Carrier Jurisdiction of Requests for Payment (Rev. 2487)

by  Find-A-Code
June 15th, 2015

Carriers have jurisdiction for all claims from the following:

• Physicians;

• Other individual practitioners;

• Groups of physicians or practitioners;

• Labs not part of a hospital;

• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));

• Ambulatory surgical centers (ASCs); and

• Independent diagnostic testing facilities (IDTFs). Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have jurisdiction for claims from the following:

• Nonimplantable durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) (including home use);

• Suppliers of enteral and parenteral products other than to inpatients covered under Part A;

• Oral drugs billed by pharmacies; and

• Method II home dialysis (for dates of service prior to January 1, 2011). Note: Please refer to Section 30.3.8 for information regarding the elimination of Method II home dialysis for dates of service on and after January 1, 2011.

The CMS maintains a list of which HCPCS codes are under DME MAC jurisdiction and which are area carrier jurisdiction, and issues updates to DME MACs and carriers as needed.

There are four DME MACs each of which is assigned specific States.

Medicare area carriers typically process Part B fee-for-service claims for services furnished in specific geographic areas (e.g., a State). However a single carrier processes all physician/supplier claims for railroad retirement beneficiaries. (See §10.1.3 for claims for Part B medical services performed outside the U.S. for individuals who reside in the U.S.).

The rules for determining jurisdiction are the same whether a claim is assigned or nonassigned (see §30.3 for assignment rules).

Further information on carriers for specific geographic areas is available on the CMS Web site at http://www.cms.hhs/contacts/incardir.asp. Most skilled nursing facilities submit claims to the FI. However, a nonparticipating skilled nursing facility (SNF) is considered a supplier and its claims are submitted to the appropriate carrier under its own Medicare supplier number.

References:

• Pub 100-04 Medicare Claims Processing Manual