(Medicare Claims Processing Manual)

If the provider/supplier requests a formal hearing (to be conducted by a member of the hearings staff of CMS) and the hearing officer reverses the revocation determination, the RO instructs the carrier and FI to pay the provider/supplier s assigned claims  (the physician component).  If the hearing officer upholds the revocation determination or if no request for a hearing is filed during the period allowed for this, the RO instructs the carrier and FI to make any assigned payments otherwise due the provide r to the beneficiary who received the services, or another person or agency authorized under the law and regulations to receive the payments (e.g., the beneficiarys legal guardian or representative payee or, if the beneficiary is deceased, the person who paid the bill).  The revocation remains in effect until the RO finds that the reason for the revocation has been removed and that there is reasonable assurance that it will not recur.  The RO decision to continue the revocation in effect may not be appeale d.  The law provides that any person who accepts assignment of benefits under Medicare and who knowingly, willfully, and repeatedly violates the assignment agreement shall be guilty of a misdemeanor and subject to a fine of not more than $2000 or imprisonment of not more than six months or both.  The RO may invoke the administrative sanction in appropriate cases to deny payment while criminal prosecution is being considered or in process, or, as an alternative, when prosecution is inappropriate or not feasibl e.  Since this sanction may in some cases interfere with effective prosecution, imposition of the sanction is discretionary rather than mandatory.   30.2.16 - Prohibition of Assignments by Beneficiaries  A3-3488.5, B3- 3060.15, B3- 7065 partial   A.  Basic Prohibition   Except as provided in subsection B, carriers pay only the beneficiary (or beneficiary legal representative or representative payee) benefits payable directly to the beneficiary FIs do not send money directly to beneficiaries, they must require providers they pay to refund monies to beneficiaries when circumstances so warrant (i.e., when a provider has collected money from a beneficiary for a demand -billed service that is later found to be covered by Medicare).  This prohibition does not, of course, apply to payment under an assignment of benefits by the beneficiary to the physician or other supplier who furnished the services or to a qualified reassignee, e.g., a hospital.  B.  Exceptions    Payment to a Government Agency.  The law does not preclude the Medicare program from paying the benefits due a beneficiary to a governmental agency or entity. However, see 30.2.1 for the effect of the requirements of the Assignment of Claims Act.    Payment Pursuant to Court Order.  The Medicare program may make payment of amounts due a beneficiary, in accordance with an assignment established by, or pursuant to the order of, a court of competent jurisdiction.  The assignment must satisfy the conditio ns in 30.2.   Payment to Agent.  The Medicare program may make payment in the name of the provider to an agent who furnishes billing or collection services.  The payment arrangement between the provider and an agent must meet the same requirements as the payment arrangement between a physician and an agent.  (See 30.2.4 for payment to an agent of a physician.)    Indirect Payment.  A carrier may make payment of amounts due a beneficiary to an entity which:   o Provides coverage of the service under a health benefits plan but only to the extent that payment is not made under Part B (i.e., the coverage which the plan provides is complementary to Medicare and covers only the amount by which the Part B payment falls short of the charge approved under the plan for the service);   o Pays the person who provided the service (or his/her reassignee under 30.2.6 -  30.2.8) an amount (including the Part B benefit) which that person accepts as full payment; or   o Has the written authorization of the beneficiary (or beneficiary representative) to receive the Part B payment.   30.3 - Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims (Rev. 1035, Issued: 08- 18-06, Effective: 07 -01-06, Implementation: 09- 18-06)  Institutional providers (those that bill Fiscal Intermediaries (FIs)) are paid direct by the FI. In contrast, physicians, practitioners, and suppliers that bill the carrier may choose to enter into a participation agreement.   Carrier Participating Providers are paid at 100 percent of the physician fee schedule and must accept assignment (must accept program payment as payment in full, except for any unmet deductible and coinsurance).  Non- participating providers are paid at 95 percent of the phys ician fee schedule and may accept assignment on a claim -by-claim basis.   Physicians and suppliers enrolled in the Medicare program under the Form CMS -855 process do not have to sign a Medicare Participating Physician or Supplier Agreement in order to bill Medicare and receive payment. However, there is a 5 percent reduction i n the Medicare approved amounts if the physician or his/her reassignee does not participate. Participation is an election that is optional to suppliers, even those that have to bill assigned.  Also, regardless of participation, some suppliers and practitioner types are required to accept assignment. This is covered in the instructions in later chapters for each service type.  30.3.1 - Mandatory Assignment on Carrier Claims  (Rev.  12448; Issued:01- 11-24; Effective: 01 -01-24; Implementation: 02- 12-24)  The following 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 amount as payment in full for their practitioner  services. The beneficiarys liability is limited to any applicable deductible plus the 20 percent coinsurance.   Assignment is mandated for the following claims:    Clinical diagnostic laboratory services and physician lab services;   Physician services to individuals dually entitled to Medicare and Medicaid;   Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors, registered dietitians/nutritionists, anesthesiologist assistants, and mass immunization roster billers.   NOTE:  The provider type Mass Immunization Roster Biller can only bill for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.    Ambulatory surgical center services; (No deductible and 25% coinsurance for colorectal cancer screening colonoscopies {G0105 and G0121) and effective for dates of service on or after January 1, 2008 G0104 also applies);    Home dialysis supplies and equipment paid under Method II for dates of service prior to January 1, 2011.  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;    Drugs and biologicals; and,    Ambulance services   When these claims are inadvertently submitted as unassigned, carriers process them as assigned.  Note that, unlike physicians, practitioners, or suppliers bound by a participation agreement, practitioners/entities providing the services/supplies identified above are required to accept assignment only with respect to these services/supplies (unless the y have signed participation agreements which blanket the full range of their services).   The carrier system must be able to identify (and update) the codes for those services subject to the assignment mandate.   For the practitioner services of physicians and independently practicing physical and occupational therapists, the acceptance of assignment is not mandatory. Nor is the acceptance of assignment mandatory for the suppliers of radiology services or diagnosti c tests. However, these practitioners and suppliers may nevertheless voluntarily agree to participate to take advantage of the higher payment rate, in which case the participation status makes assignment mandatory for the term of the agreement. Such an agr eement is known as the Medicare Participating Physician or Supplier Agreement. (See 30.3.12.2 Carrier Participation Agreement.) Physicians, practitioners, and suppliers who sign this agreement to participate are agreeing to accept assignment on all Medicare claims. The Medicare Participation Agreement and general instructions are on the CMS Web site.   Future updates to this section will be communicated in a Recurring Update Notification.    30.3.1.1 - Processing Claims for Services of Participating Physicians or Suppliers  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  The participating physician or supplier submits any claims for services furnished by the physician or supplier, except in the limited circumstances specified in 30.2.8.3 or 30.2.16.  (The exception concerns situations where the physician or supplier accepts, as full payment, payment by certain organizations.)  When an unassigned claim is received from a physician, the A/B MAC (B) must verify that the physician is participating.  The  contractor processes the claim as assigned absent clear evidence of intent by the physician or beneficiary not to assign.   Any Form CMS -1500 claim where the participating physician or supplier checks either the assignment or non- assignment block or fails to check either block, the A/B MAC (B) must treat it as assigned.   Where there is evidence of clear intent not to assign, the A/B MAC (B) must deny the claim.  Use MSN 16.6.  This item or service cannot be paid unless the provider accepts assignment.  In Spanish:   Este artculo o servicio no se pagar a menos de que el proveedor acepte asignacin.   A/B MAC (B) must identify and track assignment violations in the event sanctions must be imposed.  No Part B payment is made on a claim by a participating physician or supplier to anyone other than the physician or supplier (except in the case of court -ordered assignment to other parties under 30.2 ) even if the beneficiary has paid part of the bill.  However, if the physician or supplier collects any charges from the beneficiary before submitting the claim, he/she must show on the claim form the amount collected.  The carrier refunds directly to the  beneficiary, to the extent feasible, any over collection of deductible and coinsurance.  The physician is responsible for refunding to the beneficiary any over collection not refunded by the carrier directly.  In these latter instances, the carrier advise s the physician of his/her obligation to refund any over collections to the beneficiary.  Also, the carrier advises the beneficiary of the amount of any refund due from the physician.   30.3.2 - Nature and Effect of Assignment on Carrier Claims  (Rev. 643, Issued: 08- 12-05, Effective: 01 -01-05, Implementation: 11- 14-05)  Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare.  The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier.  The physician/supplier in return agrees to accept the Medicare all owed payment amount by the carrier as his/her full charge for the items or services.  A physician/supplier who agrees to accept assignment on all claims for Medicare services, rather than on a claim -by-claim basis is known as a participating physician/supplier.  See Publication 100- 4, chapter 1, sections 30.3 and 30.3.12.2 of the IOM.  In effect, the physician/supplier who accepts assignment on a claim -by-claim basis or who is a participating physician/supplier is precluded from charging the enrollee more t han the deductible and coinsurance based upon the approved payment amount determination.  If dissatisfied with the amount of the Medicare allowed amount, a physician/supplier may follow the procedures for appeals of contractor initial determinations.   In mandatory assignment situations, i.e., where payment under the Act can be made only on an assignment -related basis or where payment is for services furnished by a participating physician or supplier, the beneficiary (or the person authorized to reques t payment on the beneficiarys behalf) is not required to assign the claim to the physician or supplier in order for an assignment to be effective.  However, the beneficiary (or the person authorized to request payment on the beneficiarys behalf) must con tinue to authorize the release of medical or other information necessary to process the claim and request payment of Medicare benefits for the Medicare Part B covered services, equipment, or supplies pursuant to 42 C.F.R 424.32 and 424.36 (see also Pub. 100- 04, ch. 1, sect. 50.1).  Physicians or suppliers who agree to (or must by law) accept assignment from Medicare cannot attempt to collect more than the appropriate Medicare deductible and coinsurance amounts from the beneficiary, his/her other insurance, or anyone else.   In situations where mandatory assignment is not applicable and a nonparticipating physician or supplier indicates on the claim that he/she accepts assignment, but the beneficiary does not assign the claim to that nonparticipating physician/supplier -- payme nt must be made on an unassigned basis (i.e., directly to the beneficiary).