MIR-2007-5B, May 2007

Clarification of MM5488 Article Regarding Coding on CMS-1500 Form

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.

What You Need to Know
This special addition article (SE0716) clarifies MM5488 (Temporary Addition to the Administrative Simplification Compliance Act (ASCA) Exception List for Medicare Secondary Payer (MSP) Claims -- Released March 9, 2007). MM5488 related to Change Request (CR) 5488, which informed Medicare carriers and A/B MACS that a temporary waiver to a requirement of the Administrative Simplification Compliance Act (ASCA) is being granted for the copayments in MSP claims.

Specifically, SE 0716 notifies physicians and providers that your claims may be processed in error if you identify the primary payer’s primary payment in Item 29 of the CMS-1500 claim form. You must only identify and enter the beneficiary payment amount in this Item.

Background
CR 5488 instructed CMS contractors (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 these 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, carriers and A/B MACs will allow for co-payment reimbursement claims to be submitted on paper and to send reimbursement directly to the beneficiary.

In clarifying MM5488, this special addition article (SE0716) notifies physicians and providers, that in order for this temporary exception to be implemented, you must only identify the beneficiary payment amount in Item 29 of the CMS-1500 claim form. You must not identify the primary payer’s primary payment in this Item, or your claims may be processed in error.

Additional Information
You might want to review CR 5488 at http://cms.hhs.gov/transmittals/downloads/R1194CP.pdf or MM5488 at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5488.pdf on the CMS Web site.

If you have any questions, please contact your carrier or A/B MAC at their toll-free number, which may be found 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: SE0716
Related Change Request (CR)# 5488
Effective Date: N/A

Physician Quality Reporting Initiative (PQRI) Measures and Specifications
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) Quality Measures and Specifications are now available. In addition to posting the 2007 PQRI Measures Specifications, CMS has also updated the list of 2007 PQRI measure statements and descriptions. To access both the measures and measure specifications documents, visit the PQRI Web page at http://www.cms.hhs.gov/PQRI on the CMS Web site. Once there, go to the Measures/Codes section of the page and scroll down to the Downloads section. Providers may want to test their systems to be certain that claims containing the codes associated with the measures will be processed. Please note that many of the quality codes are new and will be rejected by Medicare claims processing systems prior to the July 1, 2007 HCPCS update. CMS will be issuing further information about which measures may be used for testing systems prior to the July 1 start date.