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MIR-2007 04B, April 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Temporary Addition to the Administrative Simplification Compliance Act (ASCA) Exception List for Medicare Secondary Payer (MSP) Claims (MM5488)
Provider Types Affected
Physicians and providers submitting copayment reimbursement claims to Medicare carriers and Part A/B Medicare Administrative Contractors (A/B MAC) for services provided to Medicare beneficiaries
Provider Action Needed
Impact to You
This article is based on Change Request (CR) 5488 which informs Medicare carriers and A/B MACs that a temporary waiver to a requirement of the Administrative Simplification Compliance Act (ASCA) is being granted for certain claims as discussed in this article.
What You Need to Know
An exception has been created in CR 5488 that instructs carriers and A/B MACs, who use the Medicare Multi-Carrier System (MCS) for claims processing, to grant a temporary ASCA waiver (until July 1, 2007) for Electronic Media Claim (EMC) MSP claims to allow processing of MSP claims for reimbursement of a beneficiary for copayment paid to the provider when the primary payer is an employer Managed Care Organization (MCO).
What You Need to Do
Participating Medicare providers must not accept from the beneficiary any copayment, or coinsurance, upon services rendered when the primary payer is an employer MCO insurance, or any other type of primary insurance. Providers must follow the Medicare Secondary Payer rules and bill Medicare as the secondary payer after the primary payer has made payment. Medicare will inform you on its remittance advice the amount you may collect from the beneficiary. See the Background and Additional Information sections of this article for further details regarding these changes.
Background
The Administrative Simplification Compliance Act (ASCA) requires that claims must be submitted to Medicare electronically. CR 5488 instructs MCS contractors (carriers and A/B MACs) to grant a temporary waiver (until July 1, 2007 ) for Electronic Media Claim (EMC) MSP claims to allow processing of MSP claims for reimbursement of a beneficiary for copayment paid to the provider when the primary payer is an employer Managed Care Organization (MCO). Therefore, until July 1, 2007, MCS carriers and A/B MACs are instructed to temporarily:
- Allow for copayment reimbursement claims to be submitted on paper, and
- Send reimbursement directly to the beneficiary.
Additional Information
The official instruction, CR5488, issued to your carrier and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1194CP.pdf  on the CMS Web site. If you have any questions, please contact your Medicare carrier or A/B MAC at their toll-free number, which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
Flu Shot Reminder
It’s Not Too Late to Give and Get the Flu Shot! The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember - influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. 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: MM5488
Pub. 100-4, Transmittal# R1194CP, CR# 5488
Related CR Release Date: March 9, 2007
Effective Date: April 9, 2007
Implementation Date: July 1, 2007
PQRI Information Available
A new CMS Web page dedicated to providing information on the Physician Quality Reporting Initiative (PQRI) is now available.
On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the Physician Quality Reporting Initiative. For more information, visit http://www.cms.hhs.gov/pqri  on the CMS Web site.
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