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February 2004 Part B Medicare Bulletin

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2004 Changes to Codes for ESRD Services

CMS (Centers for Medicare and Medicaid Services) provided the following instruction for Medicare contractors for operating under Medicare's contingency plan for HIPAA.

Effective January 1, 2004, CPT codes 90918-90922 for the monthly capitation payments for ESRD services and CPT codes 90922-90925 for the daily management of ESRD patients will no longer be valid. There is no grace period. Replacing these codes are several new G codes published in the November 7, 2003 Federal Register Final Rule.

HCPCS codes G0308-G0319 are for ESRD patients on dialysis other than in the home, based on the age of the patient and number face-to-face physician visits. It is not required to indicate on the claim the number of visits in more detail than already referenced in the code descriptor. For example, G0317 is for four or more encounters. It is not necessary to state separately that the physician actually saw the patient five times. The visits may occur in the physician's office, in an outpatient hospital or other outpatient setting or even in the patient's home, as well as in the dialysis facility.

These services are defined as "per month," but not as "per full month." Consequently, for ESRD patients (other than home dialysis patients) who are hospitalized during the month, the physician may bill the code that reflects the number of face-to-face visits during the month on days when the patient was not in the hospital (either admitted as an inpatient or in observation status). The CPT codes for daily services related to ESRD (90922-90925) are no longer in effect and cannot be used.

The physician should document the face-to-face encounter in a note reflecting that (s)he has seen the patient and made decisions relevant to her/his care. For example, a statement like, “I have seen and evaluated the patient and made the following adjustments”: would suffice (making no changes and stating so is also acceptable, as arriving to that conclusion requires a cognitive process).

Physicians may utilize non-physician practitioners: nurse practitioners, physician assistants, and clinical nurse specialists, who are able under the Medicare statute to furnish services that would be physician services if furnished by a physician and who are eligible to enroll in the Medicare program, to deliver some of the visits during the month. The rules for the use of these physician extenders would be consistent with the rules for split/shared evaluation and management visits: The non-physician practitioners and physician must be in the same group practice or employed by the same employer/entity; and the physician must perform some portion of the service in a face-to-face encounter, in this case one or more visits during the month with the patient. In this situation, to bill the service under the physician's UPIN/PIN, the physician and not the physician extender should be the practitioner to perform the visit with the complete assessment of the patient and to establish the patient's plan of care. If the non-physician practitioner is the practitioner who performs the complete assessment and establishes the plan of care, then the MCP service should be billed under her/his UPIN/PIN.

It is also possible for the physician to use another physician to provide some of the visits during the month, but the physician who provides the complete assessment, establishes the patient's plan of care and provides the ongoing management should be the physician who submits the bill for the monthly service. The non-MCP physician must have a relationship with the billing physician such as a partner, employee of the same practice, or supervising physician and fellow doing sub-specialty training.

Each practitioner should document in a shared medical record services he/she personally performed. Only one practitioner can bill for the management of the ESRD patient in any month.

The new HCPCS codes G0320-G0323 are for home dialysis patients. They differ according to age but do not specify the frequency of required visits with the physician throughout the month.

These codes are defined “per full month” and not “per month.” This means that if a home dialysis patient is hospitalized during the month, daily management may be reported for the days the patient is not in the hospital. For this, four new G codes have been created: HCPCS codes G0324-G0327. CPT codes 90922, 90923, 90924, and 90925 will be considered inactive for Medicare and cannot be used any longer to report daily management.

For example, if a home dialysis patient is in the hospital for 10 days (counting the calendar day of admission and the calendar day of discharge) and is cared for 20 days in his or her home, then 20 units of the code for the appropriate aged patient is billed. If a home dialysis patient receives dialysis in a dialysis center or other facility during the month, the physician is still paid the management fee for the home dialysis patient and cannot bill the codes in the range of G0308 through G0319 or CPT codes 90935 or 90937, even though the physician may see the patient during his/her center dialysis.

Documentation of all services related to ESRD should consist of what is clinically relevant, including but not limited to the patient's current status and complaints, a clinically appropriate physical examination, assessment of the patient's treatment for ESRD that includes assessment of the adequacy of the dialysis treatment, the status of the patient's vascular access, assessment and treatment of the other conditions associated with ESRD, such as anemia, electrolyte management, and bone density, as well as changes to the patient's management. Note templates are acceptable, as long as only the format is templated, whereas the content is individual to the patient.

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2004 HCPCS Deletion Codes

Due to 2004 being a leap year, the termination date for deleted codes is March 30, 2004. Previously it was published that the termination date would be March 31, 2004. January 1, 2004 is still the effective date for new procedure codes.

[EM 2003-1057 / CR 3002]

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2004 Medicare Physician Fee Schedule Increase and Extension of the Annual Participation Enrollment Period

Provider Types Affected

Physicians, Limited Licensed Practitioners, and Suppliers.

Provider Action Needed

You have until February 17, 2004, to consider the new fee schedule increase before making your 2004 participation decision. The new fee schedule incorporates increases passed by Congress and signed by the President into law on December 8, 2003.

STOP

Before making your 2004 Medicare participation decision, review the rate increase authorized by the Medicare Prescription Drug, Improvement, and Modernization Act (DIMA). If you decide to maintain the same participation status in 2004 as you have now, YOU NEED TAKE NO FURTHER ACTION.

CAUTION

After reviewing the new rates, also understand the extended timeframes for making your decision and the rules involving your 2004 payments while your decision is being processed, especially if you change your participation status.

GO

If you decide to change your participation status, be sure to complete the participation agreement that you received from your carrier and submit it to that carrier as soon as possible. Please know that we are extending the 2004 participation enrollment period and your carrier will accept the agreements postmarked as late as February 17, 2004.

Background

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA), recently passed by Congress and signed into law by the President, establishes a 1.5 percent increase in the conversion factor to be effective on January 1, 2004. On average, Medicare Physician Fee Schedule (MPFS) rates will increase by approximately 1.5 percent. However, please remember that changes to relative value units and geographic practice cost indices (GPCIs) could result in an increase that is slightly more or less than

1.5 percent for any specific service in a given area.

Because this change has happened so late in the year, the Centers for Medicare & Medicaid Services (CMS) is extending the participation enrollment period for 2004. The enrollment period will continue beyond December 31, 2003, because your carrier will accept enrollment forms that are postmarked as late as February 17, 2004. Thus, the complete enrollment period this year runs from November 14, 2003, through February 17, 2004.

Impact on Claims

Although the enrollment period runs until February 17, 2004, the effective date of the agreement will be January 1, 2004, and Medicare will be ready to process your claims in a timely and accurate manner. If you change your participation status by submitting a form after December 31, 2003, you should begin submitting claims in accordance with the participation decision you convey as soon as you submit that form.

Enrollments and withdrawals for 2004 that are received after December 31, 2003, will be recorded in your carrier's system as soon as possible after receipt. Until your form is received and recorded in your carrier's system, your 2004 claims will be processed using your 2003 status. Such claims will not be reopened or reprocessed once your form and participation status are recorded unless you specifically notify your carrier to do so.

Additional Information

The 2004 fee schedule will be posted on your carrier's Web site. If your carrier has an e-mail ListServ and you subscribe to that ListServ, you should receive notice of when the 2004 fee schedule has been posted to your carrier's Web site. Your carrier also will make hardcopies of the fee schedule available to you, upon request; however, the carrier may charge a reasonable fee to cover the expense of providing a hardcopy.

If you have any questions, please contact CIGNA Government Services at 1.866.502.9051 or visit our Web site at www.cignamedicare.com/partb/fsch .

Additionally, CMS makes information available on its Web site regarding the fee schedule. This information can be found at http://www.cms.hhs.gov/physicians/pfs/.

CMS also maintains a fee schedule lookup tool on its Web site to assist physicians. This tool can be found at http://www.cms.hhs.gov/physicians/mpfsapp/default.asp.

[EM 2004-0008 / CR 3040]

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New Physician Fee Schedule Available

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA), established a 1.5 percent increase in the conversion factor, effective January 1, 2004. On average, Medicare Physician Fee Schedule rates will increase by approximately 1.5 percent. The new 2004 Physician Fee Schedule has been posted to our Web site and can be downloaded and printed from our Web site at http://www.cignamedicare.com/partb/fsch/index.html.

The Centers for Medicare & Medicaid Services has not provided funding for the new, updated 2004 fee schedule to be mailed to providers. The new fee schedule may be ordered from CIGNA Government Services for a cost of $10 each. An order form can be found at the back of this publication.

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Reasonable Charge Update for 2004 for Splints, Casts, Dialysis Supplies, Dialysis Equipment, Therapeutic Shoes, and Certain Intraocular Lenses

Payment continues to be made on a reasonable charge basis for splints, casts, dialysis supplies, dialysis equipment, therapeutic shoes, and intraocular lenses. For intraocular lenses, payment is only made on a reasonable charge basis for lenses implanted in a physician's office. For splints and casts, payment is only made on a reasonable charge basis for splint or cast materials used by physicians to reduce a fracture or dislocation, and this payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.

The 2004 gap-filled amounts for splints and casts will be based on the 2003 amounts increased by 2.1 percent, the percentage change in the consumer price index for all urban consumers for the 12-month period ending June 30, 2003. The 2004 fees are below.

A4565 $6.50 Q4013 $11.91 Q4026 $89.32 Q4039 $6.23
Q4001 $37.50 Q4014 $20.11 Q4027 $14.31 Q4040 $15.60
Q4002 $140.02 Q4015 $5.96 Q4028 $44.66 Q4041 $15.13
Q4003 $26.61 Q4016 $10.05 Q4029 $21.87 Q4042 $25.84
Q4004 $92.13 Q4017 $6.90 Q4030 $57.58 Q4043 $7.57
Q4005 $9.81 Q4018 $10.99 Q4031 $10.94 Q4044 $12.92
Q4006 $22.11 Q4019 $3.45 Q4032 $28.79 Q4045 $8.78
Q4007 $4.91 Q4020 $5.50 Q4033 $20.40 Q4046 $14.13
Q4008 $11.06 Q4021 $5.10 Q4034 $50.75 Q4047 $4.39
Q4009 $6.54 Q4022 $9.21 Q4035 $10.21 Q4048 $7.07
Q4010 $14.74 Q4023 $2.56 Q4036 $25.38 Q4049 $1.60
Q4011 $3.27 Q4024 $4.60 Q4037 $12.45    
Q4012 $7.37 Q4025 $28.61 Q4038 $31.18    

[EM 2003-0938 / CR 2941] 

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Addition of Dentists, Podiatrists, and Optometrists to the Definitions/List of Physicians Who May Opt Out of Medicare

Prior to the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA), Section 1802(b)(5)(B) of the Social Security Act limited the types of physicians that could choose to opt out of Medicare to doctors of medicine and doctors of osteopathy. However, Section 603 of DIMA added the specialties of dentistry, podiatry, and optometry to the definition/list of physicians who may now opt out of Medicare

[EM 2004-0004 / CR 3016]

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Additional Modification Regarding Change Request CR 2963: Change in Coding on Medicare Claims for Darbepoetin Alfa Trade Name Aranesp and Epoetin Alfa Trade Name Epogen, EPO For Treatment of Anemia In End Stage Renal Disease ESRD Patients On Dialysis

This notification modifies Transmittal 18, (CR 2963) issued on October 31, 2003, by reactivating HCPCS code J0880 for Medicare purposes effective January 1, 2004. Effective for dates of service on and after January 1, 2004, J0880 will only be billable when administered in a physician 's office.

A. Background:

Prior to CR 2963 there had not been a HCPCS code that specifically identified usage for Darbepoetin Alfa (trade name Aranesp) for End Stage Renal Disease (ESRD). CR 2963 established a new HCPCS code (Q4054) for ESRD Aranesp usage only. This Q-code is effective for services provided on or after January 1, 2004. In addition, CR 2963 specified that HCPCS code J0880 would no longer be paid by Medicare effective January 1, 2004.

B. Policy:

The code J0880 injection, Darbepoetin alfa 5 mcg, was listed on the 2004 HCPCS tape as “Not Payable by Medicare” as of January 1, 2004. This notification modifies CR 2963 by removing this anticipated change in the status of the J0880 for 2004. However, J0880 will only be billable when administered in a physician's office to non-ESRD patients not on dialysis. The code J0880 will not be recognized by Medicare's outpatient code editor (OCE) or on Medicare bills from dialysis facilities. The code Q0137, injection, Darbepoetin alfa, 1 mcg (non-ESRD use) will remain active in all non-ESRD settings.

For 2004, physicians have the option of using either Q0137 or J0880 to bill for Darbepoetin alfa for non-ESRD patients not on dialysis. For ESRD patients on dialysis treated in a physician's office, code Q4054, “injection, Darbepoetin alfa, 1 mcg (for ESRD patients),” should continue to be used with the hematocrit included on the claim. (For ANSI 837 transactions, the hematocrit (Hct) value is reported in 2400 MEA03 with a qualifier of R2 in 2400 MEA02.) Claims without this information will be denied due to lack of documentation, as described in CR 2963. Physicians who provide Aranesp for ESRD patients on dialysis must bill using code Q4054.

NOTE: Billing J0880 and Q0137 for non-ESRD use on the same date of service is not allowable. Billing J0880 and Q4054 for ESRD related use on the same date of service is not allowable.

[EM 2003-1105 / CR 3037]

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Ambulance Inflation Factor (AIF)

The 2004 Ambulance Inflation Factor (AIF) is 2.1 percent.

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An Update on Chiropractic Reviews

The carriers Part B Medical Review departments recently met and compiled the following list as common reasons chiropractic claims are denied upon review:

To address the above areas, we are recommending the following to providers:

On subsequent visits the documentation must reflect:

(The above was excerpted from the provider manual that can be found at the following link, http://www.cignamedicare.com/provman/pm990307.html#chiroserv).

Additionally, we recommend:

Providers are reminded that failure to completely document the medical necessity of the chiropractor manual spinal manipulation(s) may result in the denial of the claim(s). Documentation must be legible and made available to Medicare upon request. Failure to do so may result in denial of claim(s).

As far as utilization of chiropractic manipulation, it is expected that the number of manipulations provided to any beneficiary in a given year would not be excessive. Providers who use this method in a significantly higher frequency than other chiropractors will be subject for review to determine medical necessity for the service frequency employed. Documentation, such as the following, can be submitted with claims in these instances:

These examples are not inclusive of all situations where additional allowance could be considered.

Finally, national policy only allows chiropractors to provide and bill for spinal manipulation, but labs and radiology groups are referencing their services to chiropractors. These are not valid orders and may result in denial of services.

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Initial Hospital Care Services Billing

Recent Medicare reviews of claims for Initial Hospital Care services, CPT 99221 99223, have shown several improper billing practices. This has been a problem for the last several years, in several reviews. These same errors continue to be replicated. It is our aim to educate providers, coders and billers in correct use of these codes to decrease these errors. The incorrect actions are as follows:

  1. Discharge summaries or progress notes are submitted instead of the admission/initial record. We must see the documentation of the service for which the claim is submitted the initial hospital care.
  2. Notes from ancillary personnel are submitted. This is incorrect. We must see documentation of services performed by the provider submitting the claim. There is no incident to billing in the hospital setting. Shared visits, where both the non-physician practitioner (NPP = PA, NP, CNS) and the physician each perform a face-to-face portion of the encounter, and each documents the part they did, should have all records from both providers submitted. The physician/provider cannot merely sign notes prepared by a NPP (non-physician practitioner) or ancillary person (nurse). NPPs who are enrolled providers with their own provider number may bill Medicare for these hospital services using their own PIN.
  3. Evaluation & Management services include three key components history, physical exam, and medical decision-making. Appropriate use of these hospital care codes requires all three of the components be included in the documentation. When records submitted do not meet this requirement, the claim will be reduced or denied. Please see CPT Manual (CPT 2004) for further explanation.
  4. Illegible notes are submitted. We must be able to read the name of the patient, the provider, the date of the service, and sufficient documentation to justify the level of service billed to allow reimbursement for the claim. If notes are not legible, the claim may be denied or reduced. Illegible notes should be dictated and accurately transcribed. The transcription should be reviewed by the billing provider for accuracy, and authenticated by the provider, with a notation that the note has been accurately transcribed for legibility. The original record (or a copy) as well as the transcription should be submitted for documentation.
  5. Claims may be submitted at the highest level of service without sufficient documentation to justify the level. These claims will be downcoded or denied, depending on the documentation present.
  6. Teaching physicians submit records that do not adequately document their participation in the teaching situation. Please see CMS On-line Manual System, Pub. 100-4, Chap. 12, sect. 100; Pub. 100-2, Chap. 15, sect. 30.7.
  7. Claims are submitted with an incorrect provider of service. The documentation indicates that one provider performed a service, but the submitted claim is billed by another provider. Such claims may be denied because the actual provider of the service is unidentifiable.

It is our hope that by knowing these common problems with billing for initial hospital care, providers may make corrections in the way they bill. This will result in faster claims processing, improved cash flow and less re-work for physician offices, and for Medicare.

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Fecal-Occult Blood Tests (FOBT)

Section 4104 of the Balanced Budget Act of 1997 (P.L.105-33) provides for Part B coverage of various colorectal cancer screening examinations, subject to certain frequency and payment limitations, performed on or after January 1, 1998. Coverage of these colorectal screening examinations was published in regulations at 62 FR 59079 on October 31, 1997, effective January 1, 1998. Currently, only the existing colorectal screening guaiac-based fecal-occult blood test (FOBT), G0107, is available for coverage as defined in the above regulation. In the 2003 Physician Fee Schedule final rule (67 FR 79966), the FOBT screening test regulation definition was amended, efective March 1, 2003, to provide that it could include either: (1) a guaiac-based gFOBT, or (2) other tests determined by the Secretary through a nation coverage determination. Effective for dates of service January 1, 2004, and forward, Medicare will cover a new colorectal cancer screening FOBT: Code G0328, Colorectal Cancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations.

Medicare will cover the new colorectal cancer screening FOBT G0328 beginning January 1, 2004. G0328 is payable under the clinical lab fee schedule. Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based). Refer to CMS Manual System Pub. 100-04, Medicare Claims Processing Manual, Chapter 18 §60, Preventive and Screening Services.

[EM 2003-1088 / CR 2996]

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Change in Coding on Medicare Claims for Darbepoetin Alfa (trade name Aranesp) and Epoetin Alfa (trade name Epogen, EPO) For Treatment Of Anemia In End Stage Renal Disease (ESRD) Patients On Dialysis.

GENERAL INFORMATION

Upon investigation by CMS, it was discovered that revenue codes and value codes are being used by Fiscal Intermediaries (FIs) for billing EPO usage rather than the assigned Q codes (Q9920 through Q9940).  Therefore, these Q codes for EPO will be rescinded, and the renal providers will no longer be able to use these codes for services furnished on or after January 1, 2004.  A new HCPCS code is provided for End Stage Renal Disease (ESRD) EPO usage only.  All other rules still apply for billing EPO for ESRD related anemia.

Currently, there is no code that specifically identifies usage for Darbepoetin Alfa (trade name Aranesp) for ESRD.  As a result, CMS is establishing a new HCPCS code for ESRD Aranesp usage only.  This new code, Q4054, will take affect for services provided on or after January 1, 2004.

Background

This notification contains coding instructions for administration of darbepoetin alfa (Aranesp) for ESRD patients on dialysis received on or after January 1, 2004.  This notification also list a new HCPCS code for EPO and deletes all the current “Q” codes established for EPO.  In addition, code J0880 will no longer be paid by Medicare effective January 1, 2004.  Since there is currently no payment rate for Darbepoetin alfa, CMS has determined that code Q4054 should be paid based on the Single Drug Pricer payment amount.  This payment rate will be in effect until CMS has determined an appropriate conversion factor and corresponding payment rate for Darbepoetin alfa.

B.  Policy:

All ESRD hematocrit (Hct) linked published Q codes for epoetin alfa have been deleted (Q9920 through Q9940) and replaced with Q4055.

(new) Q4054 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)
Medicare jurisdiction: DME regional carrier when self-administered for Method II home patients; FI when self-administered for Method I or Method II home patients, when administered by the hospital outpatient department, when administered to infacility patients by the dialysis facility; and carrier when incident to a physician's service.  Use this code for darbepoetin alfa (Aranesp).

(new) Q4055 Injection, epoetin alfa. 1,000 units (for ESRD on dialysis)
Medicare jurisdiction:  DME regional carrier when self-administered for Method II home patients; FI when self-administered for Method I or Method II home patients, when administered by the hospital outpatient department, when administered to infacility patients by the dialysis facility; and carrier when incident to a physician's service. Use this code for Epoetin Alfa (Epogen, EPO).

C. Provider Education:

Intermediaries and carriers shall inform affected providers by posting either a summary or relevant portions of this document on their Web site within two weeks.  Also, intermediaries and carriers shall publish this same information in their next regularly scheduled bulletin.  If they have a listserv that targets affected providers, they shall use it to notify subscribers that information about Darbepoetin Alfa (trade name Aranesp) for treatment of anemia in ESRD patients on dialysis and Epoetin Alfa (trade name Epogen, EPO) for the treatment of anemia in ESRD patients on dialysis is available on their Web site.

[EM 20013-0011/ CR2963 ]
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New Basis for Medicare Drug Payment Amounts Under Part B  Amendment of Instructions

A. Background:

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (DIMA) provides that as of January 1, 2004, the payment limits for drugs and biologicals are based on 85 percent of  the April 1, 2003 Average Wholesale Price (AWP), for those drugs and biologicals furnished on and after January 1, 2004. 

B. Policy:

The Medicare payment limits for drugs and biologicals not paid on a cost or prospective payment basis, and furnished on or after January 1, 2004, through December 31, 2004, are as described below:

The Medicare payment limit for drugs and biologicals not paid on a cost or prospective payment basis and furnished prior to January 1, 2004, is 95 percent of AWP.

Payment limits determined under this instruction shall not be updated during 2004.

EM 2003-1098 / CR 3022]
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New HCPCS Code For Ambulance Night Differential Charges

A new HCPCS code, A0800, has been established to allow suppliers eligible to bill separately for ambulance night differential charges to continue to bill for these services through the end of the transition period. Carriers eligible to pay separately for ambulance night differential charges may begin using HCPCS code A0800 on January 5, 2004, to allow ambulance suppliers billing for these services to continue to do so through the end of the transition period on December 31, 2005. Carriers that pay separately for ambulance night differential charges using HCPCS code A0999 (not otherwise classified) may continue to do so through the end of the transition period.

[EM 2004-1003/CR 3035]

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Program Integrity Manual Update

4.1.1 — Documentation Specifications for Areas Selected for Prepayment or Postpayment MR

B — Signature Requirements

Medicare requires a legible identity for services provided/ordered. The method used (e.g. hand written, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Providers using alternative signature methods (e.g. a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods. For example, a rubber stamped signature is much less secure than other modes of signature identification. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods.

All State licensure and State practice regulations continue to apply. The signature requirements described here do not assure compliance with Medicare conditions of participation.

Note that this instruction does not supersede the prohibition for Certificates of Medical Necessity (CMN). CMNs are a term of art specifically describing particular Durable Medical Equipment forms. As stated on CMN forms, “Signature and date stamps are not acceptable” for use on CMNs. No other forms or documents are subject to this exclusion.

[EM 2003-1041 / CR 2937]

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Renewed Moratorium on Outpatient Therapy Caps

I. GENERAL INFORMATION

A. Background:
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Social Security Act (the Act), required payment under a prospective payment system for outpatient rehabilitation services. Outpatient rehabilitation services include the following services:

§ Physical therapy (which includes outpatient speech-language pathology); and
§ Occupational therapy.

Section 4541(c) of the BBA required application of a financial limitation to all outpatient rehabilitation services (with the exception of outpatient departments of a hospital). There was an annual per beneficiary limit of $1500 for all outpatient physical therapy services (including speech-language pathology services) and a separate $1500 limit for all occupational therapy services in 1999. The $1500 limit was based on incurred expenses and included an applicable deductible ($100) and coinsurance (20 percent). The annual limitation did not apply to services furnished directly or under arrangement by a hospital to an outpatient, or to a hospital inpatient who was not in a covered Part A stay. The BBA provided that the $1500 limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002. Legislation extended the moratorium through CY 2002. Limits for 2003 were $1590 for each cap. Limits were in effect from September 1, 2003, until December 7, 2003. Section 624 of the Medicare Prescription Drug and Modernization Act of 2003 imposed another moratorium from the date of enactment, December 8, 2003, through December 31, 2005.

On November 14, 2003, CMS issued Transmittal 30, CR 2973, which updated the list of therapy services and announced the amount that would apply to the cap in 2004. Portions of that transmittal related to the application of financial limitations are changed by this instruction. Other parts, for example, the changes to the list of therapy services, remain in effect.

B. Policy:
From December 8, 2003, through December 31, 2005, there is a moratorium on financial limits for outpatient physical therapy and speech-language pathology. There is no financial limitation on therapy services during that time.

[EM 2003-1058 / CR 3005]

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Mandatory Electronic Medicare Claims

www.cms.hhs.gov/manuals

The ASCA (Administrative Simplification Compliance Act, Section 3 of Public Law 107-105, 42 CFR 424.32) requires that all initial claims for reimbursement under Medicare be submitted electronically as of October 16, 2003.  There are limited exceptions, including an exception for small providers. 

Initial claims are:

Initial claims do not include:

This requirement does not apply to claims submitted:

Medicare will not cover claims submitted on paper that do not meet the limited exception criteria.  Claims denied for this reason will contain the claims adjustment reason code 96 (non-covered charges) and remark code M117 (not covered unless submitted via electronic claim). 

Beginning October 16, 2003, electronically submitted claims must comply with the appropriate claim standards adopted for national use under HIPAA or with standards supported under the Medicare HIPAA contingency plan during the period that plan is in effect. 

Limited Exceptions to the Mandatory Electronic Claim Requirement

Small Providers - A small provider is defined at 42 CFR section 424 32 (d) (1) (vii) to mean A) a provider of services (as that term is defined in section 1861(u) of the Social Security Act) with fewer than 25 full-time equivalent (FTE) employees; or B) a physician, practitioner, facility or supplier that is not otherwise a provider under section 1861 (u) with fewer than 10 FTEs.  To simplify implementation, Medicare will consider all providers that have fewer than 25 FTEs and that are required to bill a Medicare intermediary to be small; and will consider all physicians, practitioners, facilities, or suppliers with fewer than 10 FTEs and that are required to bill a Medicare carrier or DMERC to be small.  Guidance for determining FTEs is included as Attachment A.  The ASCA law and regulation do not modify pre-existing laws or employer policies defining full time employment.

Although small providers have an exception to the mandatory electronic claim requirement, they are encouraged to file as many of their claims electronically as possible.  Submission of some claims electronically does not negate their small provider status nor obligate them to submit all of their claims electronically. 

Important Note:  The small provider exception for submission of paper claims does not apply to health care claim clearinghouses that are agents for electronic claim submission for small providers.  HIPAA defines a clearinghouse as an entity that translates data to or from a standard format for electronic transmission.  As such, HIPAA requires that clearinghouses submit claims electronically effective October 16, 2003 without exception. 

 Exceptions

(Rev. 44, 12-19-03)

It has been determined that due to limitations in the claims transaction formats adopted for national use under HIPAA, it would not be reasonable or possible to submit certain claims to Medicare electronically.  At the present time, only the following claim types are considered to meet this condition: 

Roster billing of vaccinations covered by Medicare-flu shots and similar covered vaccines and their administration can be billed to Medicare electronically one claim for one beneficiary at a time. In the past, roster billing allowed some suppliers to submit a single claim on paper with the basic provider and service data, to which was attached a list of the Medicare beneficiaries to whom the vaccine was administered to and related identification information for those beneficiaries.

In traditional medical situations where the provider is required to bill the other services furnished to the patient electronically, the flu shot or other vaccination is also to be included in the electronic claim sent to Medicare for the patient.

Medicare demonstration project: Claims for payment under a Medicare demonstration project that specifies paper submission—by their nature, demonstration projects test something not previously done, such as coverage of a new service. The HIPAA regulation itself makes provisions for demonstrations to occur that could involve use of alternate standards. In the event a Medicare demonstration project begins that requires some type of data not supported by the existing claim formats adopted under HIPAA, Medicare could mandate that the claims for that demonstration be submitted on paper. In the event demonstration data can be supported by an adopted HIPAA format, Medicare will not require use of paper claims for a demonstration project.  Demonstrations typically involve a limited number of providers and limited geographic areas. Providers that submit both demonstration and regular claims to Medicare may be directed to submit demonstration claims on paper. Non-demonstration claims will continue to be submitted electronically, unless another exception or waiver condition applies.

Medicare Secondary Payment Claims (MSP) MSP claims occur when one or more payers are primary to Medicare.

Multiple Payer Exception The claim formats adopted for national use under HIPAA include segments for provider or payer use to submit secondary claims as well as initial claims. Since a patient rarely has more than two insurers in total, the formats were designed for a provider to bill a payer secondarily and include payment data from one primary in the claim. In actuality, there may have been more than one primary payer. The claim formats adopted under HIPAA do not currently contain the ability to report individual service level payments made by more than one primary payer.  

Since the HIPAA claim formats do allow service level data to be submitted electronically when there is only one payer primary to Medicare, those claims can be sent to Medicare electronically.  When more than one payer is primary, the formats cannot accommodate this additional reporting and the only alternative is for providers to submit those claims to Medicare on paper with copies of the EOBs/remittance advices (RAs).

Standard Adjustment Reason Code Exception The payment segments of the claim formats adopted under HIPAA include fields for reporting of the identity of the primary payer, service procedure code, allowed amount, payment amount, and claim adjustment reason codes and amounts applied by the other payer when the billed amount of the service was not paid in full. These segments correspond to segments reported in the X12 835 remittance advice format. Since the HIPAA requirements apply only to electronic transactions, and not to paper transactions such as paper EOBs or RA notices, there is no requirement that payers use the same codes in their paper EOBs or RAs as in their electronic RAs. Medicare uses the same code set in both paper and electronic RAs, but other payers may not. Payers can elect to use different code sets in their paper transactions than their electronic transactions, or to use text messages in their paper transactions and not use codes at all. Payers that do not use the standard claim adjustment reason codes in their paper EOBs or RAs, generally use proprietary codes or massages for which there is no standard crosswalk to the 835 claim adjustment reason codes.

Providers should not try to convert non-standard messages or codes to standard claim adjustment reason codes prior to submitting these claims to Medicare electronically.  Medicare does not use the CAS segment data elements to calculate the Medicare payment in any case. Providers must, however, still report the primary's allowed, contract amount when Obligation to Accept in Full (OTAF) applies, and payment amounts for individual services to enable Medicare to calculate payment.

Claims Submitted By Medicare Beneficiaries  Obviously, claims submitted by Medicare beneficiaries are not required to be submitted electronically.  Providers are required to submit claims for Medicare beneficiaries but occasionally we do receive claims submitted by the beneficiaries themselves. 

Unusual Circumstance Waivers

In the event it is determined that enforcement of the electronic claim submission requirement would be against equity and good conscience as result of an "unusual circumstance" CMS will waive the electronic claim submission requirement for temporary or extended periods.  In those situations, providers are encouraged to file claims electronically where possible, but electronic filing is not required. 

Unusual Circumstances Waivers Subject to Provider Self-Assessment: 

The following circumstances always meet the criteria for waiver.  Providers that experience one of the following "unusual circumstances" are automatically waived from the electronic claim submission requirement.  A provider is expected to self-assess when one of these circumstances applies, rather than apply for contractor or CMS waiver approval.  A provider may continue to submit claims to Medicare on paper when one of these circumstances applies.  A provider is not expected to pre-notify their Medicare contractor(s) that one of the circumstances applies as a condition of paper submission. 

  1. Dental Claims - Medicare does not provide dental benefits. Medicare does cover certain injuries of the mouth that may be treated by dentists, but those injury treatments are covered as medical benefits. They can continue to submit claims, when appropriate, to Medicare on paper.
  2. In the event of a major storm or other disaster outside of a provider's control, a provider could lose the ability to use personal computers, or transmit data electronically. If duration is expected to be 2 business days or less, providers should simply hold claims for submission when power and/or communication are restored.
  3. A provider is not small based on FTEs, but submits fewer than 10 claims to Medicare per month on average (not more than 120 claims per year). This would generally apply to a provider that rarely deals with Medicare beneficiaries.
  4. Non-Medicare Managed Care Organizations that are able to bill Medicare for co-payments may continue to submit those claims on paper. These claims are not processable by the MSP Pay module and must be manually adjudicated by Medicare contractors.

 Unusual Circumstances Requiring Waiver Request

There are some "unusual circumstances" where a provider may submit a waiver request to their Medicare contractor.  It is the responsibility of the provider to submit documentation appropriate to establish validity of the waiver request in these situations.  Providers who feel they should qualify for a waiver as result of an "unusual circumstance" must submit their waiver requests to the Medicare carrier, DMERC or intermediary to whom they submit their claims. Requests received without documentation to fully explain and justify why enforcement of the mandatory electronic claim requirement would be against equity and good conscience will be denied. 

Medicare contractors may at their discretion approve a single waiver for up to 90 days after the date of the decision notice for a provider if the contractor considers there to be “good cause” that prevents a provider to submit claims electronically for a temporary period.  “Good cause” would apply if a provider has made good faith efforts to submit claims electronically, but due to testing difficulties, or a similar short-term problem that the provider is making reasonable efforts to rectify, the provider is not initially able to submit all affected claims electronically effective October 16, 2003.

In some circumstances, CMS approval of a waiver is required.  Waiver requests of this nature that the Medicare contractor considers an "unusual circumstance" must be reviewed and a decision must be granted by CMS/ Division of Data Interchange Standards.  The Division will issue a notice to the requestor.  Following are examples of this type "unusual circumstance".

  1. Provider alleges that the claim transaction implementation guides adopted under HIPAA do not support electronic submission of all data required for claim adjudication.  Please note: a separate instruction is forthcoming regarding submission of paper medical record attachments with electronic claims. 

    This temporary exception does not apply to submission of paper EOBs or RAs for electronic claims when Medicare is secondary and there is only one primary payer. 

  2. A provider is not small but all those employed by the provider have documented disabilities that would prevent their use of a personal computer for electronic submission of claims. 

  3. Any other unusual situation that is documented by a provider to establish that enforcement of the electronic claims submission requirement would be against equity and good conscience.

Waiver requests for this type exception must include the following: 

Please mail these request to:

CIGNA Government Services HealthCare Administration
Attn: Mail Stop 3098
Two Vantage Way
Nashville, TN 37228

Enforcement

Medicare contractors will assume for processing purposes that claims submitted by a provider on paper October 16, 2003 and later are submitted by a provider that is small or that meet exception criteria, barring information received from other sources to the contrary. 

Submission of a paper claims October 16, 2003 or later will be considered an attestation by a provider that waiver criteria are met at the time of submission.  In the event contractor staff realizes that a particular provider does not meet any of the exception criteria, paper claims submitted by that provider may be rejected in the mailroom without entry (processing) of those claims. 

Enforcement will be conducted on a post-payment basis and will entail targeted investigation of providers that appear to be submitting extraordinary numbers of paper claims. CMS will issue separate enforcement instructions to contractors. 

Electronic Claim Exceptions at CIGNA Government Services:

MSP Claims Submissions:

The free billing software, MCE (Medicare Claims Express) offered by CIGNA Government Services does not provide for MSP billing at this time. The upgrade will be provided to current users as soon as it becomes available.

Other Software Limitations

Providers who currently utilize other software for billing Medicare claims electronically may not have the capability to submit MSP claims electronically. CMS will take into account those limited situations where a provider submitted paper claims because software they were issued was temporarily unable to accommodate the submission of a particular type of claim. Providers with this particular situation will need to consider submitting a request for a waiver, due to these limitations. Follow the waiver submission instructions referenced under Unusual Circumstances Waivers.

Paper Attachments for electronic claims

Attachments to claims are only warranted when the Local Medical Review Policy requires additional documentation. The policies can be found on our website at: www.cignamedicare.com.

These claims must continue to be submitted on paper. Additional instructions on submitting these claims electronically will be issued shortly.

Attachment A

Full-time Equivalent Employee Definition and Calculation Methodology

The ASCA law and regulation do not modify pre-existing laws or employer policies defining full time employment. Each employer has an established policy, subject to certain non-Medicare State and Federal regulations, that define the number of hours employees must work on average on a weekly, biweekly, monthly, or other basis to qualify for full-time benefits. Some employers do not grant full-time benefits until an employee works an average of 40 hours a week, whereas another employer might consider an employee who works an average of 32 hours a week to be eligible for fulltime benefits. An employee who works an average of 40 hours a week would always be considered full time, but employees who work a lesser number of hours weekly on average could also be considered full time according to the policy of a specific employer.

Everyone on staff for whom a health care provider withholds taxes and files reports with the Internal Revenue Service (IRS) using an Employer Identification Number (EIN) is considered an employee, including if applicable, a physician(s) who owns a practice and provides hands on services and those support staff who do not furnish health care services but do retain records of, perform billing for, order supplies related to, provide personnel services for, and otherwise perform support services to enable the provider to function. Unpaid volunteers are not employees. Individuals that perform services for a provider under contract, such as individuals employed by a billing agency or medical placement service, for whom a provider does not withhold taxes, are not considered members of a provider's staff for FTE calculation purposes when determining whether a provider can be  considered as “small” for electronic billing waiver purposes.

Medical staffs sometimes work part time, or may work full time but their time is split among multiple providers. Part time employee hours must also be counted when determining the number of FTEs employed by a provider. For example, if a provider has a policy that anyone who works at least 35 hours per week on average qualifies for fulltime benefits, and has 5 full-time employees and 7 part-time employees, each of whom works 25 hours a week, that provider would have 10 FTEs (5+[7 x 25= 175 divided by 35= 5]).

In some cases, the EIN of a parent company may be used to file employee tax reports for multiple providers under multiple provider numbers. In that instance, it is acceptable to consider only those staff, or staff hours worked for a particular provider as identified by provider number, UPIN, or national provider identifier (NPI) when implemented to calculate the number of FTEs employed by that provider. For example, ABC Health Care Company owns hospital, home health agency (HHA), ambulatory surgical center (ASC), and durable medical equipment (DME) subsidiaries. Some of those providers bill intermediaries and some carriers. All have separate provider numbers but the tax records for all employees are reported under the same EIN to the IRS. There is a company policy that staff must work an average of 40 hours a week to qualify for full time benefits.  Some of the same staff split hours between the hospital and the ASC, or between the DME and HHA subsidiaries. To determine total FTEs by provider number, it is acceptable to base the calculation on the number of hours each staff member contributes to the support of each separate provider by provider number. First, each provider would need to determine the number of staff who work on a full time basis under a single provider number only; do not count more than 40 hours a week for these employees. Then each provider would need to determine the number of part time hours a week worked on average by all staff who furnished services for the provider on a less than full time basis.

Divide that total by 40 hours to determine their full time equivalent total. If certain staff members regularly work an average of 60 hours per week, but their time is divided 50 hours to the hospital and 10 hours to the ASC, for FTE calculation purposes, it is acceptable to consider the person as 1 FTE for the hospital and .25 FTE for the ASC.

In some cases, a single provider number and EIN may be assigned, but the entity's primary mission is not as a health care provider. For instance, a grocery store's primary role is the retail sale of groceries and ancillary items including over the counter medications, but the grocery store has a small pharmacy section that provides prescription drugs and some DME to Medicare beneficiaries. A large drug store has a pharmacy department that supplies prescriptions and DME to Medicare beneficiaries but most of the store's revenue and most of their employees are not involved with prescription drugs or DME and concentrate on non-related departments of the store, such as film development, cosmetics, electronics, cleaning supplies, etc. A county government uses the same EIN for all county employees but their health care provider services are limited to furnishing of emergency medical care and ambulance transport to residents.

Legal issues regarding the definition of providers, particularly when multiple providers have data reported under the same EIN, will be addressed in the NPI regulation when published in the Federal Register in final. For FTE calculation purposes in the interim, it is acceptable to include only those staff of the grocery store, drug store, or county involved with or that support the provision of health care in the FTE count when assessing whether a small provider waiver may apply. This process will be modified if warranted by the definitions established in the NPI final rule.

Support staff who should be included in the FTE calculation in these instances include but are not necessarily limited to those that restock the pharmacy or ambulance, order supplies, maintain patient records, or provide billing and personnel services for the pharmacy or emergency medical services department if under the same EIN, according to the number of hours on average that each staff member contributes to the department that furnishes the services or supplies for which the Medicare provider number was issued.

[EM 2003-1070 / CR 2966]

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Electronic Data Interchange Frequently Asked Questions (EDI FAQ's)

We have provided responses to frequently asked questions per our EDI Support Services Department to address common concerns regarding Electronic Data Interchange.  If you have other questions, please call the EDI Support Services Department for TN/ID at 866.520.4022 or for NC, call 866.352.1608. 

Q:  What is required to enroll for Electronic Data Interchange (EDI)?

A:  A completed EDI Enrollment Form and EDI Customer Profile.


Q:  Can I fax the EDI customer profile for change requests?

A:  Yes.


Q:  What is your fax #?

A:  615.782.4653 for TN/ID customers

     336.821.4595 for NC customers        


Q:  Who can sign the forms?

A:  We require that the provider, a delegate or an authorized official sign all change requests and new enrollments?


Q:  If I am a member of a group of healthcare providers, do I complete an agreement for each provider?

A:  No, generally only one application is required per group.  However, if you are a member of a non-uniform group (North Carolina members that have a 4 digit group number) please contact the North Carolina office at 866.3521608 for further instruction.


Q:  I want to change my billing service, vendor, or clearinghouse, what is needed?

A:  Complete the appropriate section of the EDI Customer Profile.  You can print a copy from our website at http://www.cignamedicare.com/edi/partb/forms.html


Q:  What forms do I complete to update or change my address or contact person name?

A:  An EDI customer profile.  You can print a copy from our website at http://www.cignamedicare.com/edi/partb/forms.html


Q:  I'm interested in CIGNA MCE software, what is needed?

A:  A completed EDI Customer Profile and an MCE User Agreement.  If you are not already enrolled, you must also submit a completed EDI Enrollment Form.  Additional information about MCE is found at www.cignamedicare.com/edi/partb/billing.html


Q:  I tried to download your software and I am asked to provide a password, why?

A:  You must submit a completed EDI Customer Profile.  Once it is received and processed, a password will be provided so you can download the software.


Q:  How long does it take for you to process the EDI application? 

A:  Our goal is to process the EDI applications within 10 days of receipt.  However with the current HIPAA migration, our application workload has dramatically increased and has caused the 10 day goal to be exceeded.


Q:  Where can I find a COB ONCA/medigap list?

A:  At www.cignamedicare.com/articles/dec03/cope401.html


Q. Why is CIGNA Government Services crossing all of our claims using the physician's social security number and not his/her tax id number?

A.  If you call our Crossover Inquiry Helpdesk at 615.782.4688, they can verify what information we have in our system.  In order to change the information, please contact our provider enrollment department at 866.520.4007 to change the SSN for the physician to the tax id number. Once the records are updated with provider enrollment, we will then cross the tax id number given.


Q:  Is there a deadline for the CMS Contingency Plan?

A:  The CMS Contingency Plan has been implemented for a "limited time". There has not been any formal notification advising an actual end date; however CMS recommends that entities complete all needed testing and begin submitting ANSI 4010A1 production claims immediately upon approval.

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Crossover Information

CIGNA Government Services sends adjudicated Medicare claims information to secondary insurance companies for their benefit determination. This process is called Coordination of Benefits (COB) or crossover. There are three types of COB: Complementary Crossover, Medicaid Crossover and Medigap Crossover.

Complementary Crossover

Complementary crossover is the transfer of adjudicated Medicare claims information based upon eligibility data supplied to CIGNA Government Services by the secondary insurance companies called Trading Partners.   We have service agreements with Trading Partners for automatic crossover of the claim information. According to the agreement, companies provide us with an eligibility file on a weekly or monthly basis that lists all beneficiaries that are eligible for their insurance coverage. CIGNA Government Services's crossover process is designed to match the Health Insurance Claim Number (HICN) on the adjudicated claims with the HICN provided on the eligibility files from the Trading Partners. CIGNA Government Services can not change, update or delete any records from the trading partner's eligibility file according to the service agreement.  All Complementary claim crossover files are sent each week for both assigned and non-assigned claims. No additional information is needed on the claim for the complementary crossover process to occur.

The Medicare Remittance Notice (MRN) identifies Complementary Crossover claims using the following ANSI code: MA18 for claims that have been crossed to complementary insurance companies. Several complementary insurance companies use a clearinghouse to send/receive files. The MRN will not have the name of the complementary insurance company if data is sent to a clearinghouse.

Complementary Companies as of October 2003

AAG Benefits Administrators
AARP Operations
AEGON
Aetna Healthcare
AFLAC
AFSA
Aid Association for Lutherans
Allied Benefits System
Alternative Professional Services Inc.
Amalgamated Life
American Capitol
American Family
American General
American Insurance Admin Group
American Legion
American Medical Association
American National Ins. Co.
American Republic Ins. Co.
Amerihealth
Anthem Benefits Administrators
Anthem FEP
APWU Health Plan
Atlantic American
AUSA
Bankers Fidelity Life and Casualty
BC California
BC Idaho
BCBS of Alabama
BCBS of Arizona
BCBS of Arkansas
BCBS of Illinois
BCBS of Iowa
BCBS of Kansas
BCBS of Massachusetts
BCBS of Michigan
BCBS of Michigan
BCBS of Minnesota
BCBS of Mississippi
BCBS of Missouri
BCBS of Nebraska
BCBS of New Jersey
BCBS of New Mexico
BCBS of North Carolina
BCBS of North Dakota
*BCBS of Tennessee (Only State Employees/Retirees)
BCBS of Texas
BCBS of Wisconsin
BCBS Oregon Regence
BCBS Utah Regence
Benefit Planners Limited
BeneSys Inc.
BS California
C&R Consulting
Capitol Blue Cross
Carefirst BCBS
Celtic Life Insurance
Central Benefits Life Insurance
Central States Health & Life of Omaha
Christian Fidelity Insurance
CIGNA
CAC/Mail Handlers
Continental General Insurance Co.
Continential Life Ins. Co.
Coresource
Country Life Insurance
Empire HealthChoice Inc.
Epoch Group
Equitable
Federal Home Life Insurance
FRA
GE Capitol Assurance
GE Life Assurance and Annuity
Gilsbar Ins
GEHA
Great West
Group Health Inc.
Health Care Service Corporation
Health Scope Benefit
Highmark Life & Casualty
Highmark Services Insurance
Humana Military (Tricare for Life)
ITT Hartford
Kanawha Ins. Co.
Kenyon College Retirees
KPS Health Plans
Lincoln Heritage Life Insurance
Medico Life
Mennonite Mutual Aid
MOAA
Monumental Life
Mutual of Omaha (Group)
Mutual of Omaha (Individual)
Mutual Protective
National Assoc. of Letter Carriers
Nationwide Health Plans
NEA
New Era Life Enterprise
NGS American
North American Insurance
North American Health Plans
Olympic
Oxford Life Insurance
PacifiCare Health Plan Admin.
Pekin Life Insurance
Peoples Benefit Life Ins.
Physicians Mutual Insurance Company
Pioneer
POMCO
Preferred Health Systems
Premera Blue Cross
Principal Financial Group
Principal Life Insurance
Pyramid
Regence BS
Regence BS ID Federal Employees
Regence BS of Idaho
Regence BS WA FEP
Retiree Medical Plans
ROA
SAMBA
Savers Life Insurance
State Farm Insurance Company
State Mutual Insurance
Stirling and Stirling
Thrivent Financial
TMG Health
Triwest
Unicare
Unified Life Insurance Company
Union Bankers/PMSC
Union Fidelity
Union Fidelity Life Insurance
United American Ins. Co.
United Commercial Travelers
United HealthCare
United Medical Resources
United Methodist Church
United Teacher Associates Insurance Company
USAA Life Insurance Co.
USAble Life Insurance
Wakely and Associates
Wausau Company
Westport Benefits
World Insurance Company
Worldnet Services Corp.

Medicaid Crossover

Medicaid Crossover is the transfer of adjudicated Medicare claims information based upon eligibility data supplied to CIGNA Government Services by the State Medicaid Agency.  We have a standard Trading Partner Agreement (TPA) with Medicaid Agencies for automatic crossover of claim information. All Medicaid claim crossover files are sent each week, but only for assigned claims.

The Medicare Remittance Notice (MRN) identifies Medicaid crossover claims using the following ANSI code: MA07 for claims that have been crossed successfully to Medicaid. The MRN will not have the name of the Medicaid Agency.

Medicaid Agencies as of October 2003

DMERC

Medicaid Alaska

Medicaid California

Medicaid Hawaii

Medicaid Idaho

Medicaid Iowa

Medicaid Kansas

Medicaid Missouri

Medicaid Montana

Medicaid Nebraska

Medicaid Nevada

Medicaid North Dakota

Medicaid Oregon

Medicaid South Dakota

Medicaid Utah

Medicaid Washington

Medicaid Wyoming

PART B

Medicaid North Carolina

Medicaid Tennessee (TennCare Bureau)

Medicaid Idaho

Medigap Crossover

The term “Medigap” refers to Medicare supplemental policies that are private health insurance plans designed to supplement Medicare benefits by filling in some of the “gaps” in Medicare coverage.  This type of policy typically covers the coinsurance amount (20%) that Medicare did not pay or the amount applied toward the beneficiary's deductible.  Medigap crossover is designed to lessen paperwork for the provider/supplier and beneficiary community and as an incentive for those entities who elect to be participating providers/suppliers in the Medicare program.

Medigap crossover is the transfer of adjudicated assigned claims information to the insurance companies that offer Medigap coverage.  Medigapcrossover only occurs based upon information submitted on the claim by the provider/supplier.

There are several criteria involved in a successful crossover of claims data to Medigap insurance companies:

The supplier's MRN will have the following ANSI codes: MA18 for claims that have been crossed to Medigap insurance companies and the name of company will be not provided. MA19 informs the provider that the claims have not been crossed over to the Medigap insurer because there was incomplete or invalid information on the claim. The provider must correct the information and send the Medicare claim payment information to the Medigap insurer. MA08 notifies the provider that they must send the claim to the supplemental payer.  Medicare did not forward the claim because the named insurer was not a Medigap plan or because the provider is not a participating provider.

Important!  Please use the correct individual Medigap Policy number from the patient's insurance card because the Medigap company will not pay on the crossover claims if the claim doesn't have a valid individual Medigap Policy number. Our system does not validate Medigap Policy numbers. We are sending the information that was received on Medigap claims.

Tip! When selecting a Medigap OCNA number, you will notice that the first five digits of the Medigap OCNA number and the zip code of the insurer are the same except when the address of the insurer has changed after the OCNA number was created in our system.

Medigap OCNA List as of October 2003

OCNA Company Address   City State Zip Code
60630A001 A & H Claims 4444 W Lawrence Ave Chicago IL 60630
30328A001 Academy Life Insurance Co P.O Box 26580 Austin TX 78755
46207A001 Accordia Senior Benefits P.O Box7025              Indianapolis IN 46207
37215A002 Agency Services P.O Box 17237 2550 Ridgeway Road Memphis TN 38187
83501A001 Agriculture Ins Admin P.O Box 538 Lewiston ID 83501
19801A001 AIG Life Ins Co 1 Alico Plz, 600 King Wilmington DE 19801
55403A001 Alliance Life Ins Co Of North America 1750 Hennepin Ave Minneapolis MN 55403
91367A001 Allied Life Ins Co 6400 Canoga Ave, S 100 Woodland Hills CA 91367
48152A001 American Community Mutual Ins Co 39202 W. Seven Mile Rd Livonia MI 48152
32501A001 American Exchange Life Ins Co 411 N Baylen Street Pensacola FL 32501
12205A001 American Family Life Ins Co Of NY One Marcus Blvd Albany NY 12205
53783A001 American Family Mutual Ins Co 6000 American Parkway Madison WI 53783
73106A001 American Fidelity Assurance Co 2000 Classen Blvd. Oklahoma City OK 73106
55440A001 American Hardware Mutual Ins Co P.O Box 435 Minneapolis MN 55440
76102A001 American Health & Life Ins Co 307 W 7th St, Ste 400 Ft Worth TX 76102
76702A001 American Income Life Ins Co P.O Box 2608 Waco TX 76797
75266A001 American Insurance Co Of Texas 777 Main St. Ste  900 Ft. Worth TX 76102
75070A001 American Life & Acc Ins Co P.O Box 4081 Mckinney TX 75070
32591A002 American Pioneer Life P.O Box 130 Pensacola FL 32591
32804A001 American Pioneer Life Ins Co 600 Courtland Street Orlando FL 32804
32591A001 American Progressive P.O Box 13547 Pensacola FL 32591
10509A001 American Progressive L&H NY P.O Box 23 Brewster NY 10509
38732A001 American Protective Life Ins P.O Box  1560 Cleveland MS 38732
39208A001 American Public Life Ins Co 2305 Lakeland Drive Jackson MS 39208
76107A001 American Service Life Ins Co 200 Bailey Ave Fort Worth TX 76107
53783A002 American Standard Life & Acc 6000 American Pkwy Madison WI 53783
19020A001 American Travellers Ins P.O Box 10319 Des Moines IA 50306
35289A001 Assoc Doctors Hlth & Life 4850 Street Rd Po Bx 3013 Trevose PA 19047
04106A001 Associated Hospital Service 2 Gannett Drive  Portland ME 04106
49503A001 Associated Mutual Hosp Svc Of MI 25 Jefferson Se Grand Rapids MI 49503
95350A001 Assured Investors Life Co 1005 W. Orangeburg Ave, #B Modesto CA 95350
76102A002 Atlas Life Insurance Co 110 West 7th St Ste 300 Fort Worth TX 76102
55164A002 Atrium Health Plan Inc P.O Box 4179 St Paul MN 55164
48909A001 Auto-Owners Life Insurance Co P.O Box 30660 Lansing MI 48909
60630B001 Bankers Life & Casualty 540 North College Dr  Carmel IN 46032
25325B001 BCBS Mountain State P.O Box 1353 Charleston WV 25325
91470B001 BCBS Of California P.O Box 7000 Van Nuys CA 91470
80203B001 BCBS Of Colorado 700 Broadway Denver CO 80203
06473B001 BCBS Of Connecticut P.O Box 1019 North Haven CT 64739
19801B001 BCBS Of Delaware P.O Box 1991 Wilmington DE 19801
32202B001 BCBS Of Florida 532 Riverside Ave Jacksonville FL 32202
31908B001 BCBS Of Georgia P.O Box 7368 Columbus GA 31908
64141B001 BCBS Of Kansas City P.O Box 419169 Kansas City MO 64141
70898B001 BCBS Of Louisiana P.O Box 98029 Baton Rouge LA 70898
21117B001 BCBS Of Maryland 10455 Mill Run Circle Owing Mills MD 21117
38101B001 BCBS Of Memphis P.O Box 98 Memphis TN 38101
59604B001 BCBS Of Montana P.O Box 5004 Great Falls MT 59403
20065B001 BCBS Of Natl Capital 550 12th St Sw Washington DC 20065
03306B001 BCBS Of New Hampshire 3000 Goffs Falls Road Manchester NH 31110
13501B001 BCBS Of New York 12 Rhodes Dr Utica NY 13501
10016B001 BCBS Of New York (Empire) P.O Box 1407 New York NY 10016
12205B001 BCBS Of New York 187 Wolf Rd Albany NY 12205
14240B001 BCBS Of New York (West) P.O Box 80 1901 Main St Buffalo NY 14240
13221B001 BCBS Of New York(Central) 344 S Warren Syracuse NY 13203
4369