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MIR-2007-5AB, May 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Part C Plan Type Display on the Medicare’s Common Working File (CWF) - CR5538 rescinds and fully replaces CR 5349
Provider Types Affected
Physicians, providers, and suppliers who access Medicare beneficiary eligibility data through CWF eligibility screens (e.g., HUQA, HIQA, HIQH, ELGA, ELGB, ELGH)
Provider Action Needed
Be aware of the expanded list of Medicare Advantage (MA) Plan Type Descriptions that are being displayed by Medicare’s CWF system. Being aware of the MA plan type is crucial, especially for those beneficiaries who are enrolled in Private Fee-For-Service (PFFS) plans. A plan directory, which is quite descriptive, is now available at http://www.cms.hhs.gov/MCRAdvPartDEnrolData/  .
Background
The CWF displays information on the Medicare Part C (now known as Medicare Advantage) contract number in which a beneficiary is enrolled, including the plan type description associated with the contract, and currently, CWF displays the label “HMO” for these contracts. In many of these cases, the “HMO” label is incorrect because the list of possible plan type descriptions has grown much larger since the creation of the Medicare Advantage (MA) programs.
This situation has especially become problematic for Medicare beneficiaries who are enrolled in MA Private Fee-for-Service (PFFS) contracts because PFFS contracts are labeled as “HMO” in CWF. Consequently, some providers are not recognizing that they can offer services to those beneficiaries enrolled in a MA PFFS contract.
To address this issue, the Health Plan Management System (HPMS) will modify the existing HMO address file exchange process with CWF in order to supply the list of available contract numbers and their corresponding plan type descriptions. With this new data, CWF can correctly display one of the following plan type descriptions: HMO, PPO, POS, Indemnity, or FFS Demo. The following table provides additional information to providers regarding these plan type descriptions:
| Plan Type Description |
Brief Guidance on Treating Patient |
Additional Information |
HMO |
Call plan for authorization. |
Managed Care plan with a provider network. Limited or no out-of-network coverage with the exception of emergency services. |
PPO |
You may treat the patient. |
Has a network of providers. In return for higher cost sharing, members can go out of the plan network for all plan services, including supplemental benefits. |
POS |
You may treat the patient subject to plan rules. Contact the plan for details. |
A limited out-of-network option offered by HMO plans. Contact plan for details. |
Indemnity |
You may treat the patient. |
If this is a PFFS plan, you must follow the PFFS plan’s terms and conditions of payment. If this is a Medical Savings Account (MSA) plan, the member may pay you directly. |
FFS Demo |
You may treat the patient. |
Beneficiaries remain in original Medicare and are entitled to all fee-for-service benefits. There are no changes to Medicare FFS billing instructions or claims processing. |
Additional Information
The official instruction, CR5538, issued to your carrier, intermediary, RHHI, A/B MAC, DMERC, or DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1219CP.pdf  on the CMS Web site.
If you have any questions, please contact your Medicare carrier, intermediary, RHHI, A/B MAC, DMERC, or DME 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  .
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: MM5538
Pub. 100-4, Transmittal# R1219CP, CR# 5538
Related CR Release Date: April 13, 2007
Effective Date: July 1, 2007
Implementation Date: July 2, 2007
| CPT five-digit codes, descriptions, and other data only are copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS clauses apply. |
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