Renewal to the Medicare Opt-Out Law for Physicians and Practitioners

Renewal to the Medicare Opt-Out Law for Physicians and Practitioners Prior to enactment of the MARCA of 2015, physician or practitioner opt-out affidavits were only effective for two years. As a result of changes made by MACRA, valid opt-out [...]

Opt Out and Private Contracting

Opt Out and Private Contracting Opt out does not require a physician or practitioner to initially enroll with Medicare or complete a CMS-855I application. Opting out of Medicare allows a physician or practitioner to render services to [...]

Providers Not Eligible to Opt Out and Enter Into Private Contracts

Providers Not Eligible to Opt Out and Enter Into Private Contracts Providers Who May Not Opt Out of the Medicare Program Chiropractors Opt-out law does not define ‘physician’ to include chiropractors; therefore, they may not opt out of [...]

Instructions to File

Instructions to File The requirements to opting out of Medicare are included on the forms. First, at least one private contracting agreement form must be signed between the physician or practitioner and a beneficiary. Second, the physician [...]

Requirements of Medicare Opt-Out Affidavit Agreement

Requirements of Medicare Opt-Out Affidavit Agreement Amendment 4507 of the Balanced Budget Act of 1997 permits a physician or practitioner to “opt out” of Medicare and enter into private contracts with Medicare beneficiaries if specific [...]

Organizations That Furnish Physician or Practitioner Services

Organizations That Furnish Physician or Practitioner Services Opt-out regulations apply to all items or services the physician or practitioner furnishes to Medicare beneficiaries, regardless of the location where such services are furnished. [...]

Requirements of Medicare Private Contracting Agreement

Requirements of Medicare Private Contracting Agreement Amendment 4507 of the Balanced Budget Act of 1997 permits a physician or practitioner to “opt out” of Medicare and enter into private contracts with Medicare beneficiaries. Under the [...]

Approval or Denial

Approval or Denial Once your affidavit is approved, you will receive an approval letter of opt-out status along with the opt-out effective date. Review this letter to ensure that everything is accurate and if you have any questions, please [...]

Requests for Additional information

Requests for Additional information While processing the affidavit, National Government Services may determine additional information is needed. All requested information should be submitted as soon as possible, but no later than 30 days from [...]

Early Termination for First Time Opt-Out Providers

Early Termination for First Time Opt-Out Providers Opt-out affidavits are effective for two years and cannot be terminated early unless during the first time opt-out period and within 90 days of the effective date of the affidavit. A request [...]

Standard Companion Guides

Standard Companion Guides Standard Companion Guide Trading Partner Information (275) Standard Companion Guide Trading Partner Information (277) Standard Companion Guide Trading Partner Information (278/275) Standard Companion Guide Health [...]

Targeted Probe and Educate Educational Videos

Targeted Probe and Educate Educational Videos Video Description MAC Medical Review Best Practices: Updating Your Contact Information Did you know providers can now designate a separate [...]

Medical Review: Targeted Probe and Educate Review Topics

Medical Review: Targeted Probe and Educate Review Topics Prevent technical denials by ensuring your medical records are legible and include a valid, legible provider signature. If you notice the provider signature is illegible when asked to [...]

Medical Review: Targeted Probe and Educate Review Topics

Medical Review: Targeted Probe and Educate Review Topics Prevent technical denials by ensuring your medical records are legible and include a valid, legible provider signature. If you notice the provider signature is illegible when asked to [...]

Best Practices for a Successful Targeted Probe and Educate Review

Best Practices for a Successful Targeted Probe and Educate Review Table of Contents Getting Started With TPE Notification Letter During the Review Process Post-Probe/Review Results Letter Prepare for Post-Probe Education [Return to [...]

Botulinum Toxin Best Practices

Botulinum Toxin Best Practices Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonias, spasms and twitches. They produce [...]

Medical Necessity of Vitamin D Assay Testing: Top Denials and How to Prevent Them

Medical Necessity of Vitamin D Assay Testing: Top Denials and How to Prevent Them Learn how to prevent common denials for Vitamin D Assay Testing (CPT Code 82306): 1. Testing may not be used for routine or other screening. There must be [...]

Vaccines

Vaccines Medicare covers some preventive vaccines at no cost to the beneficiary. CMS and National Government Services provide detailed educational and billing information for providers. Medicare also covers vaccines that are directly related [...]

EDI Guided Enrollment Form

MLN Connects® Newsletter: May 2, 2024

MLN Connects® Newsletter: May 2, 2024 News CMS Statement on Proposed Local Coverage Determination for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Quality in [...]

May 2024

In This Issue National Government Services Articles for Part A and Part B Providers LCD and Article Updates for April/May 2024 National Government Services Proposed LCDs for Comment (4/25/2024-6/8/2024) Top Tobacco Counseling Claim Errors [...]

Important Reminders for Your EDI Enrollment

Important Reminders for Your EDI Enrollment When completing the EDI Enrollment application, it’s important that the entity name and address you enter on the EDI enrollment form matches exactly to the information contained in the CMS-855/PECOS [...]

Billing for Drug Wastage: JW and JZ Modifier

Billing for Drug Wastage: JW and JZ Modifier Properly billing for drug wastage and associated modifiers helps to prevent claims processing errors and denials while ensuring you receive correct reimbursement. Providers and suppliers are to [...]

2024 Medicare Cost Report Due Dates

2024 Medicare Cost Report Due Dates FYE 12/31/2023 cost reports are due by 5/31/2024. We strongly encourange early filing of the cost report. Early-filed cost reports that are rejected will receive a grace period to re-submit prior to [...]

Covered Medicare Part B Drugs/Biologicals

Covered Medicare Part B Drugs/Biologicals Each drug and biologic that can be considered for coverage under Medicare Part B has its own set of coverage guidelines. Below are examples of covered Medicare Part B drugs and biologicals, which may [...]

About Prior Authorization

About Prior Authorization CMS has implemented Prior Authorization (PA) programs nationwide to ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments. PA [...]

About Hospital OPD PA Model

About Hospital OPD PA Model Table of Contents About Hospital OPD PA Model General Information Related Content [Return to Top] About the Hospital OPD PA Model CMS implemented a PA program for certain hospital OPD services for DOS on [...]

OPD Facility/Physician Communication

OPD Facility/Physician Communication What does this mean for the Part B Provider who will be performing the service in the hospital OPD? The performing provider, must work alongside the hospital OPD staff to obtain PA for the services to be [...]

Expedited Requests

Expedited Requests The requester may submit for an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. If the medical documentation does [...]

Submission of a Medicare Cost Report Reopening Request

Submission of a Medicare Cost Report Reopening Request In accordance with CMS policy (42 Code of Federal Regulations 405.1885 and CMS IOM Publication 15-1, The Provider Reimbursement Manual, Section 2931), a provider may request a reopening of [...]

CMS Medicare Administrative Contractor Information

CMS Medicare Administrative Contractor Information Note: Please do not include PHI such as Medicare numbers within emails. Navigation [Part A] [Part B] [DME MAC] [Federally Qualified Health Center] [Home [...]

MLN Connects® Newsletter: May 9, 2024

MLN Connects® Newsletter: May 9, 2024 News HHS Releases New Data Showing Over 10 million People with Medicare Received a Free Vaccine Because of the President’s Inflation Reduction Act; Releases Draft Guidance for the Second Cycle of [...]

Physicians: Are You Ordering Knee Orthosis for Your Patients?

Physicians: Are You Ordering Knee Orthosis for Your Patients? This is your opportunity to hear directly from the Medicare contractors regarding documentation required for the coverage criteria to be met. You’ll also learn how to help your [...]

Staying Up To Date on Vaccines

Staying Up To Date on Vaccines It's important to stay up to date on vaccines. Vaccines protect your patients from serious illness and can keep them out of the hospital. Talk with your patients about which vaccines may be right for them, many [...]

Hospice Certifying Physician Medicare Enrollment Information

Hospice Certifying Physician Medicare Enrollment Information Under CMS' current regulations, the hospice medical director or the physician member of the hospice interdisciplinary group (the “hospice physician”) and the attending physician (if [...]

File an Amended Cost Report

Table of Contents File an Amended Cost Report Timeframe to Amend the Medicare Cost Report [Return to Top] File an Amended Cost Report A provider may elect to submit an amended cost report subsequent to the initial filing. The Centers [...]

Get Your PS&R Reports

Table of Contents Get Your PS&R Reports Register to Receive the PS&R Report Instructions on How to Use Redesign Detail Reports [Return to Top] Get Your PS&R Reports The PS&R report is a tool used by Part A providers [...]

Get Your PS&R Reports

The PS&R report is a tool used by Part A providers and MACs to prepare and process Medicare cost reports. Table of Contents Register to Receive the PS&R Report Instructions on How to Use Redesign Detail Reports [Return to Top] [...]

Request a Due Date Extension

It may be necessary to request an extension for your cost report due date because of an extraordinary circumstance. An example of an extraordinary circumstance would be a flood or fire that forces a provider to cease operations and transfer [...]

Request a Due Date Extension

It may be necessary to request an extension for your cost report due date because of an extraordinary circumstance. An example of an extraordinary circumstance would be a flood or fire that forces a provider to cease operations and transfer [...]

File an Amended Cost Report

A provider may elect to submit an amended cost report subsequent to the initial filing. The CMS Medicare Paper-Based Manuals Publication 15-1, Provider Reimbursement Manual—Part I, Chapter 29 Section 2931.2A, allows the Medicare Administrative [...]

Prepare and Submit a Cost Report

Table of Contents Prepare and Submit a Cost Report Submit Cost Report Documentation MCReF Other Electronic Media Formats Electronic Filing Requirements and List of Vendors Approved XML IRIS Vendors Home [...]

Value-Based Insurance Design Model Hospice Benefit Component Overview

Value-Based Insurance Design Model Hospice Benefit Component Overview Beginning on 1/1/2021, CMS is testing the inclusion of the Part A Hospice Benefit within the MA benefits package through the Hospice Benefit Component of the VBID Model. [...]

Canceling a Hospice Notice of Election

Canceling a Hospice Notice of Election When a patient elects hospice, the hospice submits a NOE to the MAC to notify the MAC and all other providers that the patient is now utilizing the Medicare hospice benefit for all services related to the [...]

Medicare Part B 2024 Spring/Summer Virtual Conference: Mastering Medicare-Tuesday Tutorials for Part B Providers-Beginning June 4th!

Medicare Part B 2024 Spring/Summer Virtual Conference: Mastering Medicare-Tuesday Tutorials for Part B Providers-Beginning June 4th! Seats are filling up quickly for our 2024 Spring/Summer Virtual Conference: Mastering Medicare- Tuesday [...]

Attention All Providers, Billing Services and Clearinghouses Who Submit and Receive NGS EDI Transactions

Attention All Providers, Billing Services and Clearinghouses Who Submit and Receive NGS EDI Transactions As a reminder, when submitting the EDI Enrollment Application to National Government Services, only one form should be completed for any [...]

Hospice Billing Codes Chart

Hospice Billing Codes Chart Table of Contents Hospice Billing Codes Chart Condition Codes (CC) (UB-04 FL 18-28) Occurrence Codes (OC) and Dates (UB-04 FLs 31-34) Occurrence Span Code and Date (UB-04 FLs 35-36) Value Codes (VCs) and CBSA [...]

Completing the Advance Beneficiary Notice for Home Health Agency Demand Claims

Completing the Advance Beneficiary Notice of Noncoverage for Home Health Agency Demand Claims The purpose of the ABN is to appropriately notify a Medicare beneficiary of services that the HHA believes Medicare will not cover. In order for the [...]

Home Health Billing When a New MBI is Assigned

Home Health Billing When a New MBI is Assigned A patient’s MBI number is required on all home health billing submitted to Medicare. CMS will issue a new MBI when an original MBI may have been, or has been compromised. There are times a home [...]

Hospice Room and Board Denials

Hospice Room and Board Denials Medicare does not pay the room and board fees for hospice beneficiaries that reside in a SNF or a nursing facility (NF), as these charges are statutorily excluded from Medicare coverage. However, these charges [...]

Reporting Site of Service Codes for Home Health Care

Reporting Site of Service Codes for Home Health Care HH PPS claim payments are based on the site of the beneficiary’s care. In order for Medicare to accurately capture where home health services are provided, HHAs are required to report the [...]