Upon completion of the service-specific review, a "Post-Payment Service Specific Review Results" letter will be mailed to you detailing the outcome of the review, individual claim review determination(s) and education on the findings. The results letter will also provide contact information for the nurse who reviewed the case to assist with any additional education needs to ensure your understanding of the results, how they were determined and, if applicable, how to improve your Medicare billings.

Sole owners who are initially enrolling will use the CMS-855I. For practice locations that operate under the same tax identification number (TIN), you will submit only one CMS-855I application; however, you will need to include two Section 4B pages to identify each practice location.

If an enrolled sole owner is adding a new practice location to an existing record, this can be updated on either the CMS-855I or the CMS-855B.

For practice locations that operate under separate TINs, you will need to submit separate applications for each of the practices. 

If the practitioner rendering the service is part of a billing group, report the individual practitioner’s NPI in the 'Rendering Physician #' area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

CMS requires that any Medicare service provided or ordered must be authenticated by the author -- the one who provided or ordered that service. Certain types of signatures (e.g., illegible signatures, initials) may require the addition of a “signature attestation statement” or a signature log to the documentation to ensure the signature’s authentication. If documentation submitted for medical review does not contain a signature at all, then only a signature attestation will be accepted.

Federal regulations require that MACs maintain payment responsibility for managed care enrollees who elect hospice. 

While a hospice election is in effect, certain types of claims may be submitted to the MAC by either the hospice provider or a provider treating an illness not related to the terminal condition. The claims are subject to Medicare rules of payment.

Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services because beneficiaries cannot receive home care while they are institutionalized. A beneficiary cannot be institutionalized and simultaneously receive home care.

An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication: 

One-on-one education will be provided if requested following the conclusion of the service-specific review. The results letter will include contact information for the nurse who reviewed your claims to assist with any additional education needs you may have. Our website also has additional education and resources for your reference on the service-specific topics under review.

Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

Medicare secondary payer is used when another insurer is responsible for paying insurance benefits first for Medicare beneficiaries. Medicare may be responsible to make a secondary payment; however, the law provides many different coverage scenarios so each one must be reviewed individually. MSP information may be found on the CMS website.