University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers (Rev. 1, 10-01-03)

by  Find-A-Code
July 17th, 2015

A carrier may make Part B payment to a university-affiliated medical faculty practice plan that has the following attributes:

• There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.

• The Medical Faculty Practice Plan is a 501(c)(3) nonprofit tax-exempt organization, according to IRS regulations.

• Physicians of the faculty practice plan are employees of the University and/or medical school. The plan should furnish a copy of the employment agreement(s) between the faculty physician and the University.

• Physicians are full or part-time faculty members of the University’s School of Medicine, licensed to practice medicine in the State.

• The faculty practice plan may only be affiliated with one University, and this relationship is described in the written agreement between the University and the Medical Faculty Practice Plan.

• Members of the faculty practice plan are represented on the Governing Board of the practice plan. The Board has the authority to make or delegate management and operational decisions on behalf of the physicians participating in the practice plan.

• Faculty practice plan physicians have unrestricted access to the billing records, medical documentation, and claims forms for services submitted on their behalf by the practice plan. The faculty practice plan provides documentation establishing the existence of this policy.

• The physicians abide by the rules and regulations of the Medical Faculty Practice Plan.

• The faculty practice plan is accountable to Medicare for any claims that are submitted on behalf of the plan’s physicians for services provided to Medicare beneficiaries. Thus, the plan is responsible for refunding any overpayments to Medicare that are collected on behalf of the plan’s physicians.

Both the Medical Faculty Practice Plan and the plan’s physicians must enroll in the Medicare program by completing the Form CMS-855B and Form CMS-855R (Medicare health care provider/supplier enrollment application forms). Instructions for processing Form CMS-855B are referenced in Program Integrity Manual.

For those entities that are part of the organizational structure of the University, see §30.2.12, on payment to special accounts. These entities may include departments, specialties, practice plans, or similar subdivisions of a university or medical school.

Pub 100-04 Medicare Claims Processing Manual

References:

• Pub 100-04 Medicare Claims Processing Manual