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					                                                        Revised April 6, 2010




Medicare Resources
  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




                                                    2
Medicare Resources                                                                                           April 2010

  Navigating Medicare                                                y
                                                                     y
                                                                         Medicare Contracting
                                                                         Medicare Fee-for-Service Drugs
  Information on the Web                                             y
                                                                     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   Transplantation
   features:
   y consistent organization and navigation                         Regulations & Guidance
   y timely, relevant and accurate content
                                                                     http://www.cms.hhs.gov/home/regsguidance.asp
   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
                                                                       Act, etc.)
   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.
                                                                     http://www.cms.hhs.gov/home/
   y   Medicare General Information                                  outreacheducation.asp
   y   Appeals and Grievances
                                                                     This area of the CMS website is dedicated to educating
   y   Billing
                                                                     Medicare providers. Providers will find educational
   y   CMS Forms
                                                                     materials such as MLN Matters articles, online education
   y   Coding
                                                                     modules, and many other publications and materials
   y   Coordination of Benefits
                                                                     available for order. Providers also have the opportunity
   y   Coverage
                                                                     to interact directly with CMS through a variety of Open
   y   Demonstration Projects
                                                                     Door Forum teleconferences.
   y   E-Health
   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


                                                                3
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
   http://www.cms.hhs.gov/home/tools.asp
                                                                   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
   http://www.cms.hhs.gov/NationalCorrectCodInitEd/
  NCCI Edits for Hospital Outpatient                              Medicare Physician Fee Schedule Lookup
                                                                   http://www.cms.hhs.gov/PFSlookup/
  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
                                                                   http://www.cms.hhs.gov/MLNMattersArticles
  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
                                                                   http://www.cms.hhs.gov/MLNGenInfo
   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


                                                              4
Medicare Resources                                                                                   April 2010
  CIGNA Government Services Website                              Provider Enrollment
  http://www.cignagovernmentservices.com                          http://www.cignagovernmentservices.com/partb/
  ListServ                                                        enrollment/index.html

   http://www.cignagovernmentservices.com/
                                                                 Part B Forms
   medicare_dynamic/mailer/subscribe.asp
   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
                                                                  http://www.cignagovernmentservices.com/partb/
   segmented by specialty and special interest.
                                                                  coverage/index.html
  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
     (MEDPARD)
   y Medicare Resources Manual                                   Online Help Center
   y Part B Vendor Gazette                                        http://www.cignagovernmentservices.com/partb/
  Claims                                                          help/contact/onlinehelp.html
                                                                  The Online Help Center of CIGNA Government Services,
   http://www.cignagovernmentservices.com/partb/
                                                                  the Part B Carrier for North Carolina and Idaho is
   claims/index.html
                                                                  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)




                                                             5
                                                                                                                                                      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
(AAA)                                                                              guidance
                                                                                                                              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
                                                                                   guidance
                                       per 30 minutes                                                                         Physician must certify that DSMT is
                                                                                                                                                                              of follow-up training each year
                                                                                                                              needed

                                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
                                                                                                                                                                                                                     lab test)
                                                                                                                                                                              women                                  No deductible


                                G0101 – Cervical or vaginal cancer                                                                                                            childbearing age with abnormal
                                                                                                                                                                                                                     Copayment/coinsurance
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
                                                                                                                                                                              women

                                                                                                                              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
                                                                                                                                                                                                             high risk
                                           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
                                                                                                                                                                                                                                                           No copayment/coinsurance
 Prostate Cancer Screening                 G0103 – Prostate Specific Antigen Test (PSA)             V76.44                                            older (coverage begins the day after              Annually
                                                                                                                                                                                                                                                           No deductible
                                                                                                                                                      50th birthday)

                                                                                                                                                      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
                                                                                                                                                      over

                                                                                                    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
                                                                                                    V03.82
                                           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
                                                   hospitals only)

                                                                                                                                                      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
                                                                                                                                                      tobacco use

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
            Safety


   Begin Physical Examination                     Elements
                                                  Obtain the following:

         4. A Physical Examination




         5. End-of-Life Planning
                                                       decisions, and


   Counsel Patient                                Elements


         6. Education, Counseling, and            include the following:
            Referral Based on the Previous
            Five Components


         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
                                                                                                                                                                                                                               enrollee.
                                                                                                                                                                                      one-time preventive
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
                                                                                                                                                                                                                               information:

  IPPE HCPCS Codes                      Billing Code Descriptors                                                                                                                                                                         Medical records, including
                                                                                                                                                                                                                                         immunization records
                                        Medicare enrollment
                                                                                                                                                                                                                                          as possible
                                        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
                                        physical examination
                                                                                                                                                                                                                                                       Resources
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?
                                                                                                                                                                                                                               http://www.cms.hhs.gov/manuals/downloads/
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/
                                                                                                                                                                                                                               clm104c18.pdf
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


                                                                                                                                          January 2009
                                           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
                                                                                                                                                      Institutional Providers:
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
                                                                                                                                                                    FACILITY
                                                                                                                                    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
                                                                                                                                 Medicare may
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
Pneumococcal and
Influenza vaccines                                                                                                                                          Comprehensive Outpatient
received during the                                                                                                                  Follow                                                        75x
                                                                                                                                                          Rehabilitation Facilities (CORFs)
                                                                                                                                 administration
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
G0010                                                                                                                                                                                             TYPE
(for other than
                                                                                                                                                                    FACILITY
                                 90743 – Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use                                                                                OF BILL
OPPS hospitals)
                                                                                                                                                                 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
90471
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.
                                                                                                                                                                    Quick Facts!
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
                                                                                                                                                                    http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_
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
                                                                                                                                                                    http://www.cms.hhs.gov/manuals/downloads/clm104c18.pdf
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 50.4.4.2 - 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.
                                                                                                                                                                                                                              February 2008
ICN: 006799
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
    PQRI:                                                              claims.
    y Medicare physicians                                              Professionals participating in a registry that self-
        ƒ Doctor of Medicine                                           nominates and qualifies to submit data for the
        ƒ Doctor of Osteopathy                                         2009 PQRI incentive should expect to receive more
        ƒ Doctor of Podiatric Medicine                                 information from the registry on how to participate.
        ƒ Doctor of Optometry
        ƒ Doctor of Oral Surgery                                      Analysis and Payment
        ƒ Doctor of Dental Medicine                                    Eligible professionals who satisfactorily report quality-
        ƒ Doctor of Chiropractic                                       measures data for services furnished January 1, through
    y Practitioners                                                    December 31, 2009, will earn a single consolidated
        ƒ Physician Assistant                                          incentive payment in mid-2010. The incentive payment
        ƒ Nurse Practitioner                                           will be 2.0% of estimated total allowed charges for
        ƒ Clinical Nurse Specialist                                    covered Medicare Part B Physician Fee Schedule
        ƒ Certified Registered Nurse Anesthetist (and                  services provided January 1 through December 31,
          Anesthesiologist Assistant)                                  2009. Incentive payments will be paid to the Taxpayer
        ƒ Certified Nurse Midwife                                      Identification Number (TIN) under which the incentive-
        ƒ Clinical Social Worker                                       earning professional submitted PQRI claims.
        ƒ Clinical Psychologist
                                                                       As required by statute, the 2009 PQRI includes validation
        ƒ Registered Dietician
                                                                       processes. The determination of satisfactory reporting
        ƒ Nutrition Professional
                                                                       will itself serve as a general validation because the
        ƒ Audiologists (as of 1/1/2009)
                                                                       analysis will assess whether quality-data codes are
    y Therapists
                                                                       appropriately submitted in a sufficient proportion of
        ƒ Physical Therapist
                                                                       the instances when a reporting opportunity exists.
        ƒ Occupational Therapist
                                                                       In addition, for those professionals who achieve a
        ƒ 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.

                                                                 12
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
   hhs.gov/pqri.
                                                                     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
   agencies.
                                                                    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.



                                                               13
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:



                                                                14
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


                                                                 15
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:
   http://www.cignagovernmentservices.com/partb/help/
                                                                     y Beneficiary name;
   faqs/index.html
                                                                     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;
   http://www.cignagovernmentservices.com/partb/help/
                                                                     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 appeal
  The Medicare                                                       y Signature of the appellant.
                                                                     Supporting Documentation
  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
                                                                     delayed.
   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.




                                                                16
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.
     the documentation.
                                                                   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
                                                                   Board Review
   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
                                                                   DAB’s decision.
   If:      A portion of the claim can be allowed
            (partial reversal)…
   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).


                                                              17
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,


                                                               18
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
       customerservice@npienumerator.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,


                                                                   19
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
     application.
                                                                        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.
                                                                        other responsibilities.
   y Section 15 of the CMS-855B is not signed by the
                                                                      y Reduces Postal Expenses - Electronic claims
     authorized official.
                                                                        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                   ƒ Less staff time used for claims follow-ups and
     set up for EFT, only one EFT agreement is required for                   inquiries.
     the entire group.                                                     ƒ More time available for patient services.
   y If you are a new provider that will be reassigning your               ƒ 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
                                                                      Medicare services.

                                                                    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


                                                               20
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
                                                                       http://www.cignagovernmentservices.com/partb/
   correcting and resubmitting the claims that were
                                                                       forms/index.html
   rejected.
                                                                     y Glossary-provides common EDI terms and definitions:
  Electronic Remittance Notice (ERN)                                   http://www.cignagovernmentservices.com/partb/
                                                                       claims/edi/glossary.html
   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
   assistance.
                                                                    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
                                                                                  http://www.cignagovernmentservices.
     (Recommended)
                                                                                  com/partb/forms/index.html.
   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



                                                               21
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
                                                                   http://www.cms.hhs.gov/MLNMattersArticles/
               for each provider?
                                                                   downloads/MM3440.pdf
   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)
                                                                     format;
   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
               information.
   Question:   How long does it take for CIGNA
               Government Services to process the
               EDI application?



                                                             22
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.
                                                                      cignagovernmentservices.com/partb/education/index.
   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/
                                                                      education page.
   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
   cignagovernmentservices.com/partb/education/index.
                                                                      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/
                                                                      education/act.html.

                                                                23
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
   General NetCourses:
                                                                  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:
                                                                  education page.
   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
                                                                  www.cignagovernmentservices.com/partb/education/
   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




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