decisionhealth Newsletters, Answer Books - 2006 Issue 7 (July)
Medicare_Claims_Processing_Manual / Chapter_1 / 30.3.12.3
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Article Overview
This Medicare Claims Processing Manual section summarizes carrier rules for the limiting charge applied to nonparticipating physicians and certain covered services and supplies. It discusses how the policy changed over time, including effective dates tied to Medicare legislation, and notes the types of services affected under the physician fee schedule framework. The article is relevant to Medicare billing professionals, physicians, non-physician practitioners, and suppliers who need to understand the scope of the rule and its administrative context.
Why This Topic Matters
Understanding this guidance helps billing and reimbursement staff recognize when the limiting charge applies, how it relates to Medicare policy changes, and which provider types and service categories are addressed in the manual.
Article Sections
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Carrier Rules for Limiting Charge
Overview of the limiting charge policy for nonparticipating physicians and the general service categories addressed by the section.
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Effective Changes Under OBRA 1993
Discussion of policy expansions tied to OBRA 1993 and the effective dates associated with those changes.
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Assignment Requirement Under BIPA
Brief note on assignment requirements for drugs and biologicals furnished on or after a later effective date under BIPA.
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Limiting Charge Percentage
Statement of the percentage relationship between the limiting charge and the applicable fee schedule amount.
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Example
A numeric illustration showing the relationship among fee schedule amounts and the limiting charge.
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Secondary Payer and Indirect Payment Procedure
General note regarding situations in which the limiting charge does not apply when Medicare is secondary or an indirect payment procedure is used.
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Rounding the Limiting Charge
Administrative guidance on rounding the limiting charge consistently across services.
What You Will Learn
- How the limiting charge is described in Medicare carrier rules
- Which broad categories of services and supplies are addressed by the section
- How later legislative changes affected the scope of the policy
- What effective dates are referenced in connection with the guidance
- Which provider groups are mentioned in the administrative discussion
- How the article frames the relationship between the limiting charge and fee schedule amounts
Who Should Read This
- Medicare billing staff
- Physician practices
- Nonparticipating physicians
- Non-physician practitioners
- Suppliers
- Revenue cycle and reimbursement professionals
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