July 17th, 2015
Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under §§30.2-30.2.8. They are used whether the charges are compensation related or non-compensation related.
Chapter 26 contains general claims processing instructions. A medical group, or other entity entitled to bill and receive payment for physician services uses the current ASC X12 professional claim billing format or Form CMS-1500 to submit claims to Medicare A/B MACs (B). A single claim form may contain services furnished to the same patient by different physicians associated with the same entity. The name and address of the entity is entered in block 33 of Form CMS-1500 or in the corresponding ASC X12 837 location. For paper claims an authorized official of the entity signs in block 31. This official need not be a physician. For electronic claims a certification can be maintained on file. (See CMS EDI Web page (http://www.cms.hhs.gov/providers/edi/edi3.asp) for electronic billing formats.)
B Provider Identification Numbers
The entity’s NPI, when required, is entered in block 33a. Each physician who performs services for a patient must be identified on the Form CMS-1500 claim in block 24J for the appropriate line item in accordance with instructions in the Medicare Program Integrity Manual. (When an entity bills for an independent substitute physician under a reciprocal or locum tenens billing arrangement, the performing physicians is the physician member of the entity for whom the substitute is providing services.)
C Payment Records
Where the charges by a hospital, medical group, or other entity differ depending on the individual treating physician, A/B MACs (B) transmit the performing physician’s UPIN or NPI when required on the Common Working File (CWF) claim record. Where the charges by a hospital, medical group, or other entity are uniform regardless of the individual performing physician, claims records are prepared by entity and entity identification numbers rather than by individual physician and individual physician identification numbers. Show code 70 as specialty code on claims records where such entity’s physicians have mixed (more than one) specialties. Where all the physicians associated with such entity have the same specialty, the code used reflects the specialty, e.g., code 30 for a group of radiologists, code 11 for a group of internists.
D Outpatient Physical Therapy or Speech-Language Pathology Claims
Clinics that have been certified to provide outpatient physical therapy or speech-language pathology services to outpatients also use the ASC X12 837 professional claim format, or the CMS-1500 claim form for billing the A/B MAC (B).