evekhm/cms_iom_500 huggingface dataset:
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Therefore, a participating physician or supplier (whether an ophthalmologist, optometrist, or optician) who accepts assignment on cataract glasses with deluxe frames may charge the Medicare patient the difference between his/her usual charge to private pay  patients for glasses with standard frames and his/her usual charge to such patients for glasses with deluxe frames, in addition to the applicable deductible and coinsurance on glasses with standard frames, if all of the following requirements are met:   A. The participating physician or supplier has standard frames available, offers them for sale to the patient, and issues and ABN to the patient that explains the price and other differences between standard and deluxe frames. Refer to Chapter 30.   B. The participating physician or supplier obtains from the patient (or his/her representative) and keeps on file the following signed and dated statement:   _____________________________________________  Name of Patient        Medicare beneficiary identifier  Having been informed that an extra charge is being made by the physician or supplier for deluxe frames, that this extra charge is not covered by Medicare, and that standard frames are available for purchase from the physician or supplier at no extra charge , I have chosen to purchase deluxe frames.   ___________________  Signature          Date   C. The participating physician or supplier itemizes on his/her claim his/her actual charge for the lenses, his/her actual charge for the standard frames, and his/her actual extra charge for the deluxe frames (charge differential).   Once the assigned claim for deluxe frames has been processed, the carrier will follow the ABN instructions as described in 60.  30.3.6 - Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers  (Rev. 1, 10- 01-03) B3-3045.5  A.  General
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A.  General   No payment may be made for clinical diagnostic laboratory tests furnished by a physician or medical group unless the physician or medical group accepts assignment or claims payment under the indirect payment procedure.  Carrier direct payment to a physicia n or group after the death of the beneficiary is considered assigned payment.  Assignment may be accepted for the entire claim.  See subsections B and C if a physician wishes to accept assignment only for laboratory services.   B.  Submission of Non -EMC Claims   A nonparticipating physician or medical group who furnishes clinical diagnostic laboratory tests and other services to a beneficiary and accepts assignment only for the laboratory tests may either submit a separate (assigned) claim for them or a single cla im that includes both the assigned tests and the other unassigned services.  In the latter event, the claim must be annotated as unassigned in block 26 of the Form CMS -1500 and a special request for payment for the assigned tests written in block 25, as fo llows:  I accept assignment for the clinical laboratory tests.  C.  Submission of EMC Claims   A nonparticipating EMC physician or medical group who furnishes clinical diagnostic laboratory tests and other services and accepts assignment only for the laboratory tests may either submit a separate (assigned) data set for the tests or a single data set  that includes both the assigned tests and the unassigned other services.  In the latter event, the data set must include the unassigned indicator.  The physician or group must have filed a blanket statement agreeing to accept assignment on all clinical di agnostic laboratory tests, not withstanding the inclusion of the unassigned indicator on electronic data sets.  D.  Processing Claims   Carriers process as assigned all claims for clinical diagnostic laboratory tests as described above, including those submitted by a participating or non- participating physician or group either marked as unassigned or with no assignment option specified.  W here, however, evidence clearly shows that the beneficiary or provider refuses to assign the claim, carriers should deny it. They split a claim containing assigned laboratory tests and other unassigned services.  E.  Public Information
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Carriers must inform all physicians and medical groups of this policy annually.  30.3.7 - Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti -Markup Payment Limitation - Claims Submitted to A/ B/MACs  (Rev. 10236, Issued: 07 -31-2020, Effective: 08 -31-2020, Implementation: 08- 31-2020)    A.  General   A physician or other supplier may bill and receive payment for the technical component (TC) or professional component (PC) of a diagnostic test (other than clinical diagnostic laboratory test) that is performed by a physician or other supplier with whom the billing physician or other supplier does not share a practice.  Reimbursement for that service is subject to the anti -markup payment limitation.  If a physician or other suppliers bill or a request for payment includes a charge for a diagnostic test (ot her than a clinical diagnostic laboratory test) which the physician or other supplier did not personally perform or supervise, then payment for the test may not exceed the lesser of:    The performing physicians net charge to the billing physician or other supplier (net any discounts);    The billing physicians actual charge; or    The fee schedule amount that would be allowed for the test if the performing physician or other supplier billed directly.   (See 30.2.9 of this chapter for additional information.)   For payment to be made, the physician who acquires the TC or PC of a diagnostic test from an outside source must identify the performing physician or other supplier on the claim.  (The billing physician or other supplier should maintain a record of the performing physician or other suppliers NPI in the clinical record for auditing purposes.)   The billing physician or other supplier must also indicate on the claim that the test is subject to the anti -markup payment limitation.
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The billing physician or other supplier must also indicate on the claim that the test is subject to the anti -markup payment limitation.   See the guidelines at the official Washington Publishing Company website for how to show this on electronic claims.  If using the CMS -1500 paper claim form:   In item 20 check "yes" to indicate the test is subject to the anti- markup payment limitation and enter the amount the performing physician or other supplier charged.   In item 32 enter the name, address, and NPI of the performing physician or supplier.  If the performing physician provides the service outside the A/B MAC (B) jurisdiction where the billing physician is located, the billing physician must submit its own NP I with the name, address, and ZIP code of the performing physician or other supplier.   No payment may be made to the physician without this information unless the statement No anti -markup tests are included is annotated on the claim.  NOTE:  If the billing physician performs only the TC or the PC and wants to bill for both components of the diagnostic test, the TC and PC must be reported as separate line items if billing electronically or on separate claims if billing on paper (CMS -1500).  Gl obal billing is not allowed unless the billing physician or other supplier performs both components.  Effective for claims submitted with a receipt date on and after October 1, 2015, 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) on anti-markup claims, even if the performing physician or supplier is enrolled in a different A/B MAC (B) jurisdiction.  (See 10.1.1.2 for more information regarding claims filing jurisdiction.)   B.  Unassigned Claims with Required Documentation  A physician or other supplier may not bill an individual an amount in excess of Medicares payment, except for any deductible and coinsurance, for the TC or PC of a diagnostic test that is subject to the anti- markup payment limitation.  A/B MACs (B) must notify physicians and other suppliers that they must indicate when a diagnostic test was acquired, identify the performing physician or other supplier, and show the amount the performing physician or other supplier charged.  The notification must inform physicians and other suppliers that they are prohibited by 1842(n)(3)
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of the Act from billing or collecting an amount in excess of Medicares payment, except for the deductible and coinsurance.  Excess amounts collected from the beneficiary must be repaid.   C.  Unassigned Claims without Required Documentation   A physician may not bill a beneficiary:   If the bill does not indicate who performed the test; and   If the bill indicates that a separate physician or other supplier performed the test, it does not identify the performing physician or other supplier or does not include the amount the performing physician or other supplier charged.  The A/B MACs (B) notify the physician when a non-assigned claim for the TC or PC of a diagnostic test subject to the anti- markup payment limitation is received from either the physician or a beneficiary except when the physician submits an assigned claim and the beneficiary submits an unassigned duplicate claim.  They use the following sample letter.  Dear Doctor:   We have received an unassigned claim for diagnostic tests furnished to the patient (Beneficiary Name), on (Date of Service).  You are prohibited by 1842(n)(3) of the Social Security Act from billing or collecting any amount unless you indicate that No anti-markup tests are included or, if the diagnostic test was acquired, you indicate who performed the test and what the physician or other supplier charged you.  Some or all of the required information is missing from your patients claim.  If you have collected any amount from your patient, it must be refunded.  This claim may be resubmitted if the required information is included.   D.  Beneficiary Information Regarding Unassigned Claims   The A/B MACs (B) must notify the beneficiary that the physician is prohibited from:    Billing the beneficiary when the necessary documentation is not supplied; and   Billing or collecting an amount in excess of Medicares payment, except for the deductible and coinsurance, when the required documentation is submitted.   (See chapter 21 of this manual, for MSN messages.)   30.3.8 - Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  B3-3045.7
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B3-3045.7  For services furnished prior to January 1, 2011, the DME MACs pay only on an assignment basis for home dialysis supplies and equipment furnished to a beneficiary who had selected Method II.   Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims. All home dialysis claims must be billed by an ESRD facility and paid to  the ESRD facility under the ESRD PPS.   Refer to chapter 8 and chapter 20 for more information.  30.3.9 - Filing Claims to a Carrier for Nonassigned Services  (Rev. 702, Issued:  10- 07-05; Effective/Implementation Dates:  N/A)   A  General   Payment for Part B services furnished by a physician (or supplier) is made:    To the beneficiary on the basis of an itemized bill (nonassigned claims); or    To the physician (or supplier) who provided covered services on the basis of an assignment of benefit payments where the approved charge is the full charge for the services.   NOTE:  For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and nonassigned Part B claims for beneficiaries.   B  Conflicting Claims   Carriers must establish controls to detect and prevent payment for assigned and unassigned claims received for the same service (as well as duplicate assigned or duplicate unassigned claims.  If an appropriate assigned claim is received after an unassigned claim has been paid, carriers do not pay the subsequent claims.  Where an enrollees claim based on an unpaid bill is received and benefits are payable, carriers make payment to him/her unles s there is some definite basis for believing that payment has been assigned, e.g., the physician or supplier is a participating provider or the bill from a nonparticipating physician or supplier shows that assignment may have been made.  Carriers are instructed to inform physicians that, if they wish to be sure of receiving Part B benefits, they should accept assignment at the time services are furnished and that their submission of claims to the carrier should not be unduly delayed.   30.3.10 - Carrier Submitted Bills by Beneficiary  (Rev. 1, 10- 01-03) B3-3040.1
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30.3.10 - Carrier Submitted Bills by Beneficiary  (Rev. 1, 10- 01-03) B3-3040.1  Carriers do not make payment for non- receipted itemized bills without a Form CMS -1490S claim form signed by either the patient or his/her representative.  Note that CMS does not accept beneficiary submitted claims for items subject to mandatory assignment.   They also do not accept them for blood glucose test strips effective April 1, 2002.  30.3.11 - Carrier Receipted Bill - Definition  (Rev. 1, 10- 01-03) B3-3040.2  A receipted bill is a written acknowledgment by a person or organization furnishing specified covered services, which states that payment has been made for all services on the bill.   Where a receipted bill is submitted, benefits for the services shown on the bill should not be paid to the physician (or his/her supplier) since there can be no assignment.  (See 20)
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Where a receipted bill is submitted, benefits for the services shown on the bill should not be paid to the physician (or his/her supplier) since there can be no assignment.  (See 20)   The bill itself bearing the words received payment, paid in full, paid, or a phrase with the same meaning, is the best evidence of payment if it is signed or initialed by the physician (or his/her employee, etc.) or by the person or organization furnishing supplies or services.  There will, however, be other evidence of payment that will be acceptable, such as machine -produced bills that clearly show the amount paid for each se rvice.  A rubber-stamp imprint on the bill which includes the name of the physician or other supplier is acceptable, absent a reason to question it.  It is also reasonable to accept, as evidence of payment, a cancelled check that is related in time and amo unt to a doctors, or other Part B suppliers bill.  A bill paid by promissory note is treated as a receipted bill unless the bill shows on its face that the note is not  given and accepted unconditionally as payment of the bill. For example, a bill marked paid by promissory note or $25 paid in cash, balance paid by promissory note is treated as a receipted bill.  On the other hand, a bill marked paid subject to payment on promissory note, or which otherwise clearly indicates that the promissory note was not unconditionally accepted in payment of it, i s not a receipted bill.   30.3.12 - Carrier Annual Participation Program  (Rev. 702, Issued:  10- 07-05; Effective/Implementation Dates:  N/A)   For providers (including physicians and suppliers) who have enrolled in Medicare, to sign a participation agreement (Form CMS-460) is to agree to accept assignment for all covered services that are provided to Medicare patients.  The benefits of signing a participation agreement include:   No 5 percent reduction in the Medicare approved amount.
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 Beneficiaries with Medigap coverage (private supplemental insurance) may assign the payment on the supplemental claim to the provider or supplier.  Under the current mandatory Medigap (claim- based) crossover process, beneficiaries must assign payment on their claims to a participating provider or supplier as a condition for their claims to be forwarded to their Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy.  The Medigap insurer, in turn, must pay the participating provider or supplier directly, thereby relieving the need of having to file a second claim.  (Refer to the Medicare Claims Processing Manual, Chapter 28, Section 70.6, for more information regarding the eligibility -file based crossover process.)   Listing in the Medicare Participation Physicians/Suppliers Directory (MEDPARD) that is posted on the carrier Web site.    Participants receive direct and timely reimbursement from Medicare.   Refer to 30.3.1 for processing instructions for claims for practitioner services inadvertently submitted as unassigned.  A  Eligibility   All practitioners and suppliers eligible to receive payments under Part B of Medicare may choose to enter into a participation agreement. This includes practitioners whose services are subject to mandatory assignment. The reason why it could still be appropriate for such practitioners to enter into a participation agreement is because the mandatory assignment provisions apply only to the particular practitioner service benefit (e.g., nurse practitioner services). Thus, for example, if a nurse practitioner i s eligible to bill for, and is indeed billing under, Part B for something other than a nurse practitioner service (e.g., an EKG tracing), the mandatory assignment provision of the law does not apply to that other service. However, if the nurse practitioner  has entered into a participation agreement, that agreement requires that the nurse practitioner accept assignment for any service for which he or she submits a Medicare Part B claim.   B  Participation Enrollment Period   Carriers conduct an enrollment period on an annual basis in order to provide eligible practitioners and suppliers with the opportunity to enroll in or terminate enrollment in the participation program. They are given specific instructions each year regardi ng the dates during which the enrollment period is in effect.   C  Circumstances in Which A Participating Physician or Supplier is Not Required to Accept Assignment for Covered Services
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C  Circumstances in Which A Participating Physician or Supplier is Not Required to Accept Assignment for Covered Services   A participating physician or supplier is not required to accept assignment for covered services when an entity (other than the beneficiary), which is eligible to request direct payment from the Medicare program for the services, pays the physician or suppl ier and the physician or supplier accepts that payment as full payment.  For example, a private supplementary health benefits plan may pay the physician or supplier an amount, which the physician or supplier accepts as payment in full and then collect the Part B payment directly from the Medicare program. This procedure, called  indirect payment or payment to organizations, permits a physician or supplier to submit a single claim for the Medicare and private plan benefits to the private health benefits plan. The physician or supplier may accept plan payment in excess of the Medic are approved charge.   The availability of this procedure depends on the extent to which health benefit plans are eligible and choose to use it. The indirect payment procedure is also available to nonparticipating physicians or suppliers.  D  Entities Eligible to Enter Into Agreement to Be Participating Physicians or Suppliers   Any person or organization that is authorized to accept assignment of Medicare benefits for covered services may enter into a participating physician agreement. This includes (but is not limited to):    Practitioners such as physicians, podiatrists, dentists, optometrists, and chiropractors;    Hospitals, medical groups, and other entities which are authorized to bill and to receive payment for physician services;    Organizations such as group practice prepayment plans, prepaid health plans, HMOs, and competitive medical plans which submit claims to Medicare carriers; and   Suppliers such as independent physical therapists, medical equipment supply companies, independent laboratories, ambulance services, and portable X -ray suppliers.  E  Applicable Rules When Physicians Work for a Hospital or Medical Group  The following rules apply when physicians work for (or are members of) a hospital, medical group, or other entity:    Except in the case of university medical centers, if a hospital, medical group, or other entity bills and receives payment for physician services in the name of the entity (rather than have the individual physicians bill and receive payment in their own na mes), one participation agreement by the entity binds all physicians with respect to any services furnished for the entity.  The individual physicians do not enter into participation agreements.
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NOTE:   In university medical centers, when individual departments bill under the name and provider identification number of the department, decisions for or against participation can be made on a departmental basis.   If a physician who is associated with a particular entity has an individual practice outside the scope of the practice for which the entity bills and receives payment, he or she may choose whether to participate with respect to his/her outside practice wit hout regard to the participation status of the entity.   If individual physicians who work for an entity bill and receive payment in their own names for the services furnished for the entity, they make individual decisions as to whether to participate. These decisions apply both to the physicians services for t he entity and to any outside practice.   F  Services Subject to Agreement   The participation agreement applies to items and services for which payment is made on a fee -for-service basis by Medicare Part B carriers. A participating agreement applies to all items and services in all localities and under all names and identification numbers under which the participant does business.  The participant lists all names and identification numbers under which the participant submits claims to the carrier. This includes all names and numbers of the legal entity entering into the agreement, whether that entity is a sole proprietorship, partner ship, or corporation.   If the participant opens offices in another carrier jurisdiction during the term of the agreement, he or she must file a photocopy of the agreement with that carrier.   G  Acknowledgment of Receipt   Carriers acknowledge receipt of an agreement by sending the physician or supplier a photocopy of the agreement, which has been annotated with the effective date.   H  Where to File Agreement   An agreement is valid if it is filed with any Medicare carrier in a timely manner.   A new participant must file an original agreement with the carrier in their region and a photocopy of the agreement by a date that CMS specifies on an annual basis with any other carriers which have assigned the participant a physician identification numbe r and to which the participant submits claims. When submitting a photocopy of the agreement to a carrier, the new participant must identify in the letter transmitting the photocopy all names and identification numbers under which the participant submits cl aims to that carrier and indicate the name of the carrier to which the original agreement was mailed or delivered and the date it was mailed or delivered.