(Medicare General Information, Eligibility, and Entitlement)

The contractor must make certain that information is not released without the required authorization.  This authorization may be either indicated on the billing and admission form or on a dated statement from the beneficiary.  Where the authorizatio n is on a dated statement it must:   Authorize release of information about his/her title XVIII Medicare claim;  Designate to whom the release is authorized;   Show that the release authorized is for complementary insurance purposes (this may be implied by the  designation in the second bullet above);   Indicate whether the authorization is for a one -time or ongoing release of data (i.e., for the duration of the claims and appeals process, but not to exceed 2 years); and   Bear the signature of the beneficiary, the  beneficiary's legal guardian, or the beneficiary's authorized representative.   Where the bill contains a beneficiary signature or indicates that the beneficiary's signature authorizing release of information is contained in the provider's records, the bil l must contain the name of the complementary insurer unless a dated statement as outlined above is already on file.   Where the contractor has a dated statement on file, information may not be released for individual claims when the beneficiary indicated that they do not want disclosure on that claim.  This may be indicated on certain claims forms by the beneficiary checking an appropriate block, or by attaching a separate statement.   If someone other than the beneficiary, legal guardian, or authorized repre sentative has authorized disclosure to a third party by filling out the appropriate item on the billing form, the contractor may not release the information unless an authorization from the beneficiary is on file.  Instead, where feasible, the contractor w ill inform the beneficiary (or legal guardian or authorized representative) that the signature on the claims form does not constitute a proper authorization for disclosure and that, if the beneficiary desires information to be disclosed to a third party, t he beneficiary should send to either the contractor or the third party, a statement authorizing release.  (The contractor will indicate the necessary contents of a proper authorization or enclose an appropriate form or statement for use by the proper party  in authorizing release.)   If invalid authorizations are a frequent problem, the contractor advises third party payers to obtain appropriate ongoing consent statements from enrollees.   C. Methods of Handling Requests   Where the complementary insurers desir e title XVIII information for certain claims only, either the complementary insurer or the beneficiary may request its release.   The complementary insurer must furnish the required authorization(s) for release and must pay any charges.  (The Medicare progr am will absorb charges for supplying duplicate MSN's or billing forms to beneficiaries, their authorized representatives, and to social security offices.)  In the absence of a standing arrangement, the mere presence of an "authorization' to release and the  identification of a complementary insurer on a title XVIII billing form does not constitute a request for the "release" of information.  There must be a specific request for the information.   The contractor may enter into a standing arrangement with a com plementary insurer to provide and charge for title XVIII information, such as MSNs or deductible non- met letters, in every case in which the contractor receives a title XVIII claim which contains the necessary authorizations and identifies the complementar y insurer.   D. Release of Title XVIII Claims Information for Complementary Insurance Purposes by Providers   Contractors should be aware that, subject to specific written beneficiary authorization, providers are permitted to furnish certain limited informat ion about Medicare eligibility status and related claims information to third party payers for complementary insurance purposes.  ( See 170. )  90 - Matching MAC Health Insurance  (Rev. 1, 09- 11-02)  In using an integrated claims processing system, it is permissible to match a currently updated subscriber file against a run of currently processed Medicare claims to extract information required to pay the complementary claim provided:    When routinely securing beneficiary authorization for an ongoing release of information safeguards are maintained to ensure that, where a beneficiary revokes the authorization on the billing form or by a separate statement, there will be no release of informati on;   When a statement is not routinely secured for the ongoing release of information, controls ensure that there is an authorization per 80.1  of this chapter from each Medicare beneficiary  with complementary insurance before information is released; and    Controls ensure that no information will be released in the matching process for any Medicare beneficiary who does not have complementary insurance.   Contractors must update the subscriber  file to incorporate all terminations before each match with the Medicare claims file so that information will not be passed to the private business sector for beneficiaries who are not entitled to the complementary insurance plan.  The contractor may not permit the private business sector to have access to the Medicare claims history file.  The private business sector may use only information concerning the current claim from the current run of processed claims.   100 - Disclosure to State Agencies or to Contractors Acting for State Agencies Administering Programs Receiving Grants in Aid (Contractors)  (Rev. 1, 09- 11-02)  100.1 - Information That May Be Disclosed and Authorization Required (Rev. 1, 09- 11-02)  The contractor may disclose information on such ma tters as entitlement, benefit payment, or benefit utilization relating to an individual who has applied for benefits administered by the State welfare departments.  It may make such disclosure without the authorization of the individual or the individual's  legal representative (i.e., legal guardian appointed by a court or a parent or a minor) to any duly authorized officer or employee of a State agency administration of grants -in-aid programs under titles IV, V, or XIX or in the case of Puerto Rico, Guam, or the Virgin Islands, titles I, X, or XVI of the Social Security Act with the authorization of the individual or their authorized representative.  Medical information beyond that shown on billing forms relating to an individual (and obtained in the adminis tration of the Medicare program) may be disclosed to a State agency administering the grants -in-aid program if the State agency shows a special need for the information, and the file contains a written authorization by the beneficiary specifically consenti ng to disclosure of medical information.   Title XVIII, billing forms and completion instructions, provide for authorization by the beneficiary for the release of information to State agencies or their agents.  Where the contractor, or a third party organiz ation, is administering the medical payment program under a contract or underwriting arrangement with the State, it may release information to itself or to the third party organization on the same basis as it may release information to a State agency.   100.2 - Procedures for Supplying Title XVIII Information to State Agencies  (Rev. 1, 09- 11-02)  Contractors may provide State Medicaid agencies with Medicare claims information.  See Pub 100- 04, Chapter 28 for more information.   100.3 - Disclosure to Title V and Title XIX Agencies of Information Indicating Unprofessional or Unethical Practices by Physicians and Other Practitioners  (Rev. 1, 09- 11-02)  The release of information obtained in the administration of title XVIII indicating a course of unprofessional conduct or unethical practices by a physician or other practitioner will assist in the investigation of such conduct under titles V and XIX.  The  information to be released must have previously been released by a contractor in the administration of title XVIII to an official of a State licensing board (see 100.4  of this chapter), or to any officer, agency, establishment, or department of the Federal Government charged with the duty of conducting an investigation to determine whether there has been a violation of any provision of a Federal tax law (see 120  of this chapter).   100.4 - Disclosure to Title XIX Agencies of Physician Charge Information  (Rev. 1, 09- 11-02)  The CMS, which administers title XIX, requires a correlation between payments under that title and the fee schedule or the 75th percentile of the range of customary charges, if applicable, as determined for treatment rendered under Part B of title XVIII.  This requirement assumes that title XVIII fee schedule and medical charge experience,  where applicable, will be available to title XIX agencies.   Therefore, it is necessary that agencies administering title XIX be furnished with physician, other practitioner, and supplier identification numbers; and fee schedules and/or charges of physicia ns or other practitioners, or suppliers for services furnished to beneficiaries, to enable them to determine the amount of benefits payable for medical services furnished under Title XVIII and XIX.   As the individual title XIX programs of the several State s may differ, some variation in the type of information required can be expected.  Therefore, in order to obtain the information it needs, each State agency should consult with the title XVIII contractor(s) serving the various areas in each State concernin g the availability and format of the necessary information.  (CMS advises the appropriate State agencies of this arrangement.)   Contractor Involvement -   The contractor will normally receive the request of the State title XIX agency through the RO.   The con tractor will determine the amount of information it can furnish in accordance with the particular request. (See 10 ff of this chapter.)   The contractor will determine the charge and discuss it with the State agency. (See Medicare Carrier Manual, Part 1, 4602.6.)   If consultation or clarification of the data requested is needed, the contractor should make contact with the State agency through the RO or directly, as advised by the RO.   When all det ails are completed, the contractor should submit the requested information in final form to the RO for furnishing to the State agency.   100.5 - Electronic Reporting of Crossover Claims (Rev. 1, 09- 11-02)  Contractors may provide State Medicaid agencies wit h Medicare claims information.  See Pub 100- 04, Chapter 28 for more information.   110 - Disclosure to Peer Review Organizations (PROs)  (Rev. 1, 09- 11-02)  The CMS and/or A/B MACs (A) may furnish PROs information on claims specified by CMS for PRO review.   120 - Disclosure to the Internal Revenue Service (Contractors)  (Rev. 1, 09- 11-02)  The contractor may disclose information to the Internal Revenue Service when requested for investigation of a possible violation of the F.I.C.A., S.E.C.A., F.U.T.A., or any Federal income tax law.  The contractor will bring to the attention of the RO any problem in complying with the IRS request (e.g., machine capability, cost, etc.).   130 - Disclosure to the Office for the Civilian Health and Medical Program of the Uniformed  Services (TriCare) by Contractors  (Rev. 1, 09- 11-02)  130.1  General  (Rev. 1, 09- 11-02)  The CMS may disclose certain information to TriCare for use in administering the TriCare program.  The type of information to be made available parallels that made available to non- complementary title V and XIX State agencies and contractors.  (See 100  of this chapter.)   130.2 - Type of Information  (Rev. 1, 09- 11-02)  We expect that most requests from TriCare for information will involve primarily Part B Medicare operations in such areas as identification of physicians and other medical practitioners who may be engaging in providing excess services or fraud.  Before we release this information to a requ esting TriCare contractor that is not also a Medicare contractor, a Medicare contractor must have previously released the information in the administration of Title XVIII to:   An official of a medical or other applicable professional society or   An official  of a State licensing board, or   Any other officer, agency, establishment or department of the Federal Government charged with the duty of conducting an investigation to determine whether there has been a violation of any provision of Federal law (see 120  of this chapter).   We may also disclose to TriCare the types of data covered in 100.2 of this chapter, upon request when authorized by the beneficiary or the beneficiary's legal representat ive.  In addition, we will, upon request, make available to TriCare Economic Index Data (as prescribed by 405.502(a) and 405.504(a) of Regulations No. 5) that might affect the limits on prevailing charge levels.   130.3 - Procedures for Release  (Rev. 1, 09- 11-02)