(Medicare Claims Processing Manual)

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.   In accord with the above -cited law, regulation, and policy, IHS providers are responsible for furnishing medically necessary servi ces to their registered outpatients either directly or under arrangement.  Service unbundling is prohibited; only the provider can bill for services furnished to its inpatients and outpatients.  The CMS recommends that when services are provided under arrangements the contract should specify how much the IHS provider will pay for each contracted service.  The entity furnishing the services under arrangements with the provider must agree to accept the IHS providers payment as payment in full, and may not charge the beneficiary for such services.   The Office of the Inspector General is authorized to impose a civil money penalty against any individual who knowingly and willingly presents, or causes to be presented, a bill or request for payment, for items or s ervices furnished under Medicare, that is inconsistent with an arrangement under 1886(a)(1)(H) of the Social Security Act or is in violation of the requirement for an arrangement. See 42 CFR 1003 for more information on civil money penalties, assessments and exclusions.   40.3 - Provider Enrollment with DME MAC  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS providers and suppliers that do not currently have a supplier number and want to bill for DMEPOS items must enroll with the NSC.   Beginning July 1, 2005, IHS providers (including CAHs) and pharmacies were eligible to begin billing for DME.  The NSC must accept enrollment applications from IHS and tribally operated hospitals (including CAHs) or hospital -based facilities and pharmacies providing DME beginning April 1, 2005.  All IHS facilities and pharmacies, whether operated by the IHS or a tribe, enrolled by the NSC, shall meet all required standards as set forth in 42 CFR 424.57.  Compliance with the standards w ill be verified by the review procedures for all other DMEPOS suppliers except as discussed herein.   All IHS facilities and pharmacies, whether operated by the IHS or a tribe, shall be exempt from the comprehensive liability insurance requirements under 42 CFR 424.57(c)(10).   All IHS facilities and pharmacies, whether operated by the IHS or a tribe, shall be exempt from the requirement to provide any State licenses for their facility/business.  For example, if a DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a State that requires a bedding license, such license is not required.  However, if they provide a DMEPOS item that requires a licensed professional in order to properly provide the item, they shall  provide a copy of the professional license.  The licensed professional may be licensed in any State or have a Federal license.  For example, a pharmacy does not need a pharmacy license, but shall have a licensed pharmacist on staff.   Site visits shall be conducted for all facilities of the IHS enrolling as IHS suppliers.  For enrollment purposes Medicare recognizes those facilities operated by the IHS and those facilities operated by the tribes.   The IHS enrollment shall be in accordance with the instructi ons provided for all DMEPOS suppliers on the Form CMS -855S, except for the following clarifications.   Facilities operated by the IHS, including pharmacies are considered a Federal government organization.  An Area Director of the IHS must sign the 15 Certification Statement of the Form CMS -855S, be listed in 6 of the form and sign the letter required by 5 of the form which attests that the IHS will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.    Facili ties, including pharmacies that are tribally operated are considered tribal organizations.  The 15 Certification Statement of the Form CMS -855S must be signed by a tribal official who meets the definition of an authorized official in accordance with the p age 2 definitions shown on the Form CMS -855S.  The same authorized official must be listed in 6 of the Form CMS -855S and must sign the letter required by 5 of the form which attests that the tribe will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.   The CMS shall provide the NSC with a list of facilities of the IHS which distinguishes between IHS operated and tribally operated. On the list the NSC shall use the column entitled, FAC OPERATED BY, for this purpose.  Chapter 10 of Pub. 100- 08, Medicare Program Integrity Manual contains additional information on the Form CMS -855S.   NOTE:  Drugs furnished by tribally owned and operated facilities, including pharmacies that are covered under Medicare Parts A and B will continue to be covered and paid under the Medicare fee for service programs.  Facilities shall continue to bill their A/B MAC (A), A/B MAC (B) and DME MAC for these drugs after the implementation of Medicare Part D.   40.4 - NSC Supplier Number  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a DME Supplier, secure a Medicare supplier billing number and comply with the supplier standards  specified in 42 CFR 424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction rules. The NSC shall provide identifiers which identify IHS suppliers and IHS providers to facilitate proper reimbursement by DME MACs.   All IHS suppliers that do not have a supplier number for billing a DME MAC should complete a Form CMS -855S and obtain a supplier number from the NSC. There are two ways to obtain a supplier number from the NSC:   1) Facilities may call the NSC to request an application for Form CMS-855S. Once the facility has completed the Form CMS -855S, it shall be submitted to the NSC at the address indicated on the form; or  2) Alternatively, facilities may go to the CMS Web site, http://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/MedicareProviderSupEnroll/index.html  and download the Form CMS -855S.  The application may be completed and submitted to the NSC.  Pharmacies located in IHS providers must apply for and receive an NSC supplier number to bill for prescriptions.  50 - Reporting Requirements and Specifications  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  In order to facilitate report generation and data collection regarding IHS physicians, practitioners and services, the designated A/B MAC (B) shall assign PINs to each IHS physici an and practitioner in a manner that will allow the designated A/B MAC (B) to ascertain which facilities are IHS, Indian tribe or tribal organization. For example, the designated A/B MAC (B) may establish PINs that will allow the identification of each IHS facility, Indian tribe, and tribal organization facility. Providers request Unique Physician Identification Numbers (UPINs) from the registry.   PIN assignments will allow the identification of each IHS, Indian tribe, or tribal entity and the generation of the following reports from the PINs:   Names, locations and number of IHS entity enrollments;   Names, locations and number of Indian tribe or tribal entity enrollments;   Names, locations and number of individual practitioner enrollments;   Names and number of reassignments;   Receipt, pending and processing times for all applicants; and    Allowed charges and allowed frequencies, per quarter, by Current Procedural Terminology (CPT) code and modifier, for each provider.  NOTE: Beginning May 23, 2007, it is mandatory that the National Provider Identifier (NPI) be used in place of UPINs and PINs.   60 - Incentive Payments  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  In accordance with 1833(m) of the Act, IHS physicians who provide covered professional services in any rural or urban health professional shortage area (HPSA) are entitled to an incentive payment. IHS physicians providing services in either a rural or urban HPSA are eligible for a 10 percent incentive payment. It is not enough for the physician merely to have his/her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although frequently this is the case. The key to the  incentive payment is where the service is actually provided (place of service).  For example, an IHS physician providing a service in his/her office, the patients home, or in a hospital qualifies for the incentive payment as long as the specific location  of the service is within an area designated as a HPSA. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 250.2, for information on billing and payment in a HPSA pertinent to A/B MAC (A) claims.   Section 413a of the MMA requires that a 5 perc ent bonus payment be established for physicians in a designated physician scarcity area (PSA).  Pub. 100 -04, Medicare Claims Processing Manual, Chapter 12, 90.4 and 90.5 contains more information on billing and payment in a PSA pertinent to A/B MAC (B) c laims. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 250.2.1, for information on billing and payment in a PSA pertinent to A/B MAC (A) claims.   A physician may be eligible for both the HPSA and PSA bonuses.  70 - Covered Medicare Part B Services That May Be Paid to IHS Providers, Physicians and Practitioners  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medicare Part B covers medically necessary expenses incurred for the following medical and other health s ervices:    Diagnostic x -ray tests, and other diagnostic tests;  Physician services;   Anesthesia services (anesthesiologist, certified registered nurse anesthetist);   Practitioner services (clinical nurse specialist, clinical psychologist, clinical social worke r, nurse mid -wife, nurse practitioner, physician assistant);   Drugs and biologicals incident to a physicians service;   X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;   Implantable prosthetic devices;   Drugs use d with infusion pumps;   Epoetin Alfa (EPO);   Clinical diagnostic laboratory tests;  Physical therapy, occupational therapy (OT), speech -language pathology and audiology services;   Ambulance services;   Medical Nutrition Therapy (MNT);   Diabetes self management tr aining (DSMT);   Telehealth; and   Hemophilia clotting factors for hemophilia patients competent to use these factors (without supervision).  80 - A/B MAC (B)  - Payment Policy and Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09 -11-06)  80.1 - A/B MAC (B)  - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, 432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.