(Medicare Claims Processing Manual)

2. The legend:  These amounts apply when service is performed in a facility setting.   3. The legend:  The payment for the technical component is capped at the OPPS amount.   For the disclosure reports, the carrier shall also provide the anesthesia conversion factors.   In addition, the carrier includes language in a bulletin that provides an explanation of the facility -based fee concept (e.g., facility -based fees are linked to their own separate RVUs independent of the non facility RVUs).  D.  Disclosure to Medical Societies and Other Parties   Carriers send first class or equivalent (e.g.  UPS), free of charge, a complete fee schedule for the entire State (or your service area if it is other than the entire State) to State medical societies and State beneficiary associations.  Carriers may negotiate with them as to the medium in which the i nformation is to be furnished.  Carriers send local medical societies and beneficiary organizations a free copy of their respective locality fee schedule. If a fee schedule for the entire service area is requested by a local medical society or beneficiary organization, furnish one free c opy. If more than one copy of a complete fee schedule for the carrier service area is requested, carriers charge for extra copies in accordance with the Freedom of Information Act (FOIA) rules. If a provider requests a fee schedule for a locality in which he/she has no office, carriers may charge them in accordance with FOIA rules.   E.  Practitioners Subject to Mandatory Assignment   Some practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services.  This means that they must accept the Medicare allowed charge amount as payment in full for their practitioner services.  The beneficiarys liability is limited to any applicable deductible plus the 20 percent coinsurance.  The following practitioners must accept assignment for all Medicare covered services they furnish, and carriers do not send a participation enrollment package to these practitioners:   Specialty 32 -  Anesthesiologist assistants (AAs)    Specialty 42 -  Certified nurse midwives    Specialty 43 -  Certified registered nurse anesthetists (CRNAs)    Specialty 50 -  Nurse practitioners    Specialty 68 -  Clinical Psychologists    Specialty 71 -  Registered dietitians/nutritionists    Specialty 73 -  Mass Immunization Roster Billers    Specialty 80 -  Clinical Social Workers    Specialty 89 -  Clinical nurse specialists    Specialty 97 -  Physician assistants   Specialty E1 -  Marriage and Family Therapists   Specialty E2 -  Mental Health Counselors  NOTE:  The provider type Mass Immunization Biller (specialty 73) can bill only for influenza and pneumococcal vaccinations and administrations.  These services are not  subject to the deductible or the 20 percent coinsurance.   Although these practitioners will not be invited to officially enroll in the Medicare participation program, carriers treat them as participating practitioners for purposes of various benefits available under that program (See Section 30.3.12 in this Chapt er).  NOTE:  Although these practitioners do not have to sign participation agreements, carriers must include them in the annual MEDPARD as participating. They also include Rural Health Centers.   Carriers may create and send hardcopy fee disclosure reports to these practitioners if cost effective to do so (e.g., the carrier determines that fee disclosure to these practitioners will reduce or minimize the number of more costly inquiries it receives for fee data). To minimize report programming costs, carriers may use the same format as the physician fee disclosure report. If they use the physician fee disclosure report format for practitioner fee disclosure, carriers include a disclaimer advising the practitioner that the non-participating fee schedule amounts and limiting charges do not apply to services they furnish. If carriers elect not to routinely disclose practitioner fees, they furnish applicable fees or reasonable charge screens upon request.   The Medicare Participation Agreement and general instructions are on the CMS Web site at http://www.cms.hhs.gov/cmsforms/downloads/cms460.pdf.  F.  Supplier Fee Schedule Data   Refer to Chapter 23 for more information.   Clinical Laboratory Fee Schedule   Carriers must:    Publish clinical diagnostic lab fees in a regularly scheduled bulletin or newsletter.    Publish clinical laboratory fees in the following format:  o Header Information: Name of fee schedule and State or locality (if less than State -wide) on each report page:   o Procedure Code and Modifiers (Use procedure codes that are valid for appropriate year);   o Fee Schedule Amount; and   o Footer Information: The legend All Current Procedural Terminology (CPT) codes and descriptors are copyrighted (appropriate year) by the American Medical Association. (on each report page).   Information regarding release of this data will be issued under separate cover.   DMEPOS Fee Schedule:   Instructions for furnishing DMEPOS fee schedule data will be issued annually by CMS.   G.  Fee Schedule Printing Specifications   Carriers are to produce hardcopy disclosure material for no more than two percent of their total number of providers.  Carriers have the discretion to produce either one or two percent hardcopy versions.  The hard copy fee schedules are to be mailed to providers who are unable  to access the carrier Web site (i.e., do not have internet access). For those providers, carriers must print fee schedules on 8- 1/2 by 11- inch paper, and use a print size that accommodates up to 15 characters per inch.  The CMS prior approval for smaller print must be requested in writing from the RO. Requests are to be accompanied by print samples to assist the RO in assessing report readability.   H.  Date of HCPCS Update   The annual HCPCS update occurs on January 1 of each year. The annual HCPCS update file will be released electronically in October of each year.   I.  Medicare Participation Physicians/Suppliers Directory (MEDPARD)   Annually, within 30 days following the close of the annual participation enrollment process, carriers produce a directory listing only Medicare participating physicians and suppliers and post it on their Web site.  Carriers do not print hardcopy participat ion directories (i.e., MEDPARDs) without regional office prior authorization and advance approved funding for this purpose. Carriers load MEDPARD equivalent information on their Internet Web site. Carriers notify providers via regularly scheduled newsletter as  to the availability of this information and how to access it electronically. Carriers also inform hospitals and other organizations (e.g., Social Security offices, area Administration on Aging offices, and other beneficiary advocacy organizations) how to access MEDPARD information on the carrier Web site.   Carriers that receive MEDPARD inquires from beneficiaries who do not have access to their Web site will ascertain the nature and scope of each request and furnish the desired MEDPARD participation information via telephone or letter.   (a). Contents  Each directory has two parts. Part I shows the correct Specialty, Name, Address and Telephone Number of each participating Physician, Supplier and Group by geographic area.  The address in the directory must be the address of the physician's/supplier's place of business and not a Post Office box number.  Part II includes only the name and telephone number of all Physicians, Suppliers and Groups contained in Part I listed in alphabetic sequence.  Telephone numbers may not be omitted.  Edit the listings to assure that everyone listed in Part I is also listed in Part II (multiple addresses may be included if appropriate); physicians are listed only once by name in Part II.  When you have only the group name for participating group practices, you may list the names of physician(s) within the group, but only at the group's request.  For groups which so request, list the physicians under the group name in alphabetical sequence.  Indicate an individual physician's specialty if it differs from other specialties.  Show only the group address and telephone number. ( NOTE:   A group practicing physician who also has solo practices may appear more than once if he is participating in more than on entity.)  Do not list the names of hospital based physicians.  Where a beneficiary would not have personal choice access to a group, (e.g., the group accepts patients by referral only), list only the group name and address. Note that it accepts patients by referral only.   If a physician or supplier has multiple service locations, accommodate this in the directories to the extent possible with the information on the provider file and information obtained during the participation enrollment process.  List all independent RHCs in your area, not necessarily jurisdiction, in the MEDPARD. They are required to accept Medicare payment on claims as payment in full and, therefore, meet the acceptance criteria for a MEDPARD listing even though a participating agreement has not been signed.  Do not group independent RHCs with physicians in the directory.  List them separately on a full or partial page under the wording shown below.  Show the name, address and telephone number of each.  Treat the RHC as a group and list only the clinic name and telephone number in Part II of the MEDPARD (the alphabetical listing).  Use an indicator so the beneficiary can distinguish between a group and a RHC.  The following wording must appear above the list of independent RHCs:   Rural Health Clinics (RHCs) agree to accept payment by the Medicare program as full payment for their services, except for the applicable deductible and coinsurance amounts for which the beneficiary is responsible.  The independent RHCs in the area are li sted below:   (b). Organization (Geographic, Physician/Supplier/Group, Alphabetic)   Prepare a separate MEDPARD for each geographic area, e.g., depending upon size, one for each metropolitan area or one for each county or group of counties.  Your plan must be submitted to RO for approval prior to production.  Divide each MEDPARD into two parts.   Divide Part I first alphabetically by geographical location. Within each location, list each specialty. Under the specialty, alphabetically list Physicians, Suppliers and Groups with their addresses and telephone numbers.  Include optometry and podiatry as  specialties and not as suppliers.  Add lay terminology to all specialty headings, e.g., ophthalmology (eye disease), so that they are easily understood by the beneficiary.  Do not list any "miscellaneous" or "unknown" specialties.  These should default to "General Practice" or "Other."   Part II is a straight alphabetical listing of all Physicians, Suppliers and Groups in the directory, with their telephone numbers.  If a physician's or supplier's name and address are the same and listed more than once in Part I, list that individual only once in Part II.   (c). Paper, Print, Binding   Carriers with regional office prior authorization and advanced funding can prepare the MEDPARD in hardcopy (booklet) form on white offset book paper. Size the directory by the number of participating physicians/suppliers in your area.  Do not exceed 8 1/2 by 11 inches.  Use print comparable to 10 point type or larger which improves the readability of the directory.  Use type set print rather than computer listings.  Put all geographical location and specialty headings in bold, uppercase lettering.  Bind the directory in an attractive and distinctive cover which displays the red, white and blue emblem of the Medicare participating physician.  This emblem must show association with U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. clearly indicate on the front cover that this is a Medicare directory of participating physicians/suppliers.  Date the MEDPARD so that older editions will not be confused with subsequent ones.   The back cover should function as an envelope for the directory.  Put your name and return address in the upper left corner.  Reserve the upper right corner for 3rd class postage.  Use address labels, generated from your records of directory requests, to m ake the directory a self -mailer.   Carriers with regional office prior authorization and advanced funding for the MEDPARD in booklet form must produce it within 45 days following the close of the annual participation enrollment process.  (d). Interpretive Information  Each directory must have a Table of Contents.  Include detailed instructions on the organization of the directory.  Place your name and toll- free telephone number at the bottom of the instructions in the front of the directory.  Include detailed instructions on "how to use the directory," i.e., to locate a participating physician or supplier in a specific area:  first, find the correct county in the table of contents; second , look below the county for the city name and find the city's page number; third , turn to the appropriate page and look for the physician or supplier specialty you need; fourth , look for the names of physicians or suppliers in that specialty.  At the top of the instruction page, include the statement:  This directory contains the names, addresses, telephone numbers, and specialties of MEDICARE PARTICIPATING physicians and suppl iers.  MEDICARE PARTICIPATING physicians and suppliers have agreed to accept assignment on all Medicare claims for covered items and services.   (e). Dissemination of MEDPARD Information   Within your Medicare service area, inform the following groups how to access the MEDPARD on the carrier Web site:    Beneficiaries who request to view the MEDPARD; and    Physicians, suppliers, groups, and clinics listed in the directory who request to view the MEDPARD.   Within 30 days after the close of the annual participation enrollment period, carriers inform the following individuals/groups of the availability of their local MEDPARD on the carrier Web site:    Congressional offices;   Quality Improvement Organizations;   Senior citizen groups and other beneficiary advocacy organizations;   Social Security Offices;    State area agencies of the Administration on Aging; and   Hospitals.