evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
10 - General  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  The Indian Health Service (IHS) is the primary health care provider to the American Indian/Alaska Native (AI/AN) Medicare population. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventi ve health services to its beneficiaries, via a network of hospitals, clinics, and other entities. While 1814(c) and 1835(d) of the Social Security Act (the Act), as amended, generally prohibit payment to any Federal agency, an exception is provided for I HS/Tribally owned and operated facilities under 1880. The enactment of Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA), expanded payment for Medicare services provided in IHS /tribally owned and operated facilities beyond services provided in hospitals, skilled nursing facilities (SNFs) and swing -bed facilities.
(Medicare Claims Processing Manual)
Effective January 1, 2005, 630 of the Medicare Modernization ACT (MMA), extended to IHS facilities the ability to b ill for all Medicare Part B covered services and items that were not covered under BIPA. This includes all screening and preventive services covered by Medicare.  Section 2902 of the Patient Protection and Affordable Care Act (ACA) indefinitely extends 630 of the MMA, retroactive to January 1, 2010.  Tribally owned and operated facilities may choose to bill the Medicare program in one of two ways. First, these tribally owned and operated facilities are authorized to enroll or become certified to participate in the Medicare program as any other provider/supplier of Medicare services. Depending upon the type of supplier/provider, these entities file claims with the MAC for the type of service and which serves the specific geographic region where the facility is located.  They follow the same coverage and claims filing requirements as any other regular Medicare provider/supplier. On the other hand, since tribally owned and operated facilities are covered under the Indian Self Determination and Education Assista nce Act (ISDEA), P.L.93- 638 [25 U.S.C. 450 et seq.] (commonly referred to as 638), this affords them the option of electing the same billing rights as facilities run by the IHS. Tribally owned and operated facilities choosing this option file claims with  the designated MAC used for processing IHS claims instead of with the MAC serving the specific geographic region where the facility is located. Because many tribally owned and operated facilities elect to file claims with the Medicare contractors designat ed for IHS, many tribal facilities not actually run by IHS are considered to be IHS for Medicare billing purposes. Unless otherwise specified, any references in this chapter to IHS providers, IHS suppliers or IHS physicians or practitioners includes:  (1) tribally owned and operated facilities electing to bill as IHS; (2) tribally operated IHS facilities; (3) IHS owned and operated facilities; (4) tribally owned and IHS operated facilities.  Tribally owned and operated facilities electing to bill the MAC serving their specific geographic location should look to other pertinent chapters of this manual for instructions that apply to regular Medicare providers/suppliers, not to the provisions contained in this special chapter for IHS providers billing the designated IHS MAC.
(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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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)  For those eligible practitioners already working in or for hospitals or freestanding ambulatory care clinics, whether operated by the Indian Health Service (IHS) or by an Indian tribe or tribal organization, enroll and process requests for reassignment of benefits following the current individual practitioner enrollment and verification instructions. For practitioners enrolling to work in or reassign benefits to hospitals or freestanding ambulatory care clinics, whether operated by the IHS or by an Indian t ribe or tribal organization, it is necessary only to verify licensure in one State even if it is not the State in which the practitioners practice. This only applies to federal employees and does not apply if the practitioner/physician is enrolling to work in or to reassign to an Indian tribe or tribal organization. For those disciplines that must be legally authorized to perform services in a State, the practitioner must be legally authorized to perform the services in at least one State, even if it is not the State where the practitioner practices with the IHS. An exception to the reassignment rules was made for physical therapist/occupational therapist, for details see 40.1.4, Reassignment.   For those practitioners who are already enrolled in Medicare Part B with the designated A/B MAC (B), process requests to reassign benefits in accordance with current instructions. All other physicians and practitioners must enroll in the Medicare program with the designated A/B MAC (B).
(Medicare Claims Processing Manual)
For those individual practitioners who are employees of an IHS, tribe, or tribal facility that provides offsite care to the IHS, tribe, or tribal Medicare Part B beneficiaries, the facility can bill if the employee reassigns his right to payment. However, the IHS, tribe, or tribal faci lity cannot bill for offsite services of a contract practitioner, unless the IHS, tribe, or tribal facility owns or leases the space where that contract practitioner provides the services.   However, when an IHS provider contracts with non- IHS physicians to  perform interpretations of radiological services, the physicians may be paid by the IHS facility regardless of the location of the offsite practitioner, if services are contracted in accordance with the requirements listed in 120 of this Chapter.  See 120 in this Chapter for further information.   40.1.3 - Multiple Sites  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Multiple clinics utilizing the same TIN can be enrolled as practice locations under the owner of the TIN (i .e., the hospital). Each clinic will be assigned a separate PIN.  If the clinic has a separate TIN, then the clinic would have to enroll separately. Payment is made to the name associated with the TIN. The legal business name must be shown on the Form CMS -855 exactly as it appears on the Internal Revenue Service documentation. However, the doing business as name can be listed as the practice location.   40.1.4 - Reassignment  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  For those individual practitioners who are employees of the IHS, tribe or tribal facility that provides offsite care to the IHS, tribe or tribal Medicare Part B beneficiary, the facility can bill under reassignment from the employee. With regard to contract practitioners, the IHS, tribe, or tribal facility can accept reassignment and bill for offsite services if the space where the contract practitioner provides the service is owned or leased, by the IHS, tribe, or tribal facility.
(Medicare Claims Processing Manual)
The physical therapists/occu pational therapists that are employees of the IHS, tribe or tribal group practice will enroll in Medicare Part B and receive a PIN. The physical therapists/occupational therapists will reassign their benefits to the facility. The facility will then bill Me dicare for their services.   40.1.5 - Mobile Units (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The entity providing the service must bill for the service unless the service is provided under contractual arrangements. If the  contracted entity performs services on space that the IHS facility owns or leases, the IHS facility can bill under arrangements.   In order to purchase a professional test interpretation, the IHS physician or practitioner must have performed the technical component of the test. In order to purchase a technical component of a test, the IHS physician or practitioner must perform the professional component of the test. See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1 for more information on purcha sed tests.   40.1.5.1 - Mobile Mammography Units  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  With respect to mobile mammography units, the law provides specific standards regarding those qualified to perform mammograms and how they should be certified. The Mammography Quality Standards Act (MQSA) requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all facilities providing screening  and diagnostic mammography services (except Veterans Affairs) must have a certificate issued by the Food and Drug Administration (FDA) to operate.   All IHS providers billing for services rendered by a mobile mammography unit under reassignment must compl ete 1, 4, and 14 of Form CMS -855B. The certification number for the mammography equipment must be entered in 4.1.5 of Form CMS -855B. For more information on the MQSA file, see Chapter 18, 20.1.2 of Pub. 100- 04, Medicare Claims Processing Manual.
(Medicare Claims Processing Manual)
40.1. 6 - Clinical Laboratory, Ambulance and Medicare Part B Drugs  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Enrollment of IHS, tribe and tribal organization facilities providing clinical laboratory, ambulance services and Med icare Part B drugs must be provided through the designated A/B MAC (B). These IHS, tribe and tribal organization facilities must meet all the usual enrollment requirements for the designated A/B MAC (B). The designated A/B MAC (B) started accepting enrollm ent applications from IHS, tribe and tribal organization facilities providing clinical laboratory and ambulance services beginning September 1, 2004.  These instructions apply to freestanding or independent clinical labs and independent ambulance suppliers , but not to hospital -based ambulance providers or hospital lab services.    40.2 - Provider Enrollment with A/B MAC (A)  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  New IHS providers, including Critical Access Hospitals (CA Hs) follow the same application process as any other provider enrolling in Medicare with the designated A/B MAC (A). Instructions for completing the Form CMS-855A, Application for Health Care Providers that will bill Medicare A/B MACs (A) are found in Pub. 100- 08, Medicare Program Integrity Manual, Chapter 10.  Section 1865 of the Social Security Act and pursuant regulations provide that IHS owned/tribally operated and IHS owned/operated facilities accredited by the Joint Commission of Accreditation of Heal thcare Organization (JCAHO) or the American Osteopathic Accreditation (AOA) are deemed to meet the Medicare Conditions of Participation (COPS). A Federal survey is required for facilities without JCAHO or AOA accreditation.   Tribally owned and operated fac ilities are generally under the state survey agency jurisdiction. However, the state or the tribe may request that the survey be conducted by a Federal surveyor.   Freestanding FQHCs enroll with the designated FQHC A/B MAC (A).   40.2.1 - Provider Enrollment with A/B MAC (A)  - Ambulatory Surgical Services  (Rev. 1325; Issued:  08-29-07; Effective:  01-01- 08; Implementation:  01 -07-08)