the provisions contained in this special chapter for IHS providers billing the designated IHS MAC.   In this chapter the terms IHS provider, IHS supplier and IHS physician or practitioner pertain to the following:   IHS provider refers to all hospital or hospital based- facilities, including outpatient clinics, unless otherwise noted.