evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
An employer may establish that it qualifies to receive payment for the services of its physicians by submitting the Form CMS -855R.  The employer must provide evidence that the employee is a valid employee by providing the carrier with a Form W- 2 or other acceptable Internal Revenue Service documentation (a pay stub would suffice for new employees who do not yet have a Form W -2.).  30.2.7 - Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only  (Rev. 472, Issued:  02- 11-05, Effective:  01 -01-05, Implementation:  03- 15-05)  A carrier may make payment to an entity (i.e., a person, group, or facility) enrolled in the Medicare program that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished.  Thus, the service may be furnished on or off the pre mises of the entity submitting the bill and receiving payment.  The entity receiving payment and the physician or other person that furnished the service are both subject to the following program integrity safeguard requirements:   1. The entity receiving payment and the person that furnished the service are jointly and severally responsible for any Medicare overpayment to that entity; and,  2. The person furnishing the service has unrestricted access to claims submitted by an entity for services provided by that person.   30.2.8.2 - University -Affiliated Medical Faculty Practice Plans  - Claims Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3060.3.D   A carrier may make Part B payment to a university -affiliated medical faculty practice plan that has the following attributes:   There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.    The Medical Faculty Practice Plan is a 501(c)(3) nonprofit tax- exempt organization, according to IRS regulations.   Physicians of the faculty practice plan are employees of the University and/or medical school.  The plan should furnish a copy of the employment agreement(s) between the faculty physician and the University.   Physicians are full or part -time faculty members of the Universitys School of Medicine, licensed to practice medicine in the State.
(Medicare Claims Processing Manual)
 Physicians are full or part -time faculty members of the Universitys School of Medicine, licensed to practice medicine in the State.    The faculty practice plan may only be affiliated with one University, and this relationship is described in the written agreement between the University and the Medical Faculty Practice Plan.    Members of the faculty practice plan are represented on the Governing Board of the practice plan.  The Board has the authority to make or delegate management and operational decisions on behalf of the physicians participating in the practice plan.   Faculty practice plan physicians have unrestricted access to the billing records, medical documentation, and claims forms for services submitted on their behalf by the practice plan. The faculty practice plan provides documentation establishing the existen ce of this policy.   The physicians abide by the rules and regulations of the Medical Faculty Practice Plan.    The faculty practice plan is accountable to Medicare for any claims that are submitted on behalf of the plans physicians for services provided to Medicare beneficiaries.  Thus, the plan is responsible for refunding any overpayments to Medicare that are co llected on behalf of the plans physicians.  Both the Medical Faculty Practice Plan and the plans physicians must enroll in the Medicare program by completing the Form CMS -855B and Form CMS -855R (Medicare health care provider/supplier enrollment application forms).  Instructions for processing Form CMS -855B are referenced in Program Integrity Manual.  For those entities that are part of the organizational structure of the University, see 30.2.12, on payment to special accounts.  These entities may include departments, specialties, practice plans, or similar subdivisions of a university or medical school.  30.2.8.3 - Indirect Payment Procedure (IPP) -  Payment to Entities that Provide Coverage Complementary to Medicare Part B  (Rev. 2896, Issued: 03- 07-14, Effective: 06 -06-14, Implementation: 06- 06-14)  Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee -for-service basis may be paid to an entity using the indirect payment procedure (IPP).  Any entity registered in accordance with the  instructions in Pub. 100- 08, chapter 15, sections 15.7.9 through 15.7.9.7 and meets the following requirements can bill using the IPP:
(Medicare Claims Processing Manual)
 Provides coverage of the service under a complementary health benefit plan (this is, the coverage that the plan provides is complementary to Medicare and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan).   Has paid the person who provided the service an amount (including the amount payable under the Medicare program) that the person accepts as full payment.   Has the written authorization of the beneficiary (or of a person authorized to sign claims on the beneficiarys behalf under 42 C.F.R. 424.36) to receive the Part B payment for the services for which the entity pays.   Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, his or her survivors, or estate.    Submits any information CMS or the contractor may request, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program.    Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer.   Entities that satisfy all of the requirements above may include employers, unions, insurance companies, and retirement homes.  They also may include health care prepayment plans, health maintenance organizations (HMOs), competitive medical plans, and Medic are Advantage organizations.  The IPP permits a physician or supplier to file a single claim with the complementary insurer and receive full payment in a single payment, relieves the beneficiary of the need to file a claim, and protects the beneficiary against any financial liability for the service.   Because section 1842(h)(1) of the Social Security Act only permits physicians and suppliers to enter into participation agreements and because IPP entities do not meet the definition of a supplier as described in 42 C.F.R. 400.202, IPP entities cannot  enter into a participation agreement (Form CMS -460) with Medicare.  Therefore, IPP claims are paid at the non -participating physician/supplier rate, which is 95% of the physician fee schedule amount.
(Medicare Claims Processing Manual)
Payment under the IPP can only be made for covered Part B services.  If an IPP entity submits a claim for a beneficiarys service that has already been billed to Medicare (for example, the claim was submitted by a physician before the IPP entity submitted its claim), then Medicare cannot make payment to the IPP entity for that same service.  Conversely, if a physician or supplier submits a claim for a beneficiarys service that has already been billed to Medicare (for example, the claim was submitted by an IPP entity before the physician submitted his/her claim), then Medicare cannot make payment to the physician for that same service.  Medicare payment can only be made once for a beneficiarys specific service.  Therefore, claims for services that have alre ady been billed to Medicare shall be denied (with appeal rights) by Medicares contractors.    In addition, Medicare payment cannot be made under the IPP for services that are payable for a particular beneficiary under any other Part of Medicare.  For example, if a beneficiarys service is payable under Part C and a Medicare Advantage organization i s also an IPP entity under 42 C.F.R. 424.66, then a Medicare Part B payment under the IPP cannot be made to that Medicare Advantage organization for that beneficiarys service.  In these types of dual or multiple enrollment situations, services that are p ayable under those other Parts of Medicare (e.g., Parts C or D) cannot also be billed and paid for under Part B.  Therefore, IPP entities that submit Part B claims for services that are payable under another Part of Medicare (e.g., Part C or D) shall be denied (with appeal rights) by Medicares contractors.
(Medicare Claims Processing Manual)
Payment for IPP claims by Medicare is conditioned upon the claim and the underlying transaction complying with the Medicare laws, regulations, and program instructions applicable to IPP entities, and on the IPP entitys continued compliance with the regulatory requirements described in 42 C.F.R. 424.66.  30.2.9 Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti -Markup Payment Limitation - Claims Submitted to A/B MACs (Part B)  (Rev.  4473, Issued: 12-6- 19; Effective: 3 -9-20; Implementation: 3 -9-20)  A physician or other supplier may bill for the technical component and/or professional component of a diagnostic test that was ordered by the physician or other supplier (or ordered by a party related to the billing physician or other supplier through common ownership or control), subject to an anti -markup payment limitation, if the diagnostic test is performed by a physician who does not share a practice with the billing physician or other supplier.  (This claim and payment limitation does not apply to clinical diagnostic laboratory tests, which are paid under the Clinical Laboratory Fee Schedule.)  Under the anti-markup payment limitation, payment to the billing physician or other supplier (less the deductibles and coinsurance paid by the beneficiary or on behalf of the beneficiary) for the t echnical component or professional component of the diagnostic test may not exceed the lowest of the following amounts:  (1) The performing physician/suppliers net charge to the billing physician or other supplier.* (With respect to the technical component, the performing supplier is the physician who supervised the test, and with respect to the professional component, the performing supplier is the physician who performed the professional component;  (2) The billing physician or other suppliers actual charge; and  (3) The fee schedule amount for the test that would be allowed if the performing physician or other supplier billed directly.  (See section 10.1.1.2 for information on payment jurisdiction for services subject to the anti- markup payment limitation.)   * The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing supplier by or through the billing physician or other supplier.  Exception to the Anti -markup Payment Limitation
(Medicare Claims Processing Manual)
* The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing supplier by or through the billing physician or other supplier.  Exception to the Anti -markup Payment Limitation  If the performing physician is deemed to share a practice with the billing physician or other supplier (who ordered the test), the anti-markup payment limitation does not apply.  A performing physician is considered to share a practice with the billing physician or other supplier if the performing physician furnishes substantially all (at least 75 percent) of his or her professional services through the billing physician or other supplier.  The substantially all services requirement will be satisfied, if, at the time the billing physician or other supplier submits a claim for a service furnished by the performing physician, the billing physician or other supplier has a reasonable belief that:  (1) for the 12 months prior to and including the month in which the service was performed, the performing physician furnished substantially all of his or her professional services through the billing physician or other supplier; or (2) the performing physician will furnish substantially all of his or her professional services through the billing physician or other supplier for the next 12 months (including the month in which the service is performed).
(Medicare Claims Processing Manual)
If the performing physician does not meet the substantially all services test, the performing physician may be deemed to share a practice with the billing physician or other supplier if the arrangement complies with a site of service/same building te st.  This alternative approach requires the performing physician to be an owner, employer, or independent contractor of the billing physician or other supplier and requires that the technical component or professional component be performed in the office of the billing physician or other supplier.  The office of the billing physician or other supplier is any medical office space, regardless of the number of locations, in which the ordering physician or other supplier regularly furnishes patient care, and includes space where the billing physician or other supplier furnishes diagnostic testing services, if the space is located in the same building (as defined in 42 CFR 411.351 of the physician self-referral rules) in which the ordering physician or other ordering supplier regularly furnishes patient care.  With respect to a billing physician or other supplier that is a physician organization (as defined in 42 CFR 411.351 of the physician self- referral rules), the office of the billing physician or other supplier is space in which the ordering physician provides substantially the full range of patient care services the ordering physician provides generally.  The performance of the technical component includes, both, the conducting of the technical component as well as the supervision of the technical component.   The billing physician or other supplier must keep on file the name, the National Provider Identifier, and address of the performing physician.  The physician or other supplier furnishing the technical component or professional component of the diagnostic t est must be enrolled in the Medicare program.  No formal reassignment is necessary .  NOTE:   When billing for the technical component or professional component of a diagnostic test (other than a clinical diagnostic laboratory test) that is performed by another physician, the billing entity must indicate the name, address and NPI of the performin g physician or other supplier in Item32 of the Form CMS-1500 claim form.
(Medicare Claims Processing Manual)
Effective for claims submitted with a receipt date on and after October 1, 2015, for reference laboratory and anti-markup claims, the billing physician or supplier must report the name, address, and NPI of the performing physician or supplier in Item 32a of the CMS -1500 claim form (or its electronic equivalent), even if the performing physician or supplier is enrolled in a different A/B MAC (Part B) jurisdiction.  See 10.1.1.2 for more information regarding claims filing jurisdiction.   If the billing physician or other supplier performs only the technical component or the professional component and wants to bill for both components of the diagnostic test, the TC modifier and 26 modifier must be reported as separate line items if billing electronically (ASC X12 837 professional claim) or on separate claims if billing on paper (Form CMS -1500).  Global billing is not allowed unless the billing physician or other supplier performs both components.  Effective for claims received on or after April 1, 2004:   In order to have appropriate service facility location ZIP code and the acquired price of each test on the claim, when billing for anti -markup tests on the Form CMS -1500 paper claim form each test must be submitted on a separate claim form. Treat paper claims submitted with more than one anti -markup test as unprocessable per 80.3.2.  More than one anti -markup test may be billed on the ASC X12 837 professional claim format. When more than one test is billed, the total acquired amount must be submitted for each service. Treat claims received with multiple anti -markup tests without line l evel total acquired amount information as unprocessable per 80.3.2.
(Medicare Claims Processing Manual)
Treat paper claims submitted for anti -markup tests with both the technical component and the professional component on one claim as unprocessable per 80.3.2 unless the services are submitted with the same date of service and same place of service codes. When a claim is received that includes both services, and the date of service and place of service codes match, assume that the one address in Item 32 applies to both services. Effective for claims with dates of service on or after April 1, 2005, each component of the test must be submitted on a separate claim form. Treat paper claims with dates of service after March 31, 2005 submitted with more than one anti -markup test as unprocessable per 80.3.2.  ASC X12 837 professional electronic claims submitted for anti -markup tests with both the technical component and professional component on the same claim must be accepted. Assume that the claim level service facility location information applies to both services if line level information is not provided.  In order to price claims correctly and apply anti -markup payment limitations, global billing is not acceptable for claims received on the Form CMS -1500 or on the ASC X12 837 professional claim format. Each component must be billed as a separate line item ( or on a separate claim per the limitations described above). Treat the claim as unprocessable per 80.3.2 when a global billing is received and there is information on the claim that indicates the test was acquired.
(Medicare Claims Processing Manual)
Effective for claims with dates of service on or after January 25, 2005, A/B MAC (Part B) must accept and process claims for diagnostic tests subject to the anti- markup payment limitation when billed by suppliers (including laboratories, physicians, and independent diagnostic testing facilities [IDTFs]) enrolled in the A/B MAC (Part B) jurisdiction, regardless of the location where the service was furnished. Effective Apr il 1, 2005, A/B MAC (Part B) must price anti -markup test claims based on the ZIP code of the location where the service was rendered when billed by a laboratory or an IDTF, using a CMS -supplied national abstract file of the MPFS containing the HCPCS codes that are payable under the MPFS as either a technical component or professional component of a diagnostic test subject to the anti- markup payment limitation for the calendar year. Effective for claims with dates of service on or after October 1, 2007 throu gh 2013, A/B MAC (Part B) must use the national abstract file to price all claims for diagnostic tests subject to an anti -markup payment limitation, for all supplier specialty types (including physicians), based on the ZIP code of the location where the se rvice was rendered, in accordance with the A/B MAC (Part B) jurisdictional pricing rules specified in 10.1.1.  Beginning in 2014, A/B MAC (Part B) must refer to an Anti -markup Test Indicator linked to the HCPCS code on the MPFS to price all claims for dia gnostic tests subject to an anti -markup payment limitation, for all supplier specialty types (including physicians), based on the ZIP code of the location where the service was rendered, in accordance with the A/B MAC (Part B) jurisdictional pricing rules specified in 10.1.1.   NOTE: As with all services payable under the MPFS, the ZIP code is used to determine the appropriate payment locality and corresponding fee for the anti -markup test.  When a ZIP code crosses locality lines, CMS uses the dominant locality to determine the corresp onding fee.  lines, CMS uses the dominant locality to determine the corresponding fee.   30.2.10 - Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACS Part B
(Medicare Claims Processing Manual)
30.2.10 - Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACS Part B   (Rev.  3774, 05- 12-17, Effective: 06- 13-17, Implementation: 06- 13-17)  A. General requirements applicable to all Reciprocal Billing Arrangements   Under section 16006 of the 21st Century Cures Act, a Medicare- enrolled physical therapist may use a substitute physical therapist to furnish outpatient physical therapy services in a HPSA, a MUA, or a rural area under a reciprocal billing arrangement on or after June 13, 2017.   The patients regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis, if:    The regular physician or physical therapist is unavailable to provide the services;      The Medicare patient has arranged or seeks to receive the services from the regular physician or physical therapist;    The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days subject to the following exception: A physician or physical therapist called to active duty in the Armed Forces may bill for services furnished under a reciprocal billing arrangement for longer than the 60- day limit; and    The regular physician or physical therapist indicates that the services were provided by a substitute physician or physical therapist under a reciprocal billing arrangement meeting the requirements of this section by entering in item 24d of Form CMS -1500 H CPCS code Q5 modifier (service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area) after the procedure code.  The regular physician or physical therapist must keep on file a record of each service provided by the substitute physician or physical therapist along with the substitute physician or physical therapists NPI, and make this record available to the A/B MAC Part B upon request.