(Medicare Claims Processing Manual)

In this chapter the terms IHS provider, IHS supplier and IHS physician or practitioner pertain to the following:   IHS provider refers to all hospital or hospital based- facilities, including outpatient clinics, unless otherwise noted.   IHS su pplier refers to a freestanding (non -hospital based) entity that furnishes durable medical equipment, prosthetics, orthotics, supplies (DMEPOS), and parenteral and enteral nutrition, unless otherwise noted.   IHS physician or practitioners refers to physician and non- physician practitioners billing for services under Medicare Part B.    NOTE:   The ISDEA promotes maximum Indian participation in the government and education of the Indian people; provides for the full participation of Indian tribes in certain pro grams and services conducted by the Federal Government for Indians and encourages the development of the human resources of the Indian people; established and carries out a national Indian education program; to encourage the establishment of local Indian s chool control; to train professionals in Indian education; and establishes an Indian youth intern program.   20 - MAC Designation  (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  The designated A/B MAC (A) and A/B MAC (B) enroll IHS operated facilities, process IHS institutional claims, IHS physician and practitioner claims for IHS or tribally owned facilities and hospitals. The designated A/B MAC (B) may also enroll tribally operated facilities and process the practitioner  claims for these facilities, if the tribally operated facility chooses. All A/B MACs (A) and (B) were notified of this selection.   Should other A/B MACs (A) or (B) receive misdirected enrollment requests or paper claims for IHS physicians or practitioners , they shall forward them to the designated A/B MAC (B). However, the A/B MACs (B) that have tribally operated practitioners currently enrolled with them may continue to service these practitioners. In addition, for all tribally operated facilities, includ ing Federally Qualified Health Centers (FQHCs) providing non-FQHC services, IHS physicians and practitioners may enroll with and submit bills to their local A/B MACs (B), if they choose. A/B MACs (B) shall service these  tribally operated facilities and the ir practitioners in accordance with their normal procedures. However , IHS operated facilities may only enroll with and submit bills to the designated A/B MAC (B). Tribally owned and operated facilities, while having a choice to bill their local A/B MAC (B)  or the designated A/B MAC (B), are prohibited from billing both entities.  See Chapter 1, 10.1.9 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on misdirected claims.   20.1 - Durable Medical Equipment Medicare Administrative Cont ractors (DME MAC) Designation  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  There are four DME MACs assigned to geographical regions. Jurisdiction for DME claims is based upon the permanent residence of the beneficiary, rega rdless of the location of the supplier submitting the claim. The IHS facilities shall enroll with the National Supplier Clearinghouse (NSC) to obtain a supplier number for billing DME to the assigned DME MAC. The four DME MACs are aware of the potential fo r enrollment from IHS facilities and have been informed of the IHS facilities unique requirements for payment of claims.   20.2 - Overview of Medicare Part B Services  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  Section 630 of the MMA, indefinitely extended by 2902 of the ACA, extended to IHS providers, suppliers, physicians and practitioners, independent ambulance suppliers, hospital based ambulance providers and clinical laboratory service suppliers the ability to bill for  all Medicare Part B covered services and items which were not covered under BIPA. This includes all screening and preventive services covered by Medicare. This chapter contains the effective dates for services implemented under 630 of the MMA and 2902 of the ACA.   Beginning January 1, 2005, IHS providers and suppliers may bill Medicare for the following Medicare Part B services:    DME;   Prosthetics and orthotics;   Prosthetic devices;   Surgical dressings, splints and casts;   Therapeutic shoes;   Drugs (A/B MAC a nd DME MAC drugs);   Clinical laboratory services;  Ambulance services; and   Screening and preventive services not already covered.   Payment is made on the AIR for IHS providers.  Payment is made on the appropriate fee schedule for IHS suppliers:    The Medicare Physician Fee Schedule (MPFS);   The Clinical Diagnostic Laboratory Fee Schedule;   The Ambulance Fee Schedule;   The DMEPOS Fee Schedule;   The Anesthesia Fee Schedule; or   DME MAC Drugs -  based on the average sales price (ASP).   The nature of the provider or s upplier, the location where the service is furnished and the service being rendered determines which MAC shall be billed. Most services that are paid under a fee schedule are billed to either the designated A/B MAC (B) or the (regional) DME MAC. Some fee s chedule paid services are billed to the designated A/B MAC (A). For example, physical therapy may be billed to the designated A/B MAC (B) by an independent practitioner, but is billed to the A/B MAC (A) when provided by a hospital outpatient department or by a hospital -based facility.   Refer to 80.3 of this chapter for more information on the claims processing jurisdiction for claims filed by IHS independent ambulance suppliers.  Refer to 80.7.1 of this chapter for more information on the claims processing jurisdiction for claims filed by freestanding facilities for clinical laboratory services.   Refer to 90.2.1 of this chapter for more information on the services billed to DME MAC.   Refer to 90.2.1.1 of this chapter for more information on the services billed to the A/B MAC (A).   Refer to Chapter 1, 10.1.9 of Pub. 100- 04, Medicare Claims Processing Manual, for information on misdirected claims.   30 - Medicare Part B Services  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  Effective July 1, 2001, 432 BIPA extended payment for the services of physician and non-physician practitioners furnished in hospitals and ambulatory care clinics (services paid under the MPFS, 1848 of the Act). Clinics associated with hospitals or which are freestanding that are owned and operated by IHS or tribally owned and IHS operated are considered to be IHS and are authorized to bill only the designated A/B MAC (B) for Medicare Part B (medical insurance) services identified in 432 of BIPA 2000. Ot her clinics associated with hospitals or which are freestanding that are not considered to be IHS (i.e., IHS owned but tribally operated or tribally owned and operated) can continue to bill the local A/B MAC (B) for the full range of covered Medicare servi ces, not restricted to the limitations of the BIPA provision.    Prior to enactment of 630 of the MMA of 2003, IHS facilities were not allowed to bill for Medicare Part B services, other than those paid under the MPFS, which were covered under 1848 of the Act. Section 630 of the MMA, indefinitely extended by 2902 of the ACA, expanded the scope of items and services for which payment may be made to IHS facilities to include all other Medicare Part B covered items and services beginning January 1, 2005.   40 - Provider Enrollment  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  40.1 - Provider Enrollment with A/B MAC (B)  (Rev. 1027, Issued: 08- 11-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The designated A/B MAC (B) shall designate a consistent method of labeling all IHS -related enrollment applications. For Form CMS -855B (11/01) submission, under item 2.A.1 Supplier Identification, check the Other box and manually indicate IHS, tribes or tribal organization on the line pr ovided.  The designated A/B MAC (B) shall follow these enrollment requirements:    All applications are subject to the same processing times as all other provider enrollment applications;   If a person or entity has been issued a Drug Enforcement Agency (DEA)  certification, submit a copy of the certification for the person and the entity. Continue to process these applications because these entities are owned by another governmental agency.  Obtain a copy of the DEA certification;    All IHS entities may not have an actual street address. Continue to process these applications because these entities are owned by another governmental agency.  In addition, obtain directions to the location of the entity and/or other descriptions, leading to the location.   The fo llowing conditions must be met when the IHS computer generated enrollment form is utilized:    All pages of the submitted computer generated Form CMS -855 must display the official watermark date;    Accept these applications in hard copy only, no electronic copies;    Accept only completed applications and not fragments or pieces of an application;    The IHS generated Form CMS -855 will only be accepted by the designated A/B MAC (B) for the purposes of enrolling IHS physicians and practitioners for Medicare Part B payment.   As of October 1, 2002, only the 11/01 version of the Form CMS -855 will be accepted.  Any electronic generated forms will have to be generated from the CMS Provider Enrollment Web site. Any other enrollment forms submitted by IHS, tribes or trib al organizations after October 1, 2002, will be returned to the provider. The provider will then have to complete a new Form CMS -855 and submit to the designated A/B MAC (B) in order to enroll.   Instructions for completing the Form CMS -855S, DMEPOS Supplie r Application, can be found in Pub. 100- 08, Medicare Program Integrity Manual, Chapter 10. For more information on the Form CMS -855S, see 40.3 of this chapter.   40.1.1 - Entities  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  In order to enroll IHS clinics that are currently provider -based (and use the hospitals tax identification number (TIN)) and that wish to bill the designated Medicare Part B A/B MAC (B), the hospital must complete a Form CMS -855B and enroll as a group .  Each clinic would be reflected on the Form CMS -855 as a practice location. The doing business as name of the clinic could be reflected on the Form CMS -855, if appropriate. Provider identification numbers (PINs) and pay -to addresses must then be issued for each practice.  However, the payment would be made to the hospital.  Any clinic that bills as freestanding should submit a new and separate Form CMS -855B for just the freestanding clinic (see exception for physical/occupational therapist under Reassig nment in 40.1.4). The processing of these applications should be in accordance with the designated A/B MAC (B)s regular review and verification procedures. A separate Medicare number will be issued to the freestanding clinic.   NOTE : Tribally operated ambulatory care clinics, including those that are participating as FQHCs, are entitled to enroll their physicians and non- physician practitioners with the applicable A/B MAC (B) like any other Medicare provider.  Although FQHCs are paid on a cost basis for the professional services of physicians and practitioners, the FQHC benefit does not cover and pay for clinical laboratory and diagnostic tests. Consequently, the tribal health center can remain an FQHC and still bill their A/B MAC (B) for laboratory and diagnostic tests.  40.1.2 - Individual Practitioners  (Rev. 1643, Issued: 12- 05-08, Effective: 01- 01-07, Implementation: 03- 09-09)