(Medicare Claims Processing Manual)

The participating enrollment package is included with the CMS -855 form for new enrollees.  Carriers must furnish a special participating agreement form for new physicians or suppliers upon request or at the time you assign the new physician or supplier an identification number.   When the agreement is filed on one of the above bases, it is effective on the date of filing, i.e., the date the participant mails (postmark date) the agreement to the carrier or delivers it to the carrier. The initial period of the agreement may be less than 12 months. Otherwise, the terms of the agreement are the same as those of an agreement entered into by other physicians or suppliers. The agreement applies to all services in all localities. The physician or supplier must submit the original agreement to the carrier in their region and photocopies to all carriers with whom he or she deals.   If a physician or supplier first enters into an agreement after publication of your directory, his or her name is not included in the directory until subsequent publication. This may not occur until the next annual publication date. Carriers must make the names of those physicians or suppliers entering into agreements after the initial deadline available on the toll free telephone lines as each physician or supplier enters int o an agreement.   Note that for DMEPOS suppliers, the NSC handles the participation agreements.  30.3.12.1 - Annual Open Participation Enrollment Process  (Rev.  12448; Issued:01- 11-24; Effective: 01 -01-24; Implementation: 02- 12-24)  A.  Participation Period   The annual physician and supplier participation period begins January 1 of each year, and runs through December 31. The annual participation enrollment is scheduled to begin on November 15 of each year. Carriers will receive the participation enrollment ma terial under separate cover.   NOTE:   The dates listed for release of the participation enrollment/fee disclosure material are subject to publication of the Final Rule.   B.  Participation Enrollment and Fee Disclosure Process Background   Every year, contractors conduct an open participation enrollment period in order to provide eligible physicians, practitioners and suppliers with an opportunity to make their calendar year Medicare participation decision. The open enrollment period runs fr om November 15 to December 31.   Until 2004, the Medicare contractors mailed each provider a hardcopy package which included enrollment materials, a paper copy of the Medicare Physician Fee Schedule (MPFS), an Announcement document, the Medicare Participating Physician or Supplier Agreement (Form CMS -460), and a variety of provider education material about the Medicare program. Beginning with the 2005 mailing, CMS directed Medicare contractors to begin using a CD for the participation mailing because it was less expensive than mailing the hardcopy materials.  Beginning with the 2006 mailing, contractors placed the new Medicare fees on their Web sites and did not include the fees on the CDs due to frequent last minute changes to the MPFS.  Removing the Medicare fees from the CD provided greater flexibility for updates late in the year due to legislative changes or CMS payment policy decisions.  Since the fee schedules are no longer included on the CD, and the educational materials, as well as the Form CMS -460, are also posted on contractors Web sites, the value of the CD to the provider community has diminished.  Beginning 2011, CMS is directing contactors to produce a postcard mailing, instead of a CD, for eligible physicians, practitioners and suppliers.   B1. Postcard Mailing  No later than October 31st of each year, beginning in 2011, contactors should produce a postcard for the annual open participation enrollment period. Providers that do not have access to the internet must be educated to contact their local contractors to request a hard copy disclosure package. The annual post card will remind the Medicare health professional community to view their local contractors Web site regarding information for the upcoming open participation enrollment period. The postcard also will  remind health professionals that the new MPFS update is posted on their local contractors Web site.  Carriers/MACs must annotate the postcard with the following message:   Medicare Participating Provider Program   <Insert Upcoming Year> Participation Enrollment and Fee Disclosure Information  This is a reminder that the <insert upcoming year> Annual Participation Open Enrollment Period is approaching.  The open enrollment period runs mid- November through December 31.  Refer to your local Medicare contractors Web site at <insert the Medicare P articipating Provider Web site> to obtain more specific information about the Annual Participation Open Enrollment Period.  Medicare Physician Fee Schedule for services rendered during <insert upcoming year> are also posted on your local Medicare contract ors Web site.   If you do not have internet access, contact your local Medicare Contractor at <insert contractors toll free number>to request a hardcopy Participation Enrollment and Information Package which includes the new Medicare fees.   The carrier/MAC mails the participation enrollment postcard and/or hardcopy fee disclosure packages via first class or equivalent delivery service, and schedules the release of material so that providers receive it no later than the date provided in the annual participation enrollment instruction.   B2. Web site   Each October, carriers/MACs should post a notice on their Web site regarding the upcoming participation enrollment period reminding physicians and practitioners that the upcoming MPFS will be published on the carriers/MACs Web site after the physician fee schedule regulation is put on display.  Carriers/MACs must assure providers have access to specific information about the Annual Participation Open Enrollment Period via a single page on their Web site. Carriers/MACs must include the following information and/or links to following on this page: the Annual Announcement, the Medicare Participating Agreement (Form CMS -460), the Medicare Physician Fee Schedule Fee Disclosure, detailed  instructions for submitting the participation enrollment forms or disenrollment requests , and any supplemental educational information you see fit. Carriers /MACs  need to include information regarding whom the provider can contact if assistance is required. Also, CMS may instruct all carriers/MACs to include a specific item(s) as part of the additional supplemental material on their Web site. ( EXAMPLE:   A note from the administrator, a special file, etc.)   Carriers/MACs must place the new fees and the anesthesia conversion factor(s) on their Web site after the final rule is placed on display.  The CMS transmits the Medicare Physician Fee Schedule Database electronically to carriers/MACs each year around late-October.  CMS notifies the carrier/MACs that the annual MPFS files, including anesthesia, are available in an email notification.  The email notification also contains the file names.   The CMS will furnish carriers/MACs, via a separate instruction, with the participation materials used for the annual participation open enrollment period, including the Announcement, which shall be displayed on contractors Web site.  Carriers/MACs must mail a postcard reminding providers to look at the contractors Web site for information regarding the annual open participation enrollment period.  B3. Physicians/Practitioners/Suppliers  The postcards are sent to the following physicians and suppliers in accordance with the following guidelines no later than November 15 of each year, subject to the publication of the Final Rule:    All physician specialties included in the 01- 99 specialty range;    Independently practicing occupational and physical therapists (specialty 65 and 67);   Suppliers of diagnostic tests;    Suppliers of radiology services (including portable x- ray suppliers -specialty 63);    Multi- specialty clinics (specialty 70);    Independent laboratories (specialty 69- since they can typically bill for anatomic pathology services paid under the Physician Fee Schedule);    Mammography Screening Centers (specialty 45);    Independent Diagnostic Testing Facilities (specialty 47);    Audiologists (specialty 64); and    Independently Billing Psychologists (specialty 62).  NOTE:  Chiropractors and Mammography Screening Centers do not need to view the entire locality fee schedule report.  Therefore, carriers/MACs may add separate headings on their Web site listing the fee data for the procedure codes that they may receive payment.  Carriers/MACs send an annual participation announcement and a blank participation agreement to the following non- participating suppliers:   Ambulatory Surgical Centers (ASCs) (specialty 49); (Although ASCs must accept assignment for ASC facility services, they may also provide and bill for non-ASC facility services, which do not have to be billed as assigned and which are therefore subject to a participation election); and,    Supplier specialties other than 51- 58; (Supplier specialties 51- 58 will receive a separate enrollment package from the National Supplier Clearinghouse).   Carriers/MACs may create hard copy fee disclosure reports and send them to specialty 49, and supplier specialties other than 51- 58, if cost effective to do so (e.g., carriers determine that fee disclosure to suppliers will reduce the number of more costly supplier inquiries 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 supplier fee disclosure, carriers include a disclaim er advising the supplier that the non- participating fee schedule amounts and limiting charges do not apply to services or supplies unless they are paid for under the Physician Fee Schedule. If carriers elect not to routinely disclose supplier fees with the ir participation enrollment packages, they must furnish suppliers with their applicable fee schedules or reasonable charge screens upon request.  Instructions for completing the enrollment process for non- durable medical equipment, prosthetic, orthotic, and supplies (DMEPOS) suppliers will be issued under separate cover.  Those instructions will address the responsibilities of durable medical equipm ent regional carriers (DMERCs) and the National Supplier Clearinghouse.   C.  Minimum Requirements for Disclosure Reports for Posting on the Web and Hard Copies   Carriers must place the following information on the web sites and also in their hard copy disclosure reports.    Carriers must use valid CPT and HCPCS codes for creating disclosure reports for physician fee schedule services when posting this information on the web.  CMS provides carriers with complete locality data for all procedure codes with a status indicator of A, T, and R (for which CMS has established the RVUs) on the Medicare Physician Fee Schedule Database (MPFSDB).  Included on the MPFSDB are payments for the technical portion of certain diagnostic imaging services (including the technical portion of global imaging services) that are capped at the Outpatient Prospective Payment System (OPPS) amount. Limiting charges are included on the annual disclosure reports of providers who may be subject to the nonparti cipant fee schedule amount, if they elect not to participate for a calendar year. The limiting charge equals 115 percent of the nonparticipant fee schedule amount.   For the facility setting differential, the limiting charge is 115 percent of the nonparticipant fee for the differential amount.  The data for Locality Fee Schedule Reports are:    --Header Information  Locality identification (on each report page);    --Procedure Codes  Carriers must array all codes paid under the Physician Fee Schedule.  They include global, professional component and technical component entries where applicable:    --Par Amount (nonfacility);    --Par Amount (facility based);    --Non -par Amount (nonfacility);    --Limiting Charge (nonfacility):   --Non -par Amount (facility based); and    --Limiting Charge (facility based);    --Footer Information  The following must be included on the fee disclosure reports:    1.  The legend:  All Current Procedural Terminology (CPT) codes and descriptors are copyrighted (appropriate year) by the American Medical Association (on each report page).    NOTE:   The CMS has signed agreements with the American Medical Association regarding the use of CPT, and with the American Dental Association regarding the use of CDT, on Medicare contractor Web sites, bulletin boards and other contractor electronic communicati ons.  If the carrier uses descriptors, it must use short descriptors.  The appropriate CPT copyright year must be inserted each year.  For example:  the 2006 CPT is copyrighted 2005; the 2007 CPT is copyrighted 2006; in each case, the appropriate yea r for the copyright is inserted by the contractor.   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.