Which enrollment form to use 855A, 855B, 855I , 588 for what reason

Medicare Enrollment Application


In the enrollment process, CMS collects information about the applying provider or supplier and secures documentation to ensure that the he or she is qualified and eligible to enroll in the Medicare Program. Depending upon provider or supplier type, one of the following forms is completed to enroll in the Medicare Program

 Form CMS-855A/Medicare Enrollment Application for Institutional Providers: Application: Application used by institutional providers to initiate the Medicare enrollment process or to change Medicare enrollment information

 Form CMS-855B/Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers: Application used by group practices or other organizational suppliers, except DMEPOS suppliers, to initiate the Medicare enrollment process or to change Medicare enrollment information

 Form CMS-855I/Medicare Enrollment Application for Physicians and Non-Physician Practitioners: Application used by individual physicians or NPPs to initiate the Medicare enrollment process or to change Medicare enrollment information

 Form CMS-855R/Medicare Enrollment Application for Reassignment of Medicare Benefits: Application used by individual physicians or NPPs to initiate reassignment of a right to bill the Medicare Program and receive Medicare payments or to terminate a reassignment of benefits; and

Form CMS-855S/Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Suppliers: Application used by DMEPOS suppliers to initiate the Medicare enrollment process or to change Medicare enrollment information.

The following forms are often required in addition to the Medicare Enrollment Application:

Form CMS-588/Electronic Funds Transfer (EFT) Authorization Agreement: Medicare authorization agreement for EFTs (for providers who choose to have payments sent directly to their financial institution);

And CMS Standard Electronic Data Interchange (EDI) Enrollment Form: Agreement executed by each provider of health care services, physician, or supplier that intends to submit electronic media claims (EMC) or other EDI transactions to Medicare. This form is available from Medicare Carriers, FIs, A/B MACs, and Durable Medical Equipment Medicare Administrative Contractors and must be completed prior to submitting EMC or other EDI transactions to Medicare.


The following optional form is submitted if the provider or supplier wishes to enroll as a Medicare participating provider or supplier:

 Form CMS-460/Medicare Participating Physician or Supplier Agreement: Agreement to become a Part B participating provider or supplier who will accept assignment of Medicare benefits for all covered services for all Medicare beneficiaries. The Participating and Nonparticipating Providers and Suppliers Section of this chapter provides additional information about participating in the Medicare Program.


The above forms are available at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp on the CMS website.

Definition - physicians, practitioners, interns and residents

Physicians
The Medicare Program defines physicians to include the following:

Chiropractors;
Doctors of dental surgery or dental medicine
; Doctors of medicine and doctors of osteopathy
; Doctors of optometry
; or Doctors of podiatry or surgical chiropody.

In addition, the Medicare physician must be legally authorized to practice by a State in which he or she performs this function. The services performed by a physician within these definitions are subject to any limitations imposed by the State on the scope of practice. The issuance by a State for a license to practice medicine constitutes legal authorization. A temporary State license also constitutes legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards are used in determining whether the physician has legal authorization. If the State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within these limitations are covered



Practitioners




The Medicare Program defines a practitioner as any of the following to the extent that an individual is legally authorized to practice by the State and otherwise meets Medicare requirements: Anesthesiologist assistant (AA); Certified nurse midwife (CNM); Clinical nurse specialist (CNS); Certified registered nurse anesthetist (CRNA); Clinical psychologist (CP); Clinical social worker (CSW); Nurse practitioner (NP); Physician assistant (PA); or Registered dietician or nutrition professional.


Interns and Residents
Interns and residents include individuals who: Participate in approved Graduate Medical Education (GME) programs; or Are not in approved GME programs, but are authorized to practice only in a hospital setting (e.g., have temporary or restricted licenses or are unlicensed graduates of foreign medical schools). Also included in this definition are interns, residents, and fellows in GME programs recognized as approved for purposes of direct GME and Indirect Medical Education payments made by Fiscal Intermediaries (FI) or A/B Medicare Administrative Contractors (MAC). Receiving staff or faculty appointments, participating in fellowships, or whether a hospital includes physicians in its full-time equivalency count of residents does not by itself alter the status of "resident."


Teaching Physicians
Teaching physicians are physicians (other than interns or residents) who involve residents in the care of their patients. Generally, teaching physicians must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service in order for the service to be payable under the Medicare Physician Fee Schedule (MPFS).

Basics of Medicare part D

Part D – Prescription Drug Plan

The PDP provides prescription drug coverage to all beneficiaries who elect to enroll in a PDP or MA Plan that includes Part D.

Medicare beneficiaries may choose to join or leave a Medicare PDP during the following enrollment periods: The IEP for Part D is the 7-month period that surrounds the individual beneficiary’s first eligibility for Part D, beginning 3 months before the month of eligibility and ending on the last day of the third month following the month eligibility began. AEP, which occurs each year between November 15 and December 31. The Medicare PDP must accept all enrollments during this time. SEP, during which time beneficiaries in certain circumstances may change PDPs. The following are examples of such circumstances:

o He or she permanently moves outside the service area;
o He or she has both Medicare and Medicaid;
o He or she moves into, resides in, or moves out of an institution; or
o Other exceptions as determined by CMS.


Where to Find Additional Information About the Prescription Drug Plan

Additional information about the PDP can be found at
http://www.cms.hhs.gov/PrescriptionDrugCovGenIn on the CMS website.

An individual with Medicare and limited income and resources may qualify for extra help paying for Medicare prescription drug coverage costs. If the individual qualifies for extra help, he or she will receive assistance in paying for their drug plan’s monthly premium, yearly deductible, and prescription copayments. Applications for extra help may be filed at the local Medicaid office or by contacting the SSA.

Understand Medicare Part C - Medicare advantage

Part C – Medicare Advantage


MA is a program through which organizations that contract with CMS furnish or arrange for the provision of health care services to Medicare beneficiaries who

: Are entitled to Part A and enrolled in Part B
; Permanently reside in the service area of the MA Plan
; and Elect to enroll in a MA Plan.

Individuals with ESRD are generally excluded from enrolling in MA Plans.


Since 2006, beneficiaries have been able to enroll in regional Preferred Provider Organization (PPO) Plans throughout the U.S. In addition, beneficiaries are able to choose options such as Private Fee-for-Service Plans (PFFS), Health Maintenance Organizations, local PPOs (currently the most popular type of employer-sponsored plan), and Medicare Medical Savings Account (MSA) Plans (combines a high-deductible health plan with a MSA).

MA plans may also offer Medicare prescription drug benefits. Individuals enrolled in MA plans must receive their Medicare prescription drug benefits from their MA plan, except for MA PFFS plans that do not include drug benefits.

Medicare beneficiaries may choose to join or leave a MA Plan during one of the following election periods

: Initial Coverage Election Period, which begins three months immediately before the individual’s entitlement to both Medicare Part A and Part B and ends on the later of either the last day of the month preceding entitlement to both Part A and Part B or the last day of the individual’s Part B IEP. If the beneficiary chooses to join a Medicare health plan during this period, the Plan must accept him or her unless the Plan has reached its member limit


. Annual Coordinated Election Period (AEP), which occurs each year between November 15 and December 31. The Plan must accept all enrollments during this time unless it has reached its member limits.


 SEP, when, under certain circumstances, the beneficiary may change MA Plans or return to the Original Medicare Plan.




 Open Enrollment Period (OEP), during which time the beneficiary may leave or join another MA Plan if it is open and accepting new members. Elections made during this period must be made to the same type of plan (regarding Medicare prescription drug coverage) in which the individual is already enrolled. The OEP occurs from January 1 through March 31 of every year. If a plan chooses to be open, it must allow all eligible beneficiaries to join or enroll.

what is Medicare part B and who is covered

Part B – Medical Insurance




Some of the services that Part B, medical insurance, helps pay for include

: Medically necessary services furnished by physicians in a variety of medical settings, including but not limited to:
o The physician’s office;
o An inpatient or outpatient hospital setting; and

o Ambulatory Surgical Centers; Home health care for individuals who do not have Part A; Ambulance services; Clinical laboratory and diagnostic services; Surgical supplies; Durable medical equipment, prosthetics, orthotics, and supplies; Hospital outpatient services

; and Services furnished by practitioners with limited licensing such as:
o Audiologists;
o Certified nurse midwives;
o Certified registered nurse anesthetists;
o Clinical nurse specialists;
o Clinical psychologists;
o Clinical social workers;
o Independently practicing occupational therapists;
o Independently practicing physical therapists;
o Nurse practitioners; and
o Physician assistants.


Eligibility Guidelines

All individuals who are eligible for premium-free Part A are eligible to enroll in Part B. Since Part B is a voluntary program that requires the payment of a monthly premium, those individuals who do not want coverage may refuse enrollment. An individual age 65 years or over who is not eligible for premium-free Part A must be a U.S. resident and either a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for the five-year period immediately preceding the month the

Part B enrollment application is filed. Individuals who refused Part B and those whose Part B coverage terminated may enroll or re-enroll in Part B only during prescribed enrollment periods

For Medicare part A eligibility guidelines see the previous post.

Medicare part A - Complete eligibility guidelines

Part A – Hospital Insurance
Some of the services that Part A, hospital insurance, helps pay for include

: Inpatient hospital care
; Inpatient care in a Skilled Nursing Facility following a covered hospital stay
; Some home health care; and Hospice care.


Eligibility Guidelines


To be eligible for premium-free Part A, an individual must first be insured based on his or her own earnings or the earnings of a spouse, parent, or child. To be insured, a worker must have a specified number of quarters of coverage (QC). The exact number of required quarters is dependent on whether he or she is filing for Part A on the basis of age, disability, or ESRD. QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the individual’s working years. Most individuals pay the full FICA tax so that the QCs they earn can be used to insure them for both monthly Social Security benefits and Part A. Certain Federal, State, and local government employees pay only the Part A portion of the FICA tax. The QCs these employees earn can be used only to insure them for Part A and may not be used to insure them for monthly Social Security benefits.


Individuals Age 65 Years or Older

To be eligible for premium-free Part A on the basis of age, an individual must be age 65 years or older and either eligible for monthly Social Security or Railroad Retirement cash benefits or would be eligible for such benefits if the worker's QCs from government employment were regular Social Security QCs. Part A for the aged individual begins with the month age 65 years is attained, provided he or she files an application for Part A or for cash benefits and Part A within six months of the month in which age 65 years is attained. If the application is filed later than that, Part A entitlement can be retroactive for only six months. For Medicare purposes, individuals attain age 65 years the day before their actual 65th birthday and Part A is effective on the first day of the month upon attainment of age 65 years. For an individual whose 65th birthday is on the first day of the month, Part A is effective on the first day of the month preceding their birth month. For example, if an individual’s birthday is on December 1, Part A is effective on November 1 since for Medicare purposes, he or she attained age 65
years on November 30. Individuals who continue to work beyond age 65 years may elect to file an application for Part A only. Part A entitlement generally does not end until the death of the individual.


A second group of aged individuals who are eligible for Part A are those individuals age 65 years or older who are not insured but elect to purchase Part A coverage by filing an application at a Social Security Administration (SSA) office. Because a monthly premium is required, this coverage is called premium Part A. The individual must be a U.S. resident and either a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for the five-year period immediately preceding the month the application is filed. Individuals who want premium Part A can only file for coverage during a prescribed enrollment period and must also enroll or already be enrolled in
Part B.




Individuals Under Age 65 Years with Certain Disabilities


A disabled individual who is entitled to Social Security or Railroad Retirement benefits on the basis of disability is automatically entitled to Part A after 24 months of entitlement to such benefits. In addition, disabled persons who are not insured for monthly Social Security disability benefits but would be insured for such benefits if their QCs from government employment were Social Security QCs are deemed to be entitled to disability benefits and automatically entitled to Part A after being disabled for 29 months. Part A entitlement on the basis of disability is available to the worker and to the widow, widower, or child of a deceased, disabled, or retired worker if any of them become disabled within the meaning of the Act or the Railroad Retirement Act. Beginning July 1, 2001, individuals whose disability is Amyotrophic Lateral Sclerosis are entitled to Medicare Part A the first month they are entitled to Social Security disability cash benefits. If an individual recovers from a disability, Part A entitlement ends at the end of the month after the month he or she is notified of the disability termination. However, in the case of individuals who return to work but continue to suffer from a disabling impairment, Part A entitlement will continue for at least 93 months after the individual returns to work





Individuals with End-Stage Renal Disease
Individuals are eligible for Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application, and meet one of the following conditions

: Have worked the required amount of time under Social Security, the RRB, or as a government employee

; Are receiving or are eligible for Social Security or Railroad Retirement benefits

; or Are the spouse or dependent child of an individual who has worked the required amount of time under Social Security, the RRB, or as a government employee or who is receiving Social Security or Railroad Retirement benefits.


Part A coverage begins

: The third month after the month in which a regular course of dialysis begins

; The first month self-dialysis training begins (if training begins during the first three months of regular dialysis)

; The month of kidney transplant; or Two months prior to the month of transplant if the individual was hospitalized during those earlier months in preparation for the transplant.


Part A entitlement ends 12 months after the regular course of dialysis ends or 36 months after transplant

Where NPI printed in the Loop and CMS 1500

National Provider Identification (NPI)

The Health Insurance Portability and Accountability Act (HIPAA), federal Medicare regulations, and many state Medicaid agencies mandate the adoption and use of a standardized National Provider Identifier (NPI) for all health care
professionals.  In compliance with HIPAA, all covered health care providers and organizations must obtain an NPI for identification purposes in standard electronic transactions. In addition, based on state specific regulations NPI may be required to be submitted on paper claims. HIPAA defines a covered health care provider as any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted.

These covered health care providers must obtain an NPI and use this number in all HIPAA transactions, in accordance with the instructions in the Implementation Guides.

•     To avoid payment delays or denials, UnitedHealthcare requires a valid Billing NPI and Taxonomy Code(s) be submitted on both paper and electronic claims. In addition, UnitedHealthcare strongly encourages the submission of
all other NPIs as defined below.

•     It is important that, in addition to the NPI, you continue to submit your Tax Identification Number (TIN).

The NPI information that you report to us now and on all future claims is essential in allowing us to efficiently process claims and to avoid delays or denials.

How to submit NPI, TIN and taxonomy on a claim

The information below provides the location for NPI, TIN and Taxonomy on paper and electronic claims. See definitions in the UB-04 Data Specifications Manual.

HIPAA 837P (Professional) Claim Transaction

Primary Identifier                          Loop 2010AA, NM109
Pay-To Provider Federal Tax ID Loop 2010AB, NM109
Referring Physician Loop 2310A, NM109
Rendering Physician Loop 2420A, NM109

CMS 1500 (08-05) Professional Claim Form

Referring Provider NPI Field 17b
Rendering Provider NPI Field 24j
Service Facility Location NPI Field 32a
Billing Provider NPI Field 33a