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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Medicare Provider Enrollment

December 28th, 2012

The AAOMS has been receiving many questions relating to Medicare enrollment and the proper protocol for treating Medicare beneficiaries. This article should fully explain the options an Oral and Maxillofacial Surgeon has to treat Medicare beneficiaries. Due to the Mandatory Claims Submission Act released in 1990, all Oral and Maxillofacial surgeons are required to submit claims to Medicare for any Medicare covered services with the exception of those who have formally Opted-out. Therefore, OMS's have only three options when treating Medicare patients. Those options are:

Non-Participating
Provider

Participating Provider

Formally Opt-Out of Medicare

Non-participating providers are enrolled in Medicare but have not entered into a participating agreement with Medicare. Although, they may choose to accept Medicare’s assignment on a case-by-case basis.

Must complete a Participating Provider Agreement (CMS 460) and submit to Medicare along with a provider enrollment form indicating the intent to become a Participating Provider.

Must complete and submit an Opt-Out Affidavit to each Medicare carrier to which they submit Medicare claims in order to formally opt-out and privately contract with Medicare beneficiaries.

A non-participating provider choosing to accept assignment will be paid 5% less than a participating provider.

A participating provider must accept assignment for all covered services provided to Medicare beneficiaries.

A provider who has formally opted-out must enter into a private contract with every Medicare beneficiary presenting for care. The opt-out privileges are for a two-year period. A new affidavit must be submitted prior to the end of the two-year period if one wishes to continue their opt-out privileges

A non-participating provider choosing not to accept assignment is restricted to 115% of the Medicare-allowed fee for non-participating physicians. Failure to abide by the limiting charge, one will be subjected to monetary penalies and/or exclusion from the Medicare program.

By accepting assignment, a participating provider is paid 80% of the allowed fee-schedule amount for covered procedures. The remaining 20% may be billed to the patient, or a secondary carrier.

Information such as what needs to be included within the opt-out private contract can be found on the AAOMS website at http://www.aaoms.org

Payments for services rendered by non-participating providers are typically sent to the patient unless the provider accepts assignment. In addition, non-participating provider are not granted appeal rights.

Payment is submitted directly to the provider. Appeal rights are granted to participating physicians. Participating physicians are also listed in the beneficiary provider directory.

A provider who is formally opted-out is only expected to submit claims for those patients seen on an emergency and/or urgent care basis. The HCPCS modifier -GJ should be added onto the Medicare claim. An opted-out provider may not enter into a private contract with a patient seen on an emergency basis.

Claims Submission

Briefly mentioned above is the Mandatory Claims Submission Enforcement which can be found in Section 1848 (g) (4) of the Social Security Act. This enforcement requires Medicare participating and non-participating physicians and suppliers to submit claims to Medicare for any Medicare covered services (with the exception of those who have formally opted-out). When a provider is formally opted out of Medicare, they do not submit any claims to Medicare, but instead privately contract with patients for reimbursement. For physicians who are enrolled in Medicare (ex. a nonparticipating or participating provider) and thus submit Medicare claims, the Centers for Medicare and Medicaid Services (CMS) policy for filing Medicare Part B claims is stated below:

  • All claims for covered services rendered to Medicare beneficiaries must be submitted to the Medicare Carrier.
  • The claims filing requirement applies to all physicians and suppliers who provide services to Medicare beneficiaries.
  • Physicians and suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare participating physician and supplier program. When the provider is a non-participating physician with Medicare, they can choose to either accept assignment or choose not to accept assignment through Medicare on a claim-by-claim basis.
  • Patients should be informed that a claim will be completed and filed on their behalf. If the patient is given a copy of the claim, the following statement (or one similar) should be documented in the claim: "Do not use this bill for claiming Medicare benefits. A claim will be submitted to Medicare on your behalf by this office."

Furthermore, according to 1848 (g) (4) the Social Security Act, when a provider fails to submit a claim to a Medicare carrier on behalf of a beneficiary for a Medicare Part B covered service within one year the service was performed, they may be subject to monetary penalties detailed within the Act. Also, the Act specifies that the provider may not knowingly or willingly charge the beneficiary more than the allowed Medicare charge on a repeated basis or the same monetary penalties apply. The only situation in which physician or other supplier who is not already formally opted-out is not required to submit a claim to Medicare for covered services is when the beneficiary (or the beneficiary's legal representative) refuses to authorize the submission of a bill to Medicare. However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, despite the absence of a claim to Medicare.

Enrollment Requirements and Process

Since Medicare claim submission is mandatory for Medicare providers, Medicare providers must be properly enrolled in Medicare if they have not formerly opted-out as stated above. The April 21, 2006 the Centers for Medicare and Medicaid Services' Final Rule entitled Medicare Provider Enrollment Requirements for Providers and Suppliers, specifically states "a provider or supplier is required to have a valid Medicare billing number for the date a service was rendered in order to receive payment for covered Medicare services from either Medicare (in the case of assigned claims) or the Medicare beneficiary (in the case of unassigned claims)." This rule also requires all providers and suppliers to have a current enrollment record. To enroll into Medicare as a participating or non-participating provider, each provider must follow a few steps:

  • Each provider must have a National Provider Identifier (NPI). You may apply for an NPI at https://nppes.cms.hhs.gov. (Once enrolled, the NPI will be used as the provider's Medicare billing number.)
  • A provider interested in the enrollment process must fill out a Medicare enrollment application that may be found on the CMS website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html?redirect=/MedicareProviderSupEnroll/02_EnrollmentApplications.asp#TopOfPage . (Most OMS will complete the CMS 855I).
  • Once enrolled, Medicare providers will be issued a Medicare transaction number called the Provider Transaction Access Number (PTAN). The PTAN is used to identify the provider who renders services to a Medicare beneficiary for each practice for whom they work and should be used whenever contacting Medicare. Treating a Medicare patient without obtaining a PTAN can lead to an audit of the practice and/or sanctions imposed as outlined within the Final Rule. A physician or non-physician practitioner who renders, orders, or refers Medicare covered services and does not have a current enrollment record that contains the provider's NPI and/or PTAN will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.
  • Once the enrollment application is submitted and accepted by Medicare, the provider will obtain a current enrollment record. A current enrollment record is one that is submitted and validated via the Medicare Provider Enrollment, Chain and Ownership System (PECOS). The record must contain the physician/non-physician practitioner's National Provider Identifier (NPI) to hold validity.

More Information

The AAOMS frequently updates Medicare information, including details on opting out, to the Practice Management page of the AAOMS website at http://www.aaoms.org.

Information on the Mandatory Claims Submission Enforcement can be found in a Medicare Learning Network article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0908.pdf.

Additional information regarding the PECOS may be found on the CMS Website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html and on the AAOMS website at http://www.aaoms.org.

Provider Enrollment information can be found on the CMS Website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html . Any further questions about the best enrollment option for your practice can be directed to your practice attorney.