State Surveys and the Form CMS-855B
In general, information on the Form CMS-855B is still considered valid notwithstanding a delay in the State survey. However, the supplier must submit an updated Form CMS-855B application to the contractor if:
• The contractor becomes aware of such a delay;
• The delay is the fault of the supplier; and
• At least 6 months have passed since the contractor sent its recommendation for approval to the State.
If these criteria are met, the contractor shall send a letter to the supplier requesting an updated Form CMS-855B. The application must contain, at a minimum, any information that is new or has changed since the recommendation for approval was made, as well as a newly-signed certification statement. If no information has changed, the supplier may instead submit: (1) a letter on its business letterhead stating as such, and (2) a newly-signed Form CMS-855B certification statement.
If the supplier fails to furnish the requested information within 60 calendar days, the contractor shall submit a revised letter to the State that recommends denial of the supplier’s application.
B. Future Effective Dates
If the contractor cannot enter an effective date into PECOS because the supplier, its practice location, etc., is not yet established, the contractor may use the authorized official’s date of signature as the temporary effective date. Once the provider and the effective date is established (e.g., the tie-in notice is received), the contractor shall change the effective date in PECOS.
Indirect Payment Procedure
Indirect Payment Procedure - Background
(1) Provides coverage of the service under a complementary health benefit plan (this is, the coverage that the plan provides is complementary to Medicare benefits and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan).
(2) 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.
(3) Has the written authorization of the beneficiary (or of a person authorized to sign claims on his/her behalf under 42 CFR § 424.36) to receive the Part B payment for the services for which the entity pays.
(4) Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, his/her survivors, or estate.
(5) Submits any information that CMS or the contractor may request, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program.
(6) Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer.
Entities that comply with § 424.66(a) and the registration procedures described in sections 15.7.9.1 through 15.7.9.7 of this chapter are hereinafter referred to as “IPP entities.” An IPP entity is not a “provider” or “supplier” as those terms are defined in § 400.202; moreover, an IPP entity does not meet the definition of a “health care provider” under 45 CFR § 160.103 and, as such, is not eligible for a National Provider Identifier (NPI). Indeed, an IPP entity does not furnish Medicare services. Rather, it is an entity that provides supplementary coverage in the circumstances described in §424.66(a). To illustrate, suppose an IPP entity furnishes complementary coverage for its retired union members and is a retiree drug subsidy plan sponsor. The entity may seek to (1) pay in full its retired members' drug benefits and other Part B services, (2) bill the Part B services to Medicare, and (3) receive payment for Medicare claims. Assuming, again, that all requirements are met, entities that may utilize the IPP could include:
• Employers
• Unions
• Insurance companies
• Retirement homes
• Health care prepayment plans
• Health maintenance organizations
• Competitive medical plans
• Medicare Advantage plans
As stated, an IPP entity is not a Medicare provider or supplier. It therefore cannot enroll in the Medicare program. It is crucial, nonetheless, that Medicare obtain sufficient background information on prospective IPP entities to ensure the integrity, accuracy, and legitimacy of Medicare payments to said entities. Hence, CMS will apply the Form CMS-855 process to IPP entities consistent with our authority to request information under 42 CFR § 424.66(a)(5). For purposes of the IPP, this process is called IPP “registration,” rather than enrollment. An entity must satisfy the requirements described in 42 CFR § 424.66 and successfully complete the Form CMS- 855 registration process before it can bill Medicare under the IPP. Naturally, an IPP entity’s status as a non-provider and non-supplier will result in procedures that differ in certain aspects from those associated with the enrollment of Medicare providers and suppliers.
Submission of Registration Applications
An IPP entity’s registration application must be submitted to each Medicare claims administration contractor to which the IPP entity will be submitting claims. Claims for all Part B items and services – other than for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) – must be submitted to the A/B Medicare Administrative Contractor (MAC) or carrier based on where the service was performed or the item was furnished. Almost all claims for DMEPOS must be submitted to the DME MAC based on where the beneficiary resides. However, claims for Medicarecovered implantable devices, although classified as DME, are submitted to the A/B MACs or carriers based on where the implant surgery was performed. These jurisdictional rules for claim submission apply to submission of registration applications. As such, the IPP entity must complete and submit:
(1) Form CMS-855C and Form CMS-588 to each applicable A/B MAC to which the plan will be submitting its non-DMEPOS claims; and/or
(2) Form CMS-855C and Form CMS-588 to the National Supplier Clearinghouse (NSC).
With respect to (1) – and consistent with section 15.5.4.2(D) of this chapter - the IPP entity need only submit one Form CMS-855C application and one Form CMS-588 per contractor jurisdiction.
B. Form Completion
The IPP entity:
(1) Must use the paper version of the Form CMS-855 application.
(2) Must – in light of its ineligibility for an NPI - apply for and receive either a Health Plan Identifier (HPID) or an Other Entity Identifier (OEID) in accordance with 45 CFR §162. This is to facilitate the entity’s submission of claims under the IPP. The entity must furnish its HPID or OEID in the appropriate place on the Form CMS-855. It shall also list the HPID or OEID on the Form CMS-855 and Form CMS-588 and furnish documentation evidencing the issuance of the number (e.g., a notice from the HPID or OEID issuer identifying the number).
(3) Need not submit licensure or certification information.
(4) Shall list its main business address (e.g., its headquarters) and resident agent address (if applicable) as practice locations.
(5) Need not report medical record storage information.
(6) Need not pay an application fee (as it is not an “institutional provider” under 42 CFR §424.502), although it must receive payments via electronic funds transfer (EFT).
(7) Need not submit a Form CMS-460. Because §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” at § 400.202, IPP entities cannot enter into a participation agreement (Form CMS-460) with Medicare. The IPP entity shall therefore be treated as “non-participating.”
(8) Need not meet the applicable (a) supplier standards, (b) accreditation requirements, (c) surety bond requirements, and (d) liability insurance requirements if the IPP entity is a DMEPOS supplier. (The NSC may need to relax certain edits in the Provider Enrollment, Chain and Ownership System (PECOS).) Moreover, the contractor need not perform a site visit.
(9) Meet the attestation requirements in subsection (C) below.
C. Attestation
1. Contents
The IPP entity must submit with each registration application a signed attestation statement certifying that for each claim it submits, all of the following requirements in 42 CFR §424.66 are met:
(1) The entity provides coverage of the service under a complementary health benefit plan and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan.
(2) The entity has paid the person (i.e., the physician or other supplier) who provided the service (including the amount payable under the Medicare program) an amount that the physician or other supplier accepts as full payment.
(3) The entity has the written authorization of the beneficiary (or other person authorized to sign claims on the beneficiary’s behalf under 42 CFR §424.36) to receive the Part B payment for the services paid by the entity.
(4) The entity relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, the beneficiary’s survivors, or the beneficiary’s estate.
(5) The entity agrees to submit any information requested by CMS or by a Medicare contractor, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program.
(6) The entity agrees to identify and exclude from its requests for payment all services for which Medicare is the secondary payer.
This attestation is necessary to help ensure that the entity is in compliance with the provisions of §424.66. As already stated, compliance with § 424.66 is a prerequisite for initial and continued registration as an IPP entity. Since the IPP entity may be submitting applications in multiple jurisdictions, it is acceptable for the entity to submit a photocopy of a signed attestation rather than an originally signed attestation.
2. Signature
An “authorized official” - as that term is defined in 42 CFR §424.502 – must sign all attestations, though the same authorized official need not sign all attestations. The certification statement on the Form CMS-855C supplements - and does not supplant - the attestation referred to above. The IPP entity is bound by the terms of the certification statement to the same extent as it is bound by the attestation’s terms.
.jpg)
No comments:
Post a Comment