Provider Types Affected
Indian Health Services (IHS) facilities wishing to enroll as Medicare suppliers

Provider Action Needed

Impact to You
Section 630 of the Medicare Modernization Act (MMA) permits IHS facilities to directly bill for itemized DMEPOS as of January 1, 2005. Previously, IHS facilities could not directly bill Medicare for DMEPOS.

What You Need to Know
This article is based on information from Change Request (CR) 3845, which provides Medicare manual instructions describing how Indian Health Service (IHS) facilities enroll as DMEPOS suppliers.

What You Need to Do
See the Background and Additional Information sections of this article to find out further details regarding these changes.

Background
The Medicare Modernization Act (MMA, Section 630) permits Indian Health Service (IHS) facilities to directly bill for itemized Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) as of January 1, 2005. Previously IHS facilities could not directly bill Medicare for DMEPOS. The MMA also provides for all Medicare Part B services to be billed including all preventive services.

To enable direct billing of DMEPOS, an IHS facility must enroll with the National Supplier Clearinghouse (NSC) and secure a Medicare supplier billing number. For enrollment purposes, Medicare recognizes two types of IHS facilities:

• Facilities wholly owned and operated by the IHS; and
• Facilities that are owned by the IHS but tribally operated or totally owned and operated by a tribe.

The Application
To enroll, the IHS facility must complete a Medicare Supplier Enrollment Application: CMS-855S
Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Suppliers
 
CMS-855S must be completed in accordance with its associated instructions, except as follows:

• Facilities that are totally owned and operated by the IHS are considered a governmental organization. An Area Director of the IHS must sign the Section 15 Certification Statement of the CMS-855S, be listed in Section 6 of the form and sign the letter required by Section 5 of the form, which attests that the IHS will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.
• Facilities that are tribally operated are considered tribal organizations. The Section 15 Certification Statement of the CMS-855S must be signed by a tribal official who meets the definition of an authorized official in accordance with the page 2 definitions shown on the CMS-855S. The same authorized official must be listed in Section 6 of the CMS-855S and must sign the letter required by Section 5 of the form which attests that the tribe will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.

Facility Requirements
IHS facility requirements include the following:

• Site visits will be required for all IHS facilities enrolling for DMEPOS. This includes all hospitals and pharmacies. All IHS facilities enrolled by the NSC must meet all required standards as verified by the review procedures for all other DMEPOS suppliers except as discussed in this article.
• All IHS facilities, whether operated by the IHS or a tribe, must be exempt from the comprehensive liability insurance requirements under 42 CFR Sec. 424.57(c)(10).
• All IHS facilities, whether operated by the IHS or a tribe, will be exempt from the requirement to provide any state licenses for their facility/business. For example, if the DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a state that requires a bedding license, such licensure is not required for Medicare enrollment.

However, if they provide a DMEPOS item that requires a licensed professional in order to properly provide the item, the IHS facility must provide a copy of the professional license. The licensed professional can be licensed in any state or have a federal license. For example, a pharmacy does not need a pharmacy license, but must have a licensed pharmacist.

Assignment of Specialty Codes and Appropriate Billings
Upon successful enrollment, the NSC will provide identifiers identifying IHS enrollments and IHS hospitals in order to facilitate proper reimbursement by durable medical equipment regional carriers (DMERCs).

The NSC will enroll all Indian Health Service (IHS) facilities including all hospitals and clinics (free standing or hospital based). This includes all facilities whether wholly owned and operated by the IHS or tribally owned and/or operated. For any IHS facility that enrolls, the NSC will issue a supplier number with:

• An A9 specialty code for newly enrolled IHS DMEPOS suppliers which are not hospitals; or
• An A9/A0 specialty code for newly enrolled IHS DMEPOS suppliers which are IHS/tribal hospitals and hospital based facilities to include Critical Access Hospitals (CAHs).

The specialty indicator will ensure that the claims are paid appropriately by either the FI or DMERC. IHS facilities with a specialty code of A9/A0 must submit claims for prosthetics, orthotics, and surgical dressings to their Medicare FI for payment and not to a DMERC.

Implementation
The implementation date for CR3845 is April 3, 2006.

Additional Information
IHS facilities that are tribally owned and/or operated are advised that their Medicare beneficiaries are not responsible for deductibles or coinsurance. However, Medicare still pays these IHS facilities a payment that is at 80 percent of the DMEPOS fee schedule. The remaining 20 percent will be shown as a CO denial on the remittance advice with an adjustment reason code of B6 indicating “This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty.”

For further details, please see the official instruction issued to your DMERC/carrier/intermediary regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/ on the CMS Web site. From that Web page, look for CR 3845 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your DMERC/carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.

Pub. 100-8, Transmittal# 133 , CR# 3845
Medlearn Matters Number: MM3845

Related CR Release Date: November 18, 2005

Effective Date: January 1, 2005
Implementation Date: April 3, 2006

Posted: 12/02/2005

CPT codes, descriptions, and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.