MIR-2007-2AB, February 2007

Revisions to Procedures to Establish Good Cause and Qualified Independent Contractor (QIC) Jurisdictions

Provider Types Affected
Physicians, providers and suppliers who bill Medicare contractors (A/B Medicare Administrative Contractors (A/B MAC), fiscal intermediaries (FI), carriers, regional home health intermediaries (RHHI), durable medical equipment regional carriers (DMERC) or durable medical equipment Medicare administrative contractors (DME MAC)) for services provided to Medicare beneficiaries.

Background
The purpose of CR 5386 is to notify providers and suppliers of the restructured Part B/DME QIC jurisdictions . Under the new jurisdictions, three QICs will process reconsiderations as follows:

• Two QICs will process reconsiderations of carrier and A/B MAC redeterminations effective November 15, 2006 for contractors that process claims in the North jurisdiction and January 1, 2007 for contractors that process claims in the South jurisdiction. Your contractor will reference the appropriate QIC in the Medicare Redetermination Notice (MRN). In order to expedite your request for appeal, please make sure you follow the instructions on your MRN regarding where to submit your request for reconsideration. If you have already submitted a reconsideration request with the incumbent QIC, please do not submit a duplicate request.; and
• The third QIC will process all reconsiderations of DMERC and DME MAC redeterminations effective December 1, 2006. LN Matters Number: MM5386 Related Change Request Number: 5386

Key Points

• Your contractor will reference the appropriate QIC with jurisdiction in the redetermination letter.
• One QIC will process all reconsiderations of DME claims.
• There are two QIC jurisdictions for Part B claims: a North jurisdiction and a South jurisdiction.
  • The North QIC jurisdiction includes the following states: Alaska, Arizona, Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, District of Columbia, New York, Pennsylvania, New Jersey, Delaware, Maryland, Ohio, Kentucky, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Missouri, Iowa, Washington, Oregon, Nevada, Idaho, Wyoming, Montana, California, Utah, Kansas, Nebraska, North Dakota, South Dakota, Hawaii, American Samoa, Guam, and the Northern Marianas Islands.
  • The South QIC jurisdiction is comprised of the following states: Colorado, Connecticut, New Mexico, Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, Florida, North Carolina, South Carolina, Virginia, West Virginia, Puerto Rico, and Virgin Islands.

Additional Information
If you have questions, please contact your Medicare A/B MAC, FI, carrier, RHHI, DMERC, or DME MAC, at their toll-free number, which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip   on the CMS Web site.

For complete details regarding this Change Request (CR) please see the official instruction (CR5386) issued to your Medicare A/B MAC, FI, carrier, RHHI, DMERC, or DME MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1136CP.pdf on the CMS Web site.

For additional supporting information that details the general appeals process in initial determinations please see MLN Matters article MM4019 at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4019.pdf on the CMS Web site.

MLN Matters article MM3530, which can be found at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3530.pdf on the CMS Web site, provides a detailed explanation of the term “vacate a dismissal” as well as more background information about the second level of appeals process for Medicare Part A and Part B claims called “reconsiderations.”

Flu Shot Reminder
As a respected source of health care information, patients trust their doctors’ recommendations. If you have Medicare patients who haven’t yet received their flu shot, help protect them by recommending an annual influenza and a one time pneumococcal vaccination. Medicare provides coverage for flu and pneumococcal vaccines and their administration. - And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot. Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article 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.

MLN Matters Number: MM5386
Pub. 100-4, Transmittal# R1136CP, CR# 5386
Related CR Release Date: December 22, 2006
Effective Date: January 1, 2007
Implementation Date: April 2, 2007

Do you have your NPI?
National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.