Payment

• What do you need to know about payment from Medicare? Use the links below to get the fee schedules, find out what services are covered, and more.
  

   

  Fee Schedules 

  Medicare fee schedules - Novitas  

  Physician Fee Schedule Look-Up - CMS 

  National Physician Fee Schedule Relative Value File: Medicare Fee Schedules 

  Durable Medical Equipment, Prosthetics/Orthotics & Supplies Fee Schedules – CMS
   

  Wellness and Preventive Services   

  Medicare Preventive Services – CMS 

  The ABCs of Providing the Initial Preventive Physical Examination - CMS 

  The ABCs of Providing the Annual Wellness Visit - CMS 

  Annual Wellness Visit Brochure – CMS
   

  Accreditation   

  Advanced Diagnostic Imaging – Accreditation Requirements - CMS

  Advanced Imaging Needs Accreditation (Action, Apr. 1, 2011)

  Billing Requirements 

  Electronic Billing (EDI) Center - Novitas

  Claims and Billing Center - Novitas
    

  ABN  

  Advance Beneficiary Notice of Noncoverage - Charging for Services Not Covered by Medicare (PDF) (March 2010)

  Dual-Eligible  

  Payment for Patients Dually-Eligible for Medicare and Medicaid 

  SE1128 – Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs) - CMS

  Here’s How You’ll Get Paid for Dual-Eligible Patients (TMA Practice E-Tip)

Medicare Enrollment

• Use these links for information on Medicare enrollment.
  

   

  Provider Enrollment Center – Novitas 

  Medicare Participating Physician or Supplier Agreement - Novitas

  Internet-Based PECOS Enrollment   

  EDI Enrollment Forms – Novitas

  Electronic Funds Transfer (EFT) Authorization Agreement - Novitas

  Opting Out of Medicare (Private Contracting) & Current Opt-Out Listing  - Novitas

  Medicare Enrollment Guidelines for Ordering/Referring Providers (PDF) - CMS

   

  Enrollment Applications 

  CMS-855B Medicare Enrollment Application (PDF)

  How to Complete the CMS-855B Enrollment Application — Tutorial  

  CMS-855I Medicare Enrollment Application (PDF)

  How to Complete the CMS-855I Enrollment Application — Tutorial 

  CMS-855R Medicare Enrollment Application (PDF)

  How to Complete the CMS-855R Enrollment Application — Tutorial 

Provider-Supplier Enrollment Fact Sheets

• The fact sheets below provide education to specific provider types on how to enroll in the Medicare Program and maintain their enrollment information using internet-based PECOS (Provider Enrollment, Chain, and Ownership System). They are available in downloadable format from the Medicare Learning Network®:
  

   

  “Medicare Fee-For-Service (FFS) Physicians and Non-Physician Practitioners: Protecting Your Privacy – Protecting Your Medicare Enrollment Record” advises FFS physicians and non-physician practitioners on how to ensure their enrollment records are secure and up-to-date.

  “The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers” explains general Medicare enrollment information relevant to physicians and other Part B suppliers.

  “The Basics of Internet-Based PECOS for DMEPOS Suppliers” describes general Medicare enrollment information relevant to DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) suppliers.

  “The Basics of Medicare Enrollment for Institutional Providers” explains general Medicare enrollment information relevant to institutional providers. 

  “The Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursement” describes general Medicare enrollment information relevant to those physicians required to enroll in Medicare for the sole purpose of certifying or ordering services for Medicare beneficiaries.

  “The Basics of Internet-Based PECOS for Physicians and Non-Physician Practitioners” provides an overview of how physician and non-physician practitioners can enroll in Medicare using internet-based PECOS.

  “The Basics of Internet-Based PECOS for Provider and Supplier Organizations” describes how provider and supplier organizations can enroll in Medicare using internet-based PECOS.

  “Internet-Based PECOS Contact Information” provides contact information for technical assistance with internet-based PECOS.

   

  Click here for a complete list of all MLN products related to Medicare provider-supplier enrollment.

Medicare Recovery Audit Contractor (RAC)

• Recovery Audit Contractors, which are required under the Tax Relief and Health Care Act of 2006, are tasked with detecting and correcting past improper Medicare payments.
  

   

  Stay Clear of Medicare Fraud Charges  

  RAC Program Overview – CMS  

  RAC Program Information – Connolly, Inc. 

  Provider Options - RAC Overpayment Determination (PDF) – CMS 

  Recovery-Audit-Program/Downloads/Providers_ADRLimit_Update-03-12.pdf (PDF) – CMS

  Are You Checking the OIG Exclusions List?
  Periodically check the Office of Inspector General (OIG) Individual/Entity Exclusions list. This list should not only be checked prior to employment but also throughout one's employment. No payment should be made by a federal program to an excluded individual.

  Office of Inspector General (OIG) Work Plan 

   

  Recovery Audit Contractor (RAC) Presentation 

  
  Connolly Consulting, LLC was named Medicare's, Jurisdiction C Recovery Audit Contractor (RAC).

  Audio File  |  Slide Presentation  |  Hand-outs  |  Connolly Contact Form (PDF) 

  Presented by: 
  Amy Reese, CMS' RAC contact for Jurisdiction C;
  Patricia Fenton, RN, BSN, CCM, CMS Nurse Consultant in the Division of Recovery Audit Operations;
  Christine Castelli, Connolly Consulting's former point-of-contact for Region C RAC program

   

  Healthcare Provider Compliance Training Videos – OIG 

Medicare Advantage Plans

• More than ten million Medicare beneficiaries currently receive their Medicare coverage through Medicare Advantage (MA); a program in which Medicare contracts with and pays private health plans to provide coverage for Medicare benefits.
  

   

  10 Things to Know About Medicare Advantage

  Medicare Advantage and Part D Rules

  CMS Medicare Advantage (MA) / Part D Contract and Enrollment Data

  CMS Approved Medicare Advantage Plans - Identify the HMO, PPO, SNP, MSA, PFFS health plans available in your area. The data can be sorted by state, county, insurer name, plan name, or by type of health plan offered.

  CMS Medicare Managed Care Manual (PDF)

  CMS Private Fee-For-Service (PFFS) FAQs (PDF)

  Reimbursement for Vaccines and Vaccine Administration Under Medicare Part D – CMS (MLN Matters) 

  Help Patients Avoid Medicare Advantage Fraud

Coding

• Find the proper coding information using the following links.
  

   

  Medicare Part B Newsletter Index 

  International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

  National Correct Coding Initiative (NCCI) Edits for Physicians  

   Evaluation & Management Center - Novitas

Incentive Programs

• Find out about the various incentive programs that are available.
  

   

  CMS Incentive Programs 

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  Electronic Health Record (EHR) Incentive Program  

  EHR Incentive Program Resource Center  

  CMS EHR Incentive Programs Web page 

   

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  E-Prescribing Incentive Program 

  2012 E-Prescribing Incentive Requirements (PDF)

  E-prescribing Resource Center  

  Medicare's Practical Guide to the E- Prescribing Incentive Program (PDF) - CMS

   

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  End Stage Renal Disease (ESRD) Quality Incentive Program (QIP)   

  ESRD Overview – CMS

   

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  Health Professional Shortage Area (HPSA) Bonus Payments  

  HPSA Bonus Payments Overview – CMS 

   

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  HPSA Surgical Incentive Payment (HSIP) 

  HPSA Bonus Payments Overview – CMS 

  HPSAs Eligible for the Medicare Physician Bonus Payment – HRSA

  Major Surgical Procedures Furnished in Health Professional Shortage Areas (HPSAs) – CMS (MLN Matters)

   

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  Physician Quality Reporting System (PQRS)  

  PQRS Resource Center  

  PQRS Overview – CMS 

  Physician Quality Reporting System – CMS (MLN Fact Sheet)   

   

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  Primary Care Incentive Payment Program (PCIP)  

  Incentive Payment Program for Primary Care Services – CMS (MLN Matters) 

  Eligibility for New Providers Enrolled in Medicare – CMS (MLN Matters)

  FAQs on the Primary Care Incentive Payment Program (PCIP) - CMS (MLN Matters) 

Helpful Links

• Use the following links to get additional information on the Medicare program.
  

   

  MLN Guided Pathways to Medicare Resources (PDF) - Includes updated information on Medicare resources that provide a fundamental overview of the Medicare program. For all Medicare providers 

  Guided Pathways Intermediate Part B Booklet (PDF) - Includes updated information on Medicare Professional/Practitioner/Supplier Requirements, Coverage and Reimbursement (General Intermediate Level), Coverage and Reimbursement (By Practitioner Type), Coverage and Reimbursement (By Type of Service), Services by Other Practitioners, Services by Suppliers, Coding, Billing and Reimbursement, DMEPOS (Independent Diagnostic Testing Facility), Quality, including; Medicare approved facilities, Medicare health support, PQRI, QIO and quality initiatives.

  Medicare Opt-Out Calculator - Use this calculator to determine the net annual financial impact of opting-out of Medicare and compare to the effect the Medicare fee change will have on practice revenues.

  Centers for Medicare and Medicaid Services 

   Novitas Solutions 

  Novitas Medicare Part B Center 

  TMA Knowledge Center – Ask TMA

  The CMS Quarterly Provider Update 

Medicare News