Revised April 6, 2010
Information Provided by CIGNA Government Services Part B
© 2010 Copyright CIGNA.
Medicare Resources April 2010
Table of Contents
Navigating Medicare Information on the Web 3
Provider Web Tools 4
Preventive Care 6
Important Messages 12
Comprehensive Error Rate Testing (CERT): What Does This Mean to You? 13
The Medical Review Process 14
The Medicare Appeals Process 16
Provider Enrollment 18
Electronic Data Interchange (EDI) 20
Provider Outreach & Education 23
Medicare Resources April 2010
Navigating Medicare y
Medicare Fee-for-Service Drugs
Information on the Web y
Medicare Fee-for-Service Payments
Medicare Secondary Payer Recovery
y Prescription Drug Coverage
CMS Official Website y Prevention
http://www.cms.hhs.gov y Provider Enrollment & Certification
y Quality Initiatives/ Patient Assessments Instruments
The Centers for Medicare & Medicaid (CMS) Website
y consistent organization and navigation Regulations & Guidance
y timely, relevant and accurate content
y improved Google search feature, and much more…
This area of the CMS website provides users with tools
The CMS website is organized in four levels: such as the CMS Internet Only Manual (IOM) system,
Program transmittals, and current legislation impacting
Top-Level Subject Area (Medicare) the Medicare Program.
L L L
Category (Health Plans) y Guidance (Manuals, Rulings, Transmittals, etc.)
L L y Health Insurance Reform (COBRA Continuation of
Section (Service Area) Coverage, etc.)
L y HIPAA Administrative Simplification (HIPAA General
Page Information, Educational Materials, Enforcement, etc.)
y Legislation (CLIA, EMTALA, Freedom of Information
At any time during your visit you can navigate back to y Regulations and policies (Medicare Modernization
the Top-Level Subject Area that displays all categories in Update, Quarterly Provider Updates, etc.)
that area. y Review Boards
The website has one-stop-shopping areas called Centers Research, Statistics, Data, & Systems
that are targeted to your specific professional needs.
For example, if you are a Provider or Partner you will http://www.cms.hhs.gov/home/rsds.asp
have the option to browse the website by your area Users will find current statistics, trends, reports, and
of interest. For example, specific Provider and Partner other useful data in this area of the CMS website.
Centers will be available to help bring you the most up- y CMS Information Technology
to-date information. y Computer Data and Systems
y Files for Order
Medicare Home Page y Monitoring Programs
http://www.cms.gov/ y Research
This Medicare-dedicated page offers useful links to y Statistics, Trends, and Reports
the following subject areas, and also provides an Outreach & Education
opportunity to browse by provider type or special topic.
y Medicare General Information outreacheducation.asp
y Appeals and Grievances
This area of the CMS website is dedicated to educating
Medicare providers. Providers will find educational
y CMS Forms
materials such as MLN Matters articles, online education
modules, and many other publications and materials
y Coordination of Benefits
available for order. Providers also have the opportunity
to interact directly with CMS through a variety of Open
y Demonstration Projects
Door Forum teleconferences.
y Eligibility and Enrollment y Medicare Learning Network (MLN) (Educational Web
y End-Stage Renal Disease Guides, MLN Matters Articles, MLN Products, etc.)
y Fraud & Abuse y Outreach (Open Door Forums, Physician Regulatory
y Health Plans Issues Team (PRIT), etc.)
y Medicare Advantage y Training
Medicare Resources April 2010
Site Tools & Resources of service. All HCPCS/CPT codes do not have an MUE.
This webpage has links to the MUE Frequently Asked
Questions and Answers (FAQs), MUE files, and the
Many of the most commonly used tools and resources Publication Announcement Letter which explain most
available from the CMS website are conveniently aspects of the MUE program.
housed in this central location.
y Acronym Lookup Tool Internet-Based PECOS
y Frequently Asked Questions https://pecos.cms.hhs.gov/pecos/login.do
y Mailing Lists This website allows registered users to securely and
y Medicare Coverage Database electronically manage Medicare enrollment information.
y Medicare Physician Fee Schedule Lookup Registered users may:
y Submit an enrollment application to Medicare.
Provider Web Tools y View or update existing enrollment information.
y View the status of applications submitted to Medicare
from this website.
NCCI Edits for Physicians y Voluntarily withdraw enrollment in Medicare
NCCI Edits for Hospital Outpatient Medicare Physician Fee Schedule Lookup
Departments View physician service information, geographic practice
http://www.cms.hhs.gov/Hospital OutpatientPPS/ cost indices and payment policy. The MPFSDB has
NCCI Edits promote uniformity among the contractors information listed by CPT/HCPCS code regarding code
that process Medicare claims in interpreting Medicare description, global period, Professional/Technical
payment policies. The edits are pairs of services that components, Status Codes, Multiple Surgery Payment
normally should not be billed by the same provider for Adjustment, Bilateral Surgery, Assistant at Surgery,
the same patient on the same day. Co-Surgery, Team Surgery, Services Subject to Special
The NCCI edits will be posted as a spreadsheet that will Payment Rules for supplies/administration, Type of
allow users to sort by procedure code and by effective Physician Supervision Required for Diagnostic Tests, and
date. A “Find” feature will allow users to look for a Endoscopic Base Codes.
specified code. The edit files are indexed by procedure
code ranges for easy navigation. The NCCI is updated MLN Matters: Information for Medicare
on a quarterly basis. Providers
NPI Registry This page includes links to educational articles and
https://nppes.cms.hhs.gov/NPPES/ related Change Requests, in order to present consistent
NPIRegistryHome.do information to providers.
The NPI Registry enables you to search for a provider’s
NPPES information. All information produced by the NPI Medlearn Learning
Registry is provided in accordance with the NPPES Data Network (Medlearn) Website
Dissemination Notice. Information in the NPI Registry is
updated daily. You may run simple queries to retrieve
this read-only data. For example, users may search for a The Medicare Learning Network (MLN) is your
provider by the NPI or Legal Business Name. There is no destination for educational information for Medicare
charge to use the NPI Registry. fee-for-service providers. Located in the Centers for
Medicare & Medicaid Services (CMS), the Medicare
Medically Unlikely Edits (MUEs) Learning Network is a brand name for official CMS
http://www.cms.hhs.gov/ national provider education products designed to
NationalCorrectCodInitEd/08_MUE.asp#TopOfPage promote national consistency of Medicare provider
information developed for CMS initiatives.
The CMS developed Medically Unlikely Edits (MUEs)
to reduce the paid claims error rate for Part B claims.
An MUE for a HCPCS/CPT code is the maximum units
of service that a provider would report under most
circumstances for a single beneficiary on a single date
Medicare Resources April 2010
CIGNA Government Services Website Provider Enrollment
Part B Forms
By joining the CIGNA Government Services electronic http://www.cignagovernmentservices.com/partb/
mailing list, you can get immediate updates on all forms/index.html
Medicare information, including: Medicare publications,
important Medicare Program updates, workshops, Coverage and Pricing
and Medical Review information. The LISTSERV is
segmented by specialty and special interest.
Part B Publications y Fee Schedules
y Health Professional Shortage Areas (HPSAs)
http://www.cignagovernmentservices.com/partb/ y Medical Review Articles
pubs/index.html y Local Coverage Determinations
y Medicare Bulletins
y News & News Archive Education
y Fee Schedules http://www.cignagovernmentservices.com/partb/
y Specialty Manuals education/index.html
y EDI Connection y Online Education Center
y Provider Manual y Ask the Contractor Teleconferences (ACT),
y Medicare Participating Physicians/ Suppliers Database y ID & NC-specific Education Resources
y Medicare Resources Manual Online Help Center
y Part B Vendor Gazette http://www.cignagovernmentservices.com/partb/
The Online Help Center of CIGNA Government Services,
the Part B Carrier for North Carolina and Idaho is
designed to provide easy access to your most frequently
y Crossover Information requested information, forms, and publications.
y IVR instructions
y Comprehensive Error Rate Testing (CERT)
y Electronic Data Interchange (EDI)
Quick Reference Information:
Medicare Preventive Services
SERVICE HCPCS/CPT CODES ICD 9 CM CODES WHO IS COVERED FREQUENCY BENEFICIARY PAYS
Effective January 1, 2009 Copayment/coinsurance
G0402 – IPPE
Deductible applies prior to January
Initial Preventive Physical G0403 – EKG for IPPE Once in a lifetime benefit per 1, 2009
Examination (IPPE) G0404 – EKG tracing for PPE All Medicare beneficiaries whose first beneficiary
No specific diagnosis code required No deductible applies for code
Also known as the “Welcome G0405 – EKG interpret & report Part B coverage began on or after Must be furnished no later than 12
for IPPE G0402, effective for dates of service
to Medicare Physical Exam” or January 1, 2005 months after the effective date of the
Important – Effective for dates of service on or on or after January 1, 2009
“Welcome to Medicare Visit” first Medicare Part B coverage begins
after January 1, 2009, the screening EKG is
an optional service that may be performed as Deductible still applies for G0403,
a result of a referral from an IPPE G0404, and G0405
Medicare beneficiaries with certain
risk factors for abdominal aortic
Ultrasound Screening for No specific code
aneurysm Once in a lifetime benefit per eligible Copayment/coinsurance
Abdominal Aortic Aneurysm G0389 – Ultrasound exam AAA screen Contact local Medicare Contractor for
Important – Eligible beneficiaries must beneficiary, effective January 1, 2007 No deductible
receive a referral for an AAA ultrasound
screening as a result of an IPPE
80061 – Lipid Panel
Report one or more of the following All asymptomatic Medicare
Cardiovascular Disease 82465 – Cholesterol No copayment/coinsurance
codes: beneficiaries Every 5 years
Screenings 83718 – Lipoprotein No deductible
V81.0, V81.1, V81.2 12-hour fast is required prior to testing
84478 – Triglycerides
82947 – Glucose, quantitative, blood (except
reagent strip) V77.1 Medicare beneficiaries with certain
beneficiaries diagnosed with
Report modifier “TS” (follow-up service) risk factors for diabetes or diagnosed
82950 – Glucose, post-glucose dose (includes pre-diabetes No copayment/coinsurance
Diabetes Screening Tests for diabetes screening where the with pre-diabetes
glucose) No deductible
beneficiary meets the definition of Beneficiaries previously diagnosed with
82951 – Glucose Tolerance Test (GTT), three tested but not diagnosed with
pre-diabetes diabetes are not eligible for this benefit
specimens (includes glucose) pre-diabetes, or if never tested
Medicare beneficiaries at risk
G0108 – DSMT, individual session, per 30 for complications from diabetes,
No specific code within a continuous 12-month
Diabetes Self-Management minutes recently diagnosed with diabetes, or Copayment/coinsurance
Contact local Medicare Contractor for period
Training (DSMT) G0109 – DSMT, group session (2 or more), previously diagnosed with diabetes Deductible
per 30 minutes Physician must certify that DSMT is
of follow-up training each year
97802, 97803, 97804, G0270, G0271
Medical Nutrition Therapy Contact local Medicare Contractor for Medicare beneficiaries diagnosed Copayment/coinsurance
Services must be provided by registered counseling
(MNT) guidance with diabetes or a renal disease Deductible
dietitian or nutrition professional
Copayment/coinsurance for Pap test
childbearing age with abnormal collection
G0123, G0124, G0141, G0143, G0144, Pap test within past 3 years
Screening Pap Tests V76.2, V76.47, V76.49, V15.89, V72.31 All female Medicare beneficiaries (No copayment/coinsurance for Pap
G0145, G0147, G0148, P3000, P3001, Q0091
women No deductible
G0101 – Cervical or vaginal cancer childbearing age with abnormal
Screening Pelvic Exam screening; pelvic and clinical breast V76.2, V76.47, V76.49, V15.89, V72.31 All female Medicare beneficiaries Pap test within past 3 years
examination No deductible
All female Medicare beneficiaries age Copayment/coinsurance
Screening Mammography 77052, 77057, G0202 V76.11 or V76.12 Annually
40 or older No deductible
Female Medicare beneficiaries ages Copayment/coinsurance
Screening Mammography 77052, 77057, G0202 V76.11 or V76.12 One baseline
35 - 39 No deductible
Quick Reference Information:
Medicare Preventive Services
SERVICE HCPCS/CPT CODES ICD 9 CM CODES WHO IS COVERED FREQUENCY BENEFICIARY PAYS
G0130, 77078, 77079, 77080, 77081, 77083, Contact local Medicare Contractor for Medicare beneficiaries at risk for Every 24 months Copayment/coinsurance
Bone Mass Measurements
76977 guidance developing Osteoporosis More frequently if medically necessary Deductible
G0104 – Flexible Sigmoidoscopy
G0105 – Colonoscopy (high risk)
G0106 – Barium Enema (alternative to and older No copayment/coinsurance or
Every 4 years or once every 10
G0104) years after having a screening deductible for Fecal Occult Blood
G0120 – Barium Enema (alternative to Use appropriate code Individuals at high risk no colonoscopy Tests
G0105) minimum age requirement
Colorectal Cancer Screening Contact local Medicare Contractor for
G0121 – Colonoscopy (not high risk) guidance 24 months at high risk every 10 For all other tests copayment/
barium enema as an alternative years not at high risk coinsurance apply
G0122 – Barium Enema (non-covered) to a high risk screening
G0328 – Fecal Occult Blood Test (alternative colonoscopy if the beneficiary is No deductible
to 82270) at high risk at high risk every 4 years not at
82270 – Fecal Occult Blood Test
All male Medicare beneficiaries 50 or Copayment/coinsurance
Prostate Cancer Screening G0102 – Digital Rectal Exam (DRE) V76.44 older (coverage begins the day after Annually
50th birthday) Deductible
All male Medicare beneficiaries 50 or
Prostate Cancer Screening G0103 – Prostate Specific Antigen Test (PSA) V76.44 older (coverage begins the day after Annually
Medicare beneficiaries with diabetes
G0117 – By an optometrist or ophthalmologist mellitus, family history of glaucoma,
Annually for beneficiaries in one of Copayment/coinsurance
Glaucoma Screening G0118 – Under the direct supervision of an V80.1 African-Americans age 50 and over,
the high risk groups Deductible
optometrist or ophthalmologist or Hispanic-Americans age 65 and
V04.81 Once per influenza season in the fall
90655, 90656, 90657, 90658, 90660 or winter No copayment/coinsurance
Influenza Virus Vaccine – Influenza Virus Vaccine V06.6 – When purpose of visit was to All Medicare beneficiaries
G0008 – Administration receive both influenza virus Medicare may provide additional flu No deductible
and pneumococcal vaccines shots if medically necessary
90669 – Pneumococcal Conjugate Vaccine Once in a lifetime
90732 – Pneumococcal Polysaccharide Medicare may provide additional No copayment/coinsurance
Pneumococcal Vaccine V06.6 – When purpose of visit was to All Medicare beneficiaries
Vaccine vaccinations based on risk and provided
receive both pneumococcal No deductible
that at least 5 years have passed since
G0009 – Administration and influenza virus vaccines
receipt of a previous dose
90740, 90743, 90744, 90746, 90747
– Hepatitis B Vaccine
Medicare beneficiaries at medium to Copayment/coinsurance
Hepatitis B (HBV) Vaccine G0010 – Administration V05.3 Scheduled dosages required
high risk Deductible
90471 or 90472 – Administration (OPPS
Medicare beneficiaries who use
99406 – counseling visit; intermediate, tobacco and have a disease 2 cessation attempts per year
greater than 3 minutes up to 10 Use appropriate code or adverse health effect linked Each attempt includes maximum of
Smoking and Tobacco-Use Copayment/coinsurance
minutes Contact local Medicare Contractor for to tobacco use or take certain 4 intermediate or intensive sessions,
Cessation Counseling Deductible
99407 – counseling visit; intensive, greater guidance therapeutic agents whose up to 8 sessions in a 12-month
than 10 minutes metabolism or dosage is affected by period
This quick reference information chart was prepared as a service to the public and is not intended to grant rights or impose obligations. This chart may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
CPT only copyright 2008 American Medical Association. All Rights Reserved. January 2009 ICN# 006559
Medicare Preventive Services Quick Reference Information:
The ABCs of Providing the Initial Preventive Physical Examination
The Initial Preventive Physical Examination (IPPE), also known as the “Welcome to Medicare Physical Exam” or the “Welcome to Medicare Visit,” is a preventive evaluation and management (E/M) service. The
goals of the IPPE are health promotion and disease detection. All components of the IPPE must be provided, or provided and referred, prior to submitting claims for the IPPE visit.
Components of the IPPE (as of January 1, 2009)
Acquire Patient History Elements
At a minimum, obtain the following:
1. Review of Individual’s Medical
and Social History
2. Review of Individual’s Potential
Use any appropriate screening instrument recognized by national professional medical organizations to obtain current or past experiences with depression or
(Risk Factors) for Depression
and Other Mood Disorders other mood disorders
Use any appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum,
the following areas:
3. Review of Individual’s
Functional Ability and Level of
Begin Physical Examination Elements
Obtain the following:
4. A Physical Examination
5. End-of-Life Planning
Counsel Patient Elements
6. Education, Counseling, and include the following:
Referral Based on the Previous
7. Education, Counseling, and
Referral for Other Preventive
Services preventive services.)
Medicare Part B Preventive Services Medicare Part B Preventive Services
Who Is Eligible to Receive the IPPE?
Bone Mass Measurements Effective for dates of service on or after
after the effective date of their Medicare Part B
is a one-time
ultrasound screening for the early detection of AAAs as part of their IPPE.
**NEW: screening EKG is no longer a required part of the IPPE. It is optional and may Preparing Eligible Medicare Patients
for the IPPE Visit
Providers can help eligible Medicare patients
get ready for their IPPE visit by encouraging
them to come prepared with the following
IPPE HCPCS Codes Billing Code Descriptors Medical records, including
interpretation and report
A full list of medications and
supplements, including calcium and
initial preventive physical examination vitamins–how often and how much of
each is taken
Frequently Asked Questions
or copayment still applies. The deductible still applies to the optional http://www.cms.hhs.gov/MLNProducts/
checkup” that some seniors may receive every year or two from their downloads/mps_guide_web-061305.pdf
Can a separate E/M service be billed at the same visit as the IPPE?
Who can perform the IPPE? clm104c12.pdf
The IPPE must be furnished by either a physician (a doctor of medicine or
nurse practitioner, or clinical nurse specialist). http://www.cms.hhs.gov/manuals/downloads/
Are clinical laboratory tests part of the IPPE?
provider may want to make referrals for such tests as part of the IPPE. – Update to the Initial Preventive Physical
Is there a deductible or coinsurance/copayment for the IPPE? http://www.cms.hhs.gov/transmittals/
effective date. downloads/R1615CP.pdf
This quick reference information chart was prepared as a service to the public and is not intended to grant rights or impose obligations. This chart may contain references or links to statutes, regulations or other interpretive materials. The information provided is only intended to be a
MEDICARE PREVENTIVE SERVICES
QUICK REFERENCE INFORMATION:
MEDICARE PART B IMMUNIZATION BILLING
(Influenza, Pneumococcal, and Hepatitis B)
Immunization Procedure Codes & Descriptors What’s New?
ADMINISTRATION FREQUENCY OF CPT CODE 90669
VACCINE CODES & DESCRIPTORS
& DIAGNOSIS CODES ADMINISTRATION Effective for dates of service on or after January 1, 2008,
90655 – Inﬂuenza virus vaccine, split virus, preservative free, for children 6-35 months use CPT code 90669 on claims when billing for
of age, for intramuscular use pneumococcal conjugate vaccine, polyvalent, for children
under 5 years, for intramuscular use.
Once per ﬂu
90656 – Inﬂuenza virus vaccine, split virus, preservative free, for use in individuals 3 season in the
Influenza Vaccine years and above, for intramuscular use fall or winter
Administration Code: G0008 Additional Billing Information
90657 – Inﬂuenza virus vaccine, split virus, for children 6-35 months of age, Medicare may
Diagnosis Code: V04.81 for intramuscular use provide additional TYPE
ﬂu shots OF BILL
90658 – Inﬂuenza virus vaccine, split virus, for use in individuals 3 years of age and if medically
necessary Hospitals, Other than
above, for intramuscular use Indian Health Service (IHS) 12x, 13x
Hospitals and Critical Access
90660 – Inﬂuenza virus vaccine, live, for intranasal use Hospitals (CAHs)
Pneumococcal 90669 – Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, IHS Hospitals 12x, 13x, 83x
Vaccine Once in a lifetime /
for intramuscular use IHS CAHs 85x
Administration Code: G0009 cover additional
90732 – Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed CAHs: Method I 85x
Diagnosis Code: V03.82 vaccinations and Method II
patient dosage, for use in individuals 2 years or older, for subcutaneous or
based on risk
intramuscular use Skilled Nursing Facilities (SNFs) 22x, 23x
Home Health Agencies (HHAs) 34x
Influenza vaccines Comprehensive Outpatient
received during the Follow 75x
Rehabilitation Facilities (CORFs)
same visit guidelines for
Use inﬂuenza and pneumococcal vaccine codes
Administration Codes: inﬂuenza and Independent and Hospital-Based 72x
G0008: Influenza pneumococcal Renal Dialysis Facilities
G0009: Pneumococcal vaccines
Revenue Codes: 0636 - vaccine
Diagnosis Code: V06.6 0771 - administration
Hepatitis B Virus
(HBV) Vaccine Additional Billing Info for Hepatitis
90740 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose B Vaccinations: *
Administration Codes: schedule), for intramuscular use
(for other than
90743 – Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use OF BILL
Rural Health Clinic 71x
For OPPS hospitals (TOB 90744 – Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), Scheduled doses (RHC) Independent
34x) billing for the Hepatitis for intramuscular use required
Federally Qualiﬁed 73x
B vaccine administration: Health Center (FQHC)
90746 – Hepatitis B vaccine, adult dosage, for intramuscular use
Immunization administration Revenue Code: 052x
90747 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose
90472 schedule), for intramuscular use *While Hepatitis B is a covered vaccine that is given by
Each additional vaccine RHCs and FQHCs, it does not constitute a billable visit.
Diagnosis Code: V05.3
Current Procedural Terminology © 2007 American Medical Association. All Rights Reserved.
Frequently Asked Questions
• Enrolled providers may roster bill for ﬂu and pneumococcal
Does a Part B deductible or coinsurance apply for adult immunizations covered by Medicare? vaccinations even if they are not a mass immunizer.
Neither a Part B deductible nor coinsurance applies to the inﬂuenza virus or pneumococcal vaccines. However, a Part B deductible
plus 20 percent of the Medicare coinsurance amount applies to the Hepatitis B Virus (HBV) vaccine. • All physicians, non-physician practitioners, and suppliers who
administer the inﬂuenza virus vaccination and the pneumococcal
If a beneﬁciary receives a ﬂu vaccination more than once in a 12-month period, will Medicare still pay for it? vaccination must take assignment on the claims for the vaccine.
Yes. Medicare pays for one ﬂu vaccination per ﬂu season; however, a beneﬁciary could receive the ﬂu vaccine twice in a calendar • Inﬂuenza, pneumococcal, and hepatitis B vaccinations and their
year for two different ﬂu seasons and the provider would be reimbursed for each. For example, a beneﬁciary could receive a ﬂu administration are covered Part B beneﬁts and are NOT covered
vaccination in January 2008 for the 2007-08 ﬂu season and another ﬂu vaccination in November 2008 for the 2008-09 ﬂu season and Part D beneﬁts.
Medicare would pay for both vaccinations.
Will Medicare pay for the pneumococcal vaccination if a beneﬁciary is uncertain of his or her vaccination history? Resources
Yes. If a beneﬁciary is uncertain about his or her vaccination history in the past ﬁve years, the vaccine should be given and Medicare
will cover the revaccination. If a beneﬁciary is certain that more than ﬁve years have passed, revaccination is not appropriate unless The Guide to Medicare Preventive Services for Physicians,
the beneﬁciary is at highest risk. Providers, Suppliers, and Other Health Care Professionals
Does Medicare cover the HBV vaccine for all Medicare beneﬁciaries? web-061305.pdf
No. Medicare provides coverage for certain beneﬁciaries at medium to high risk for HBV. These individuals include those with End Inﬂuenza (Flu) Season Educational Products and Resources
Stage Renal Disease (ESRD), persons who live in the same household as an HBV carrier, and workers in healthcare professions who http://www.cms.hhs.gov/MLNProducts/Downloads/ﬂu_products.pdf
have frequent contact with blood or blood-derived body ﬂuids during routine work.
CMS Website Adult Immunization Web Page
When a beneﬁciary receives both the inﬂuenza and pneumococcal vaccines on the same visit, would a provider continue to report http://www.cms.hhs.gov/AdultImmunizations/
separate administration codes for each type of vaccine?
Yes. Although the provider would use diagnosis code V06.6 when an individual receives both vaccines, separate administration codes Medicare Claims Processing Manual –
for inﬂuenza (G0008) and pneumococcal (G0009) should be reported. Chapter 18, Preventive and Screening Services
Can the inﬂuenza, pneumococcal, and HBV vaccinations all be roster billed?
No. Only the inﬂuenza and pneumococcal vaccines are eligible for roster billing. Roster billing does not apply to the HBV vaccine. Medicare Beneﬁt Policy Manual –
Chapter 15, Section 126.96.36.199 - Immunizations
What is a mass immunizer? http://www.cms.hhs.gov/manuals/downloads/bp102c15.pdf
A mass immunizer offers ﬂu and/or pneumococcal vaccinations to a large number of individuals and may be a traditional Medicare
provider or supplier or a nontraditional provider or supplier (such as a senior citizen’s center, a public health clinic, or community Adult Immunizations Brochure
pharmacy). Mass immunizers must submit claims for immunizations on roster bills and must take assignment on both the vaccine http://www.cms.hhs.gov/MLNProducts/downloads/Adult_
and its administration. A mass immunizer should enroll with the carrier or Part A/B Medicare Administrative Contractor (A/B MAC) Immunization.pdf
prior to ﬂu season. Please see the next question for more enrollment information.
CDC Vaccines & Immunizations
Do providers that only provide immunizations need to enroll in the Medicare Program? http://www.cdc.gov/vaccines/default.htm
Yes. Providers must enroll in the Medicare Program even if immunizations are the only service they will provide to beneﬁciaries.
They should enroll as provider specialty type 73, Mass Immunization Roster Biller by completing Form CMS-855I for individuals or For beneﬁciary-related information
Form CMS-855B for a group. Visit http://www.cms.hhs.gov/MedicareProviderSupEnroll/ to locate these forms. Providers who do http://www.medicare.gov
not provide other covered services to Medicare beneﬁciaries complete only the portion of the enrollment form that applies to mass 1-800-MEDICARE (1-800-633-4227)
immunizers. New providers must also ﬁrst receive a National Provider Identiﬁer (NPI) prior to enrollment. Visit https://nppes.cms.hhs. TTY users (1-800-486-2048)
gov for NPI enrollment information.
The Medicare Learning Network (MLN) is the brand name for
ofﬁcial CMS educational products and information for Medicare
May a single claim form be submitted containing information for both the pneumococcal and inﬂuenza vaccinations when the fee-for-service providers. For additional information visit the
vaccinations are administered on the same visit and roster billed? Medicare Learning Network’s web page at
No. Separate CMS claims must be used for each vaccine. Each claim must have an attached roster bill listing the beneﬁciaries who http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
received that type of vaccination.
This quick reference information was prepared as a service to the public and is not intended to grant rights or impose obligations. This quick reference information may contain references or links to statutes, regulations, or other policy
materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the speciﬁc statutes, regulations and other
interpretive materials for a full and accurate statement of their contents.
Current Procedural Technology (CPT) is copyright 2007 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable FARS/DFARS Restrictions Apply to Government
Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
The International Classiﬁcation of Diseases, 9th Revision, Clinical Modiﬁcation (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Ofﬁce, is the only ofﬁcial
Federal government version of the ICD-9-CM. ICD-9-CM is an ofﬁcial Health Insurance Portability and Accountability Act standard.
Medicare Resources April 2010
Important Messages Measures/Codes
There are 153 Quality Measures established for 2009, of
which 52 are new measures that address areas such as:
Physician Quality Reporting Initiative osteoarthritis, back pain, melanoma, oncology, coronary
(PQRI) artery disease, and hepatitis, while 18 of the new
The Medicare Improvements for Patients and Providers measures are reported exclusively through registries.
Act of 2008 (MIPPA) (Pub. L. 110-275) made the PQRI In addition, PQRI measures can be reported for seven
program permanent, but only authorized incentive (7) measures groups in 2009. Measures groups were
payments through 2010. Eligible professionals who created for specific conditions that are addressed by at
meet the criteria for satisfactory submission of quality least 4 measures that share a common denominator
measures data for services furnished during the specification: Diabetes Mellitus, Chronic Kidney Disease,
reporting period, January 1, 2009 - December 31, 2009, Preventive Care, Coronary Artery Bypass Graft Surgery,
will earn an incentive payment of 2.0 percent of their Rheumatoid Arthritis, Perioperative Care, and Back Pain.
total allowed charges for Physician Fee Schedule (PFS) The complete listing of 2009 quality measures
covered professional services furnished during that is available at: http://www.cms.hhs.gov/PQRI/
same period (the 2009 calendar year). Downloads/2009_PQRI_MeasuresList_030409.pdf.
Eligible Professionals Reporting
Under PQRI, covered professional services are those Eligible professionals do not have to enroll or file an
paid under or based on the Medicare Physician Fee intent to participate in the PQRI program. Professionals
Schedule (PFS). To the extent that eligible professionals who choose to participate by reporting quality
are providing services which get paid under or based on measures data through claims can simply report the
the PFS, those services are eligible for PQRI. appropriate quality data codes on service lines of Part
The following professionals are eligible to participate in B Physician Fee Schedule (PFS) professional-services
y Medicare physicians Professionals participating in a registry that self-
Doctor of Medicine nominates and qualifies to submit data for the
Doctor of Osteopathy 2009 PQRI incentive should expect to receive more
Doctor of Podiatric Medicine information from the registry on how to participate.
Doctor of Optometry
Doctor of Oral Surgery Analysis and Payment
Doctor of Dental Medicine Eligible professionals who satisfactorily report quality-
Doctor of Chiropractic measures data for services furnished January 1, through
y Practitioners December 31, 2009, will earn a single consolidated
Physician Assistant incentive payment in mid-2010. The incentive payment
Nurse Practitioner will be 2.0% of estimated total allowed charges for
Clinical Nurse Specialist covered Medicare Part B Physician Fee Schedule
Certified Registered Nurse Anesthetist (and services provided January 1 through December 31,
Anesthesiologist Assistant) 2009. Incentive payments will be paid to the Taxpayer
Certified Nurse Midwife Identification Number (TIN) under which the incentive-
Clinical Social Worker earning professional submitted PQRI claims.
As required by statute, the 2009 PQRI includes validation
processes. The determination of satisfactory reporting
will itself serve as a general validation because the
Audiologists (as of 1/1/2009)
analysis will assess whether quality-data codes are
appropriately submitted in a sufficient proportion of
the instances when a reporting opportunity exists.
In addition, for those professionals who achieve a
Qualified Speech-Language Therapist
reporting rate at or above 80% for each of fewer than
three PQRI measures submitted through claims, a
measure-applicability validation process will determine
whether they should have submitted quality-data codes
for additional measures.
Medicare Resources April 2010
Additional Information CRC will follow the claims until they’re adjudicated, and
then compare the contractor’s final claims decision
Medicare providers may access additional PQRI
with its own. Instances of incorrect processing (e.g.,
information, including a complete list of quality
due to questions of medical necessity, inappropriate
measures from the CMS website at: http://www.cms.
application of medical review policy, etc.) become
targets for correction or improvement in appropriate
E-Prescribing Incentive Program ways. Consequently, it is CMS’s intent that the Medicare
Section 132 of the Medicare Improvements for Patients Trust Fund benefits from improved claims accuracy and
and Providers Act of 2008 (MIPPA) authorizes a new and payment processes.
separate incentive program for eligible professionals
who are successful electronic prescribers (e-Prescribers)
How Else Are Providers And Suppliers
as defined by MIPPA. The program began January 1, Impacted By CERT?
2009 and provides incentives for eligible professionals Providers and suppliers of the sampled claims will
who are “successful e-prescribers”. For more information be asked during the course of the CERT review, to
about the Medicare e-prescribing incentive program provide additional information (e.g., medical records,
you can download the “Medicare’s Practical Guide certificates of medical necessity, etc.) for CRC staff to
to the E-prescribing Incentive Program” or visit the verify services billed were delivered, medical necessity
e-prescribing incentive program information page at for the services rendered, and the appropriateness of
http://www.cms.hhs.gov/ERXIncentive/. the claims processing procedures. If contacted, you will
be provided with the details regarding the information
needed to complete the review.
Comprehensive Error Rate It is the responsibility of the provider and supplier to
Testing (CERT): What Does
furnish all documentation upon request. The requested
documentation must be sent to the address provided in
This Mean to You?
the request letter. If the documentation is not received
within the timeframe provided, CRC determines the
services billed should be denied for insufficient or no
What is Comprehensive documentation, ultimately resulting in an overpayment
Error Rate Testing (CERT)? request. CRC’s findings are sent to CIGNA Government
In order to improve the processing and medical decision Services. CIGNA then recoups all monies paid by
making involved with payment of Medicare claims, Medicare that CRC deems should be denied or reduced.
CMS began a new program effective August 2000. This Documentation should reflect the medically necessary
program is called Comprehensive Error Rate Testing level of service required by the problem and the care
(CERT) and was implemented in order to achieve goals actually rendered, which should be reflective of the
of the Government Performance and Results Act of claim submitted.
1993, which sets performance measurements for federal
Why does CRC want our medical records?
CRC requests documentation from providers through
Under CERT, an independent contractor (known as the a random monthly sampling to determine whether
CERT Documentation Contractor (CDC)) will select a claims are paid appropriately based on the provider’s
random sample of claims processed by each Medicare documentation of the service. The claims payment error
contractor. The CERT Review Contractor’s (CRC) medical rate is calculated based on errors such as:
review staff (to include nurses, physicians, and other
y A system processing error
qualified healthcare practitioners) will then verify that
y Incorrect medical review
contractor decisions regarding the claims were accurate
y Provider billing error (coverage or coding)
and based on sound policy. CMS will use CRC’s findings
y Medical records that do not support the service billed
to determine underlying reasons for errors in claims
y Failure to submit documentation
payments or denials, and to implement appropriate
corrective actions aimed toward improvements in the If the provider does not submit the medical records for
accuracy of claims and systems of claims processing. the claim in question, an overpayment will be assessed
On a monthly basis, the CDC will request a small for that claim and the provider will have to repay the
sample of claims—approximately 200—from each monies requested.
contractor, as the claims are entered into their system.
Medicare Resources April 2010
Which Medical Record Should We Send? for ensuring that services are rendered in the most
Follow the directions in the Request for Medical Records cost-effective manner (i.e., consideration is given to the
from CDC. A list of required documents is included in location of service and the complexity and level of care
the letter, along with a bar coded cover sheet, which provided).
must be attached. Send the records to the address For Medicare to ensure that payment is made only for
on the CDC request letter. Please, include all the reasonable and necessary services, CIGNA Government
information requested for the service in question. Services is required to perform extensive data analysis
Any time you receive a letter from CDC requesting on the frequency a service is allowed. The focus is
documentation, be sure to send the requested on how providers and their services are trended and
documentation to CDC with a copy of the bar coded what Medicare does through the Medical Review (MR)
cover sheet within 45 days from the date of the initial process when coverage and utilization problems are
request. This information may now be faxed (preferred identified, resulting in various plans of action to correct
method) to 240.568.6222 or mailed to the following the problem.
address: The goal of the MR program is to reduce payment error
CERT Documentation Office by identifying and addressing billing errors concerning
9090 Junction Drive, Suite 9 coverage and coding made by providers. To achieve the
Annapolis Junction, MD 20701 goal of the MR program, CIGNA Government Services:
Note: Please do not send the requested records to y Proactively identifies potential billing errors
CIGNA Government Services. concerning coverage & coding made by providers
through analysis of data (e.g., profiling of providers,
services, or beneficiary utilization) and evaluation of
Will We Be In Violation of the Health other information (e.g., complaints, enrollment, and/
Insurance Portability and Accountability or cost report data);
Act (HIPAA) standards? y Takes action to prevent and/or address the identified
HIPAA Privacy Rule permits disclosure of personal error. Errors identified will represent a continuum of
health information to carry out treatment, payment, or intent, and;
health care operations. When beneficiaries enroll in the y Publishes Local Coverage Determinations (LCDs)
program, they are informed of Medicare’s use of their to provide guidance to the public and medical
personal health information to carry out health care community about when items and services will be
operations. CRC performs health care operations as a eligible for payment under the Medicare statute.
business associate of CMS with respect to the HIPAA Progressive Corrective Action
Privacy Rule. Providing the requested documentation Progressive Corrective Action (PCA) is an operational
does not violate the minimum necessary provision of principle upon which all medical review activity
the HIPAA Privacy Rule and does not require additional is based. It serves as an approach to performing
beneficiary authorization. medical review and assists contractors in deciding
how to deploy medical review resources and tools
Is There Any Risk In Payment When CRC appropriately. It involves data analysis, error detection,
Reviews a Claim/Line? validation of errors, provider education, determination
CRC has the same authority to deny claims that do not of review type, sampling claims, and payment recovery.
meet Medicare coverage guidelines as the Carrier or The contractor may use any information they deem
Fiscal Intermediary (FI). Therefore, if CRC makes a denial necessary to make a prepayment or postpayment
on a previously approved claim/line, an overpayment claim review determination. This includes reviewing
will be assessed and repayment of overpaid dollars will any documentation submitted with the claim as well
be required from that provider. as soliciting documentation from the provider or other
entity when the contractor deems it necessary and in
accordance with CMS guidelines.
The Medical Review Process There are various types of corrective actions that may
All Medicare contractors are required to ensure that be taken in the event a problem is discovered during
reimbursement is made only for those services that the PCA process. Actions will be taken according to the
are reasonable and necessary. For medically necessary classification of the problem, as appropriate. Possible
services, CIGNA Government Services is also responsible actions that may be taken include:
Medicare Resources April 2010
y Development of provider education and feedback asp.
y Development of a Local Coverage Determination
y Performance of pre-payment review Local Coverage Determinations (LCDs)
y Performance of post-payment review A Local Coverage Determination (LCD) is a formal
y Performance of proactive measures related to MR statement developed through a specifically-defined
records requests process that:
y Defines the service
Provider Outreach and Education y Provides information about when the service is
While the medical review process assures appropriate considered reasonable and necessary
claims payment through the review of claims, the y Outlines any coverage criteria and/or specific
Provider Outreach and Education (POE) program assures documentation requirements
appropriate claims payment through proactive provider y Provides specific coding and/or modifier information
education. The success of this goal is measured by the y Provides references upon which the policy is based
continual reduction in the national claims payment
error rate. Inherent to that success is a comprehensive Local Coverage Determinations are developed to
effort to educate healthcare providers on coverage and specify under what clinical circumstances a service
coding principles to ensure correctly billed claims. is reasonable and necessary. They serve as an
administrative and educational tool to assist providers in
Medical review and CERT findings drive CIGNA submitting claims correctly for payment.
Government Services’ POE efforts. CIGNA Government
Services analyzes medical review data, prioritizes issues, LCDs outline how contractors will review claims to
and designs educational interventions that best address ensure that they meet Medicare coverage and coding
incorrect billing issues. requirements. Contractors must ensure that all LCDs
are consistent with all statutes, rulings, regulations,
Along with planned MR activities, provider feedback and and national coverage, payment, and coding
education developed according to the review findings policies. All current, draft, and archived LCD policies
are an essential part of the PCA process. When individual are available under the “Medical Review Policies”
reviews are conducted, focused provider education section of the following Web page: http://www.
is carried out through direct contact between CIGNA cignagovernmentservices.com/partb/coverage/index.
Government Services and the provider via telephone, html.
letter, and/ or face-to-face contact. The overall goal of
providing feedback and focused provider education is Submitting Documentation
to ensure the development of proper billing practices.
This helps to ensure that claims are submitted and paid
for Medical Review
correctly because the provider better understands what To perform an effective medical review of services
to expect when a claim is submitted to Medicare. rendered by a provider, it may be necessary for the
provider to furnish specific documentation upon
Coverage Determinations request by CIGNA Government Services. The following
There are two different types of coverage policies: points should be kept in mind:
y National Coverage Determinations (NCD)
y Every service billed must be documented since there
y Local Coverage Determinations (LCD)
must be clear evidence in the patient’s record that the
service, procedure, or supply was actually performed
National Coverage Determinations (NCDs) or supplied.
National Coverage Determinations describe whether y The medical necessity for choosing the procedure,
specific medical items, services, treatment procedures, service, or medical supply must be substantiated.
or technologies can be paid for under Medicare in y Every service must be coded correctly. All diagnosis
accordance with title XVIII of the Social Security Act, and codes must be coded to the highest level of
in Medicare regulations and rulings. The NCD database specificity, and procedure codes, diagnosis codes, and
is organized by categories, e.g., medical procedures, modifiers must be current.
supplies, and diagnostic services. y The documentation must clearly indicate who
performed the procedure or supplied the equipment.
Once published, an NCD is binding for all Medicare
y Although it may be dictated or transcribed, legible
contractors and providers or suppliers. These policies
documentation is required. Existing documentation
are national in scope and may be accessed on the CMS
may not be embellished. However, additional
website at: http://www.cms.hhs.gov/center/coverage.
documentation that supports a claim may be
Medicare Resources April 2010
submitted. First Level of Appeal: Redetermination
y Voluntary disclosure of information by the provider A redetermination is an examination of a claim made
is encouraged. When an error is discovered, any by carrier personnel that are independent of those
overpayments should be returned to Medicare. originally involved. The appellant (the individual making
the appeal) has 120 days from the date of the initial
Medical Review Frequently claim determination to file an appeal. A redetermination
can be requested in writing, to the local Medicare
Asked Questions (FAQs) carrier. No monetary threshold is required to be met.
CIGNA Government Services will address at least
quarterly “Frequently Asked Questions” related to Requesting a Redetermination in Writing
coverage and Local Coverage Determination policy A request for a redetermination can be filed on Form
issues. CMS-20027, available at: http://www.cms.hhs.gov/
CMSForms/CMSForms/list.asp, or in any other format
Providers may access these quarterly FAQs at: that includes:
y Beneficiary name;
y Medicare Health Insurance Claim (HIC) number;
Providers may submit questions to the website at: y Name and address of physician or supplier;
y Date of initial determination;
y Date(s) of service the initial determination was issued;
contact/onlinehelp.html y Which item(s) if any, and/or service(s) are at issue in
The Medicare y Signature of the appellant.
Appeals Process Incoming redetermination requests submitted without
necessary supporting documentation will be given
Appealing Medicare Decisions second priority to redetermination requests submitted
Once the initial claim determination is made, physicians with appropriate documentation. Consequently,
and suppliers may have the right to appeal. The right to determinations or decisions on redetermination
appeal claim denials generally depends on whether the requests that are submitted without appropriate
claim was assigned documentation to support the contention that the
or unassigned. initial determination was incorrect could possibly be
y For assigned claims, the physician or supplier may Providers should be specific about what they want to
request a redetermination. appeal and why. A copy of the claim and any supporting
y For nonassigned claims, typically only the documentation should be sent with the request for a
beneficiary or his/her representative can request redetermination. Mark your envelope to the attention
a redetermination. A physician or supplier may of the Appeals department and clearly state in the
request a redetermination if he or she was liable inquiry that a redetermination is being requested. Do
for services that were denied or reduced based not submit second requests or check the status of your
on medical necessity guidelines. The physician or redertermination before the 60 days have elapsed.
supplier may also request a redetermination on
behalf of the beneficiary with the beneficiary’s signed Written requests for redeterminations should be sent to:
authorization. Idaho Providers:
CIGNA Government Services
Five Levels in the Appeals Process Attn: Appeals Department
Medicare offers five levels in the Part B appeals process. PO Box 22990, Nashville, TN 37202
The levels, listed in order, are:
North Carolina Providers:
y Redetermination; CIGNA Government Services
y Reconsideration; Attn: Appeals Department
y Hearing with an Administrative Law Judge (ALJ); PO Box 24770, Nashville, TN 37202
y Departmental Appeal Board review; and
y Judicial review in US District Court.
Medicare Resources April 2010
Tips for Requesting Redeterminations: Second Level of Appeal: Reconsideration
y A review must be requested within 4 months of the A reconsideration may be requested, if the appellant is
original claim determination (i.e., the date on the dissatisfied with the redetermination decision. There is
Medicare Remittance Notice). no minimum amount in controversy required. Effective
y When documentation is submitted with your January 1, 2006, a Qualified Independent Carrier
request, be sure the patient’s name is identified on (QIC), independent from the carrier processing the
every page. The Appeals department cannot accept redetermination, will conduct the reconsideration to
documentation that does not indicate the name of determine if the carrier’s decision followed Medicare
the patient even if the name is on previous pages of guidelines.
Filing a Reconsideration Request
y If you wish to appeal remarks code CO-97 (Medicare
does not pay for these charges because the cost A written reconsideration request must be filed
of the care before surgery is part of the approved within 180 days of the redetermination. The request
amount for the surgery.”), be sure the modifier you must clearly explain why the redetermination was
append is applicable to the actual procedure code. unsatisfactory. The request, a copy of the MRN, and any
y Modifiers 24, 25, and 57 should only be appended on other useful documentation should be sent to the QIC
evaluation and management procedure codes. The presiding over the case. Providers may also choose to
Appeals department has received corrected claims complete the Form CMS-2033, available at: http://www.
with these modifiers appended to a surgical code, cms.hhs.gov/CMSForms/CMSForms/list.asp, to request a
which isn’t appropriate. reconsideration. Instructions for contacting the QIC will
y Modifiers 54, 55, 58, 78, and 79 should only be be included in the provider’s notice of redetermination
appended on surgical procedure codes. decision.
y If you wish to appeal remarks code CO-50, (The Third Level of Appeal: Administrative Law Judge
information we have does not support the need for If at least $120.00 remains in controversy following the
this service.), effective October 1, 2002, the Appeals QIC’s decision, a request can be made within 60 days of
department can no longer add any diagnosis to a receipt of the QIC determination for an Administrative
claim. If the documentation submitted supports Law Judge (ALJ). The QIC decision will include
another diagnosis than what was submitted on the instructions for obtaining an ALJ hearing. Hearing
initial claim, they cannot add that diagnosis, unless preparation procedures are set by the ALJ.
the claim has the new diagnosis on it. This is part of
HIPPA guidelines. Fourth Level of Appeal: Departmental Appeals
Redetermination Decision Notification: If the appellant is dissatisfied with the ALJ’s decision,
When the redetermination request is received from an he or she may request a review by the Departmental
appellant (for assigned claims), a written response will Appeals Board (DAB). There are no requirements
be sent: regarding the amount of money in controversy. The
If: The original Decision is upheld… request for a DAB review must be submitted within 60
Then: A detailed letter will be sent explaining why days of receipt of the ALJ’s decision, and should specify
additional payment cannot be allowed. the issues and findings by the ALJ being contested.
If: The original claim decision can be changed Fifth Level of Appeal: Judicial Review
(full reversal) and payment is due… in US District Court
Then: The beneficiary will receive an adjusted MSN, If $1,220.00 or more is still in controversy following the
and the physician or supplier will receive DAB’s decision, judicial review before a US District Court
an adjusted RA. A check will be issued for the judge can be considered. The appellant must request a
service(s)/items(s). US District Court hearing within 60 days of receipt of the
If: A portion of the claim can be allowed
Then: The beneficiary will receive an adjusted MSN, For Additional Information:
and the physician or supplier will receive
For additional information about the appeal
an adjusted RA. A Medicare Redetermination
process, please visit: http://www.cms.hhs.gov/
Notice (MRN) will be sent explaining the
OrgMedFFSAppeals on the Web.
rationale for the decision. A check will be
issued for the allowed service(s)/item(s).
Medicare Resources April 2010
Provider Enrollment communications to providers.
CIGNA Government Services sends a courtesy letter to
providers within 15 days acknowledging receipt of the
Important Medicare Provider Enrollment application. The letter states that complete and accurate
Information from CIGNA Government applications are processed timely. If a complete and
Services to North Carolina and Idaho accurate application is received, a change of information
or reassignment is processed within 45 days and initial
Providers enrollments within 60 days. The courtesy letter also
For the most current Provider Enrollment information states that if the application was not complete and
and important updates, please visit the CIGNA accurate, the provider will receive a letter within 60
Government Services website at: http://www. days requesting additional information. CMS allows
cignagovernmentservices.com/partb/enrollment/index. extended processing times for incomplete or inaccurate
html applications, up to 180 days.
From the time a provider receives a letter requesting
To Facilitate the Enrollment Process, Before You additional information, the provider is controlling the
Submit an Application . . . remaining time required to complete the application.
y You MUST have a National Provider Identifier (NPI). Therefore, it is imperative that providers or their
An NPI is required for an enrolled provider to change representatives respond timely and fully to the requests
information or for a new provider to apply for a for information. If a provider doesn’t respond timely to
Medicare number. Your application will be delayed the request for additional information, the application
if you fail to provide an NPI with your original will be rejected and returned. To reapply, the provider
submission. See below for additional details. will need to complete an entirely new application and
y You MUST agree to accept Electronic Payment. start the process over.
This federally-mandated requirement applies to
established providers submitting a change of How to Submit a Provider
information who are not already set up for electronic Enrollment Application
payment, as well as all new enrollees. An Electronic All enrollment applications/forms must be submitted via
Funds Transfer Authorization Agreement (EFT) form regular mail to:
must be included with your application request.
Your application will be delayed if you fail to include CIGNA Government Services
a completed EFT Agreement with your original Provider Enrollment Department
submission. See below for additional details. PO Box 25226, Nashville, TN 37202
y You MUST submit a COMPLETE AND ACCURATE Special mail handling may delay the delivery and
enrollment application. You must comply with processing of your application.
all the directions on the enrollment applications,
including submission of the mandatory attachments. Current Enrollment Process Details
Incomplete or inaccurate applications cannot be y To obtain the most current versions of the CMS-855
processed. applications, please download the forms from the
Please know that it may take up to 180 days to complete CMS website at: http://www.cms.hhs.gov/CMSForms/
applications that are submitted with incomplete or CMSForms/list.asp.
inaccurate information. y Contractors are required to develop any missing
information in any required field.
Checking the Status of Your Application For example:
It is not an expectation of the Centers for Medicare & y If the zip code is missing on an address, we must send
Medicaid Services (CMS) that contractors provide status a letter to the provider requesting a resubmission of
updates for applications in process. CIGNA Government the address page to include the zip code. This would
Services provides a toll-free number for providers who also require the provider to submit a new signature
need enrollment information or for those inquiring page with the corrected address page. This will delay
about information CIGNA Government Services has the processing of the application.
requested to support the providers’ applications. CIGNA y All new enrollments or changes to existing provider
Government Services does not provide status updates information must include the individual National
on applications; however, providers can determine Provider Identifier (NPI) in the designated sections
approximate processing time through the following of the application. If an individual is joining a group,
Medicare Resources April 2010
the group NPI is also required. To apply for an NPI, physicians and non-physician practitioners should
you may access the NPI application form at: http:// change passwords periodically, at least once a
www.cms.hhs.gov/CMSForms/CMSForms/list.asp. year. Please read the document entitled, “Medicare
If you need additional information regarding NPI, Physician and Non-Physician Practitioners -
you may contact the Enumerator, Fox Systems, Protecting Your Privacy, Protecting Your Medicare
directly by calling 1-800-465-3203, or e-mail them at: Enrollment Record.” which is available in the
email@example.com. Download section of this page.
y A copy of the NPI notification letter from the 2. Go to Internet-based PECOS by clicking on the link
enumerator must be attached to every application, found in the section titled, “Related Links Outside
even if it was previously submitted with another CMS” (at the bottom of this page) and complete,
application. review, and submit the electronic enrollment
y At the time of initial enrollment or a change to application via Internet-based PECOS.
existing provider information (if the provider is not
receiving electronic payment), an Electronic Funds 3. Print, sign and date the 2-page Certification
Transfer Authorization Agreement (CMS-588) must be Statement and mail the Certification Statement
submitted. The CMS-588 form may be downloaded and all supporting paper documentation to the
at: http://www.cms.hhs.gov/CMSForms/CMSForms/ Medicare contractor within 7 days of electronic
list.asp submission. Note: A Medicare contractor will not
y If a provider wants to enroll as a Participating Provider process an Internet enrollment application without
(PAR), the Participation Provider Agreement (CMS-460) the signed and dated Certification Statement. In
must be included with the enrollment application. addition, the effective date of filing an enrollment
The provider has application is the date the Medicare contractor
up to 90 days after enrollment to submit a PAR receives the signed Certification Statement that is
Agreement. The current PAR Agreement form can be associated with the Internet submission.
downloaded at: http://www.cms.hhs.gov/CMSForms/ Internet Based PECOS is available online at: https://
CMSForms/list.asp. The effective date of the PAR pecos.cms.hhs.gov/pecos/login.do.
Agreement cannot be prior to the contractor’s
documented receipt date of the PAR Agreement. Common Errors that Delay the
y Providers must attach an actual copy of their medical/ Enrollment Process
professional license to their initial enrollment
y The provider submits an outdated application. These
applications. An “internet copy” is not acceptable.
forms will be immediately rejected and returned. They
Internet Based PECOS cannot be processed. All applications must include a
2006 release date.
The Centers for Medicare & Medicaid Services (CMS) y The application does not include the NPI or NPI
has implemented an Internet-based Medicare provider notification letter. Providers must obtain an NPI before
enrollment process, known as Internet-based Provider submitting a Medicare enrollment application. The
Enrollment, Chain and Ownership System (PECOS). NPI must be entered in the appropriate field on the
Internet-based PECOS is available to physicians, non- application(s) and the NPI notification letter must be
physician practitioners, and provider and supplier attached.
organizations in all States and the District of Columbia. y A Physician Assistant submits a CMS-855R instead of a
Internet-based PECOS will allow physicians, non- CMS-855I application.
physician practitioners, and provider and supplier y A provider fails to submit a newly signed certification
organizations the option of enrolling, making a change page when submitting changes to
in their Medicare enrollment information, viewing the application.
Medicare enrollment information, or tracking the status y A provider submits a photocopied or faxed signature
of their Medicare enrollment applications throughout page. Signature pages must contain an original
the Internet submission process. signature.
y Section 4B of the CMS-855R (Authorized/Delegated
For physicians and non-physician practitioners, there
Official) is not signed or dated.
are three basic steps to completing an enrollment
y An application is submitted to the incorrect Part B
action using Internet-based PECOS. Physicians and non-
contractor, or a DMERC application (CMS-855S) is
physician practitioners must:
submitted to the Part B contractor.
1. Have an NPPES User ID and password to use y A group submits a CMS-855A application (for Part A)
Internet-based PECOS. For security reasons,
Medicare Resources April 2010
to a Part B Contractor.
y All required sections on the CMS-855 applications are Electronic Data
not completed and/or all questions are not answered.
y The CMS-855 application is missing the date the Interchange (EDI)
supplier and/or individual started rendering services
at that location. The Benefits of Electronic Communication
y The CMS-855B does not include one managing of Data and Information
employee in addition to listing all owners/directors/
y Reduces Administrative Processes - Submitting
officers and/or partners. This section is also to be
Medicare claims electronically greatly reduces
completed for any delegated officials listed on the
the cost by eliminating the manual paper claims
completion process. By billing claims electronically
y The section of the CMS-855 pertaining to adverse
providers and staff have more time for patients and
legal actions is not completed.
y Section 15 of the CMS-855B is not signed by the
y Reduces Postal Expenses - Electronic claims
submission to the Medicare program will virtually
eliminate the post office expenses from your claims
Additional Provider Enrollment Tips: administrative overhead.
y If applying under a Tax Identification Number, y Increases Accuracy in Claims - It has been proven
you must submit IRS documentation. Acceptable that less manual handling of claims, results in less
documentation includes a CP575 (a computer- likelihood of manual errors. EDI moves your data
generated letter), a Form 990, a quarterly tax coupon electronically (without human intervention – and
or other IRS correspondence that contains the without creating human errors in the process). EDI
applicant’s legal business name and tax identification improves efficiencies on your end and ours and allows
number. A W-9 and SS-4 Form are not acceptable. your data to move into the processing system. Most
y Individual practitioners joining a group are not claims complete processing without intervention.
required to submit an Electronic Funds Transfer y Improves Office Management
Agreement (EFT) (CMS-588). For groups not currently Less staff time used for claims follow-ups and
set up for EFT, only one EFT agreement is required for inquiries.
the entire group. More time available for patient services.
y If you are a new provider that will be reassigning your Will positively impact your office’s bottom line.
benefits to an entity, you must complete the CMS- y Claims Are Received, Processed, Paid Faster -
855R application along with the CMS-855I application. Electronic claims without errors are actually received,
y Sole owners must complete the CMS 855I application. processed and paid faster. The claims payment floor,
The requirement of the 855R to reassign to one’s own allows electronic claims to be released for payment
entity has been eliminated. on the 14th day after receipt. For paper claims, the
y The legal business name must be written on the federal requirement is 27 days for payment release.
CMS-855 application exactly as it appears on the IRS
document. EDI Products and Services
Electronic Medicare Claims
Submitting your claim information electronically has
proven to be the most efficient way to process your
claims -- and you’re paid sooner.
Electronic Beneficiary Eligibility (available to
participating providers only)
The capability to verify beneficiary eligibility for covered
Electronic Claims Status Inquiry
Find out if your claims have been paid, denied, or are still
pending. Part B EDI accepts the ANSI 4010A1 276/277
Claims Status Inquiry/Claims Status Response paired
Medicare Resources April 2010
transaction sets. Claims Status Inquiry (CSI) allows CIGNA Quarterly Medicare Bulletin
providers to check the status of claims within three CD-ROM includes the EDI Enrollment forms on it.
days of successful transmission. There is a separate y For providers with internet access the EDI Enrollment
application required for this service. Please contact the forms and instructions can be downloaded at: http://
EDI Support Services Department at: 1.866.520.4022 for www.cignagovernmentservices.com/partb/forms/
ID or 1.866.352.1608 in NC for more information. index.html
y We will be happy to mail or fax the enrollment forms
Electronic Receipt Listing (ERL) to your office. Please call 1.866.520.4022 for Idaho-
An ERL is a report that list claims received by CIGNA based providers assistance. For North Carolina based
Government Services, in an electronic list. These reports providers, please call 1.866.352.1608 for assistance.
can be provided to the provider, their contracted
clearinghouse, or billing service should the provider Locating Web-based forms and resources at:
request it. This report also lists all claims that were http://www.cignagovernmentservices.com
rejected and are not in the system for processing.
y EDI Enrollment Forms and instructions:
The information on this report aids you in promptly
correcting and resubmitting the claims that were
y Glossary-provides common EDI terms and definitions:
Electronic Remittance Notice (ERN) http://www.cignagovernmentservices.com/partb/
An ERN is an electronic payment report, listing claims y Products & Services-explains EDI functions available
that have been paid and/or denied. The once enrolled:
ERN may permit the provider to utilize automatic http://www.cignagovernmentservices.com/partb/
posting capability if they use a practice management claims/edi/services.html
system. y Technical Support-provides internal CIGNA
Government Services EDI contact information: http://
Electronic Funds Transfer (EFT) www.cignagovernmentservices.com/partb/claims/
EFT automatically transfers Medicare payments to the edi/support.html
provider’s banking account. This works the same way y HIPAA Approved Vendor and Trading Partners List
as direct deposit. This service is available through the (Billing Services, Software Vendors,
Provider Enrollment Department at CIGNA Government Clearinghouses): http://www.cignagovernment
Services. For more information on this feature, please services.com/hipaa/partb directory.html
call the Provider Enrollment team at 1.866.520.4007 for
EDI Frequently Asked Questions (FAQ’S)
CIGNA Government Services Free Billing Question: What is required to enroll for Electronic
Software - MCE 3.2 (Medicare Claims Express) Data Interchange (EDI)?
Answer: A completed EDI Enrollment Form and EDI
“Free” HIPAA compliant claim preparation software:
Customer Profile. Both are available at:
y Internet Downloadable copy available
y CD-ROM copy available upon request
y Prepares only Medicare claims and Medicare Question: Can I fax the EDI Customer Profile and EDI
Secondary Payer (MSP) when there is only one Enrollment forms once they
primary payer to Medicare are completed?
y Submits using current ANSI X12 4010A1 format Answer: Yes.
y Operates on IBM or compatible systems Windows © Question: What is your fax number?
98, ME, NT, 2000, XP Answer: 1.336.821.4595 for Idaho and
Additional information available at: North Carolina customers.
http://www.cignagovernmentservices.com/partb/ Question: Who can sign the forms?
claims/edi/billing.html Answer: We require that the provider, a financially
responsible party, or an
Getting Started with EDI authorized official sign all change requests
y For providers who do not have Internet access, the and new enrollments. If you need
Medicare Resources April 2010
additional information regarding Answer: Our goal is to process the EDI applications
authorized and delegated officials, you within 10 business days of receipt.
may contact the EDI Support Services
Department at: 1.866.352.1608. Mandatory Electronic Medicare Claims
CMS has published an MLN Matters article (MM3440),
Question: If I am a member of a group of healthcare
which is available on the Internet at:
providers, do I complete an agreement
for each provider?
Answer: No, generally only one application is
required per group. However, if you are a Medicare Remit Easy Print (MREP)
member of a non-uniform group (North
Carolina members that have a 4 digit Software
group number) please contact the North Are you still using the Standard Paper Remittance
Carolina office at 1.866.352.1608 for (SPR)? Save time and money by taking advantage of
further instruction. FREE Medicare Remit Easy Print (MREP) software now
available for viewing and printing the HIPAA compliant
Question: I want to change my billing service, Electronic Remittance Advice (ERA)! The MREP software
vendor, or clearinghouse, what is needed? gives providers and suppliers the following abilities:
Answer: Complete the EDI Customer Profile. You
can print a copy from our website at: y Easy navigation and viewing of the ERA using your
http://www.cignagovernmentservices. personal computer;
com/partb/forms/index.html y Print the ERA in the Standard Paper Remittance (SPR)
Question: What forms do I complete to update or y Search capability that allows providers and suppliers
change my address or contact the ability to find claims
person name? information easily;
Answer: An EDI Customer Profile. You can print a y Print and export reports about ERAs including denied,
copy from our website at: adjusted and deductible
http://www.cignagovernmentservices. applied claims;
com/partb/forms/index.html y Easy-to-use method to archive, restore and delete
Question: I’m interested in CIGNA MCE free billing imported ERAs
software, what is needed?
Answer: A completed EDI Customer Profile and an Providers and suppliers can view and print as many
MCE User Agreement. If you are not or as few claims as needed. This will be especially
already enrolled in EDI, you must also helpful when you need to print only one claim from
submit a completed EDI Enrollment Form. the remittance advice when forwarding the claim to a
Additional information about MCE is found secondary payer. This free software can save you time
at: http://www.cignagovernmentservices. resolving Medicare claim issues. Take advantage of
com/partb/claims/edi/billing.html the MREP features unavailable with the SPR. In order
to utilize the MREP software, you will need to receive
Question: I tried to download your software and I am a HIPAA compliant ERA. Contact the EDI Help Desk at
asked to provide a password, why? 866.352.1608 for NC and 866.520.4022 for ID to find out
Answer: You must submit a completed EDI more about MREP and/or for information on how to
Customer Profile, MCE User Agreement, receive a HIPAA compliant ERA. Take advantage of this
and if you are not already enrolled in EDI, new software. Begin using MREP today!
you must also submit a completed EDI
Enrollment Form. Once it is received and For additional information on the Medicare Remit Easy
processed, a password will be provided so Print (MREP) please visit:
you can download the software. This http://www.cignagovernmentservices.com/partb/
process allows us to keep track of our MCE claims/edi/easy_print.html.
users, for future upgrades and other
Question: How long does it take for CIGNA
Government Services to process the
Medicare Resources April 2010
Suppression of Standard Paper Remittance Workshops/Seminars
Advice (SPR) to Providers and Suppliers Also CIGNA Government Services offers a number of
Receiving Electronic Remittance Advice (ERA) for workshops and seminars throughout the year at various
45 Days or More locations across the state. The workshops vary in subject
matter, from our annual Medicare Updates workshops
On June 1, 2006, carriers and DME-MACs ceased sending
to our Medicare Basics (101) and Medicare Intermediate
standard paper remittance (SPR) advices to you (or a
(102) seminars. Make sure you are prepared for all of the
billing agent, clearinghouse, or other entity representing
Medicare changes and updates by attending one of our
you), if you have been receiving 835s or electronic
workshops or seminars throughout the year.
remittance advice (ERA) transactions, either directly or
through a billing agent, clearinghouse, or other entity For additional details, including a schedule of upcoming
representing you, for 45 days or more. workshops and seminars, you may visit: http://www.
If you need a paper copy of a remittance advice for
html, and then click on the link to your state-specific
accounts reconciliation or to forward to secondary/
tertiary payers, be aware that the Centers for Medicare
& Medicaid Services (CMS) has developed software that Webinars and Teleconferences
gives you a tool to view and print an 835 in a readable
format locally on your computer. This software is called The Provider Outreach and Education (POE) department
Medicare Remit Easy Print (MREP). Your clearinghouse offers several educational programs through Webinars
may also offer software that allows you to view and print and Teleconferences throughout the year. Webinars
your remittance advice. are live, one-hour, interactive conferences that you
can view online from the comfort of your own office.
Make certain that your billing staffs are aware of these The audio portion of the Webinar is handled just like
changes. Try MREP software to view and print your own a regular telephone call, giving the user the ability to
remittance and see the benefits for yourself. Or, check listen to the presentation and ask questions of the
with your clearinghouse to see if it provides similar presenter. The POE team also occasionally offers regular
software. teleconferences on various subjects to help providers
further understand current Medicare issues.
Provider Outreach For additional details, including a schedule of upcoming
Webinars and teleconferences, you may visit: http://
& Education www.cignagovernmentservices.com/partb/education/
index.html, and then click on the link to your state-
specific education page.
CIGNA Government Services
Education & Workshops Ask the Contractor Teleconferences
CIGNA Government Services offers our customers the CIGNA Government Services hosts quarterly “Ask the
opportunity to learn about Medicare changes that affect Contractor Teleconferences” for Part B providers in Idaho
everyone and receive additional training on current and North Carolina. These teleconferences provide an
policies and guidelines. opportunity to share information, answer questions, and
identify problems in a timely way. Participants learn from
CIGNA Government Services, in conjunction with the
each other’s discussions and receive useful clarifications
Centers for Medicare & Medicaid Services, is working
regarding the different rules and instructions associated
to offer our providers a wider variety of methods and
with coverage, coding, and payment.
technological tools to make education more readily
available, helping to reduce the amount of travel, Providers participate toll-free in their state-specific
challenging schedules, and office hours. teleconference. Representatives from departments
throughout the CIGNA Government Services
The CIGNA Government Services Web Site Events/
organization (Medical Review, Provider Contact Center,
Workshops Home Page located at: http://www.
Claims, Appeals, EDI, Provider Enrollment, MSP, Provider
Outreach and Education, etc.) are available to answer
html is your best source of information for upcoming
questions and listen to your comments.
or ongoing Medicare information resources. Bookmark
this page and visit us monthly to find out all the latest For additional details, including schedules for upcoming
opportunities. You can click on your state-specific page Ask the Contractor Teleconferences, you may visit:
to find out what is happening in your area. http://www.cignagovernmentservices.com/partb/
Medicare Resources April 2010
Online Education Center POE Advisory Group
Online education courses are tutorials and training CIGNA Government Services invites interested parties
courses available on demand from the CIGNA to participate in the Provider Outreach and Education
Government Services website to fit the needs of (POE) Advisory Group. The primary function of the
your busy schedule. Each course contains a pre-test Advisory Group is to assist the Provider Outreach and
and a post-test so you can evaluate your knowledge Education team in the creation, implementation, and
of the subject. CIGNA Government Services will review of provider education strategies and efforts. The
continue to launch several Online Education Courses Advisory Group provides input and feedback on training
throughout the year. Be sure to sign-up for our E-Mail topics, provider education materials, and dates and
Express Notification System (ListServ) at: http://www. locations of provider education workshops and events.
cignagovernmentservices.com/medicare_dynamic/ The group also identifies salient provider education
mailer/subscribe.asp so you can be notified via e-mail issues, and recommends effective means of information
when new tutorials are available. dissemination to all appropriate providers and their staff.
The following Online Education Courses are currently The Advisory Group is used as a provider education
available from the CIGNA Government Services website: consultant resource, to assist our Provider Outreach and
http://www.cignagovernmentservices.com/medicare_ Education team in the planning of educational events
dynamic/Education/index.asp. and activities.
For additional details on the POE Advisory
Group in your area, you may visit: http://www.
y Navigating the CIGNA Government Services Web Site cignagovernmentservices.com/partb/education/index.
html, and then click on the link to your state-specific
Current Part B NetCourses:
y Advance Beneficiary Notice (ABN)
y Benefits of EDI Calendar of Events
y Billing MSP Claims Electronically
Please take a moment to review the Provider Outreach
y Chiropractic Service Errors
and Education Calendar of Events. There is a listing
y Claim Exceptions
by type of event and an option to see the activities
y Comprehensive Error Rate Testing (CERT) Program
displayed in a monthly calendar format. Visit: http://
y EDI Products and Services
y Evaluation and Management, Module 1
index.html, and then click on the link to your state-
y Evaluation and Management, Module 2
specific education page. Be sure to register or mark your
y Evaluation and Management, Module 3
calendars for the Medicare educational events that will
y Getting Started with EDI
be most valuable to you and your staff!
y Guidance for Completing the CMS Enrollment Forms
y Medicare Appeals Process
y Medicare Part B Procedure Coding
y Medicare Physician Fee Schedule Database
y Part B Medical Review
y Provider Enrollment: An Overview
y Subsequent Hospital Visits
y Understanding the Medicare Remittance Notice