What is Medicare jurisdiction D?
JD processes FFS Medicare DME claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming.Dec 28, 2021
Which has been replaced with Medicare administrative contractors?
Which Medicare contractor processes and pays for Medicare claims?
Who monitors the Medicare administrative contractors?
CMS conducts QASP reviews to ensure that MACs are providing the quality of services required in their contracts. MACs are expected to comply with stringent performance requirements for QASP standards; a number of standards require 100-percent performance compliance.
What jurisdiction is New York for Medicare?
What jurisdiction is Michigan in for Medicare?
What Medicare jurisdiction is Minnesota in?
What Medicare jurisdiction is Pennsylvania?
| MAC Summary Table | ||
|---|---|---|
| Current MAC Jurisdictions | New MAC Jurisdictions | States |
| Jurisdiction 11 is now M | M | NC, SC, VA, WV |
| Jurisdiction 12 is now L | L | DE, DC, MD, NJ, PA |
| Jurisdiction 13 is now K | K | CT, NY |
Who handles Medicare claims?
What does MAC stand for in hospice?
Who is the Mac for Wisconsin?
| State Name | MAC-Part B |
|---|---|
| Hawaii | Noridian Healthcare Solutions, LLC (01212, MAC B) |
| Idaho | Noridian Healthcare Solutions, LLC (02202, MAC B) |
| Illinois | National Government Services, Inc. (06102, MAC B) |
| Indiana | Wisconsin Physicians Service Insurance Corporation (08102, MAC B) |
In what year did Medicare stop paying for all consultation codes from the CPT?
DME MAC Jurisdiction D - DME Facts
JD processes FFS Medicare DME claims for Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming
Who were the former contractors in this jurisdiction?
Learn about the former contractors in this jurisdiction at Archives: DME MAC Jurisdiction D.
Is Medicare a covered contractor?
Reimbursements made pursuant to Medicare Part A and/or B, or Medicaid, are considered to be federal financial assistance – not supply or service contracts. Therefore, health providers who enter into agreements to receive reimbursements for services provided to Medicare beneficiaries are not considered covered contractors because of the reimbursement relationship. However, the OFCCP may have jurisdiction over a healthcare provider receiving Medicare reimbursements if the provider also holds a separate covered federal contract or subcontract for the provision of medical services or supplies. Potential covered contracts or subcontracts may include contracts related to Medicare Advantage (Part C) or Part D programs, contracts with another Federal Program, and contracts with prime contractors of other Federal Programs.
Is an insurance carrier a federal contractor?
When an insurance carrier enters into a prime contract with a Federal Program for the provision of health insurance, the insurance carrier is a federal contractor for purposes of OFCCP jurisdiction. However, insurers often enter into agreements with healthcare providers to reimburse the provider for the cost of eligible medical good and services that it provides to an insured. According to the directive, these insurance reimbursement agreements between insurers and healthcare providers do not create a covered subcontractor relationship. Because the prime contract is an insurance contract solely for the provision of health insurance to Federal Program members and beneficiaries, the payment of fees directly to healthcare providers is neither necessary to the performance of the prime contract nor the fulfillment of an element of the prime contract. However, a qualifying subcontractor relationship would be established if the reimbursement agreement was combined with a contractual obligation to provide medical services.
What is the OFCCP?
Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) recently issued a new directive designed to provide comprehensive guidance for determining whether a healthcare provider or insurer falls within the jurisdiction of the OFCCP as a federal contractor or subcontractor. The directive addresses jurisdictional coverage based on a healthcare provider or insurer’s relationship with three nationwide federal health programs: Medicare, TRICARE and the Federal Employees Health Benefits Program (FEHBP).
What is a covered federal subcontractor?
A company that enters into a subcontract with a prime contractor for supplies or services necessary to the performance of the covered federal contract is a covered federal subcontractor. In addition, when a covered subcontractor contracts with another company to provide supplies or services necessary to the performance of the prime contract or to fulfill an element of the prime contract, another subcontract relationship is created and the OFCCP may assert jurisdiction over both subcontractors.
What is a prime contract?
A company that enters into a prime contract with a governmental agency under one of the Federal Programs to provide insurance, healthcare services, administrative support ( e.g., claims processing), or a combination of these services, is a federal contractor and will be subject to the jurisdiction of the OFCCP if the applicable coverage thresholds are met. Generally, a company must have one or more federal contracts that, when aggregated, are worth $10,000 or more, in order to fall within the OFCCP’s jurisdiction under Executive Order 11246. A company with 50 or more employees is required to develop a written affirmative action plan for women and minorities if it has a contract of $50,000 or more. A company must have a single contract worth at least $10,000 to be covered by Section 503 of the Rehabilitation Act. The single contract threshold is $100,000 under the Vietnam Era Veterans Readjustment Assistance Act.
What is OFCCP 293?
On December 16, 2010, the OFCCP issued Directive No. 293, an internal memorandum entitled "Coverage of Health Care Providers and Insurers" ("Directive No. 293"). Directive No. 293, which does not appear to have been published publicly by the OFCCP, is a 12-page document offering instructions for how the Office intends to carry out its coverage assessments in the health care industry. Directive No. 293 includes the Office's first formal statement that participating in Medicare Part C (Advantage) or Medicare Part D (covering prescription drug plans) may subject a health care provider to the OFCCP's jurisdiction.
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Why is Noridian not paying DME?
Noridian made improper payments to DME suppliers because Noridian did not have controls to ensure that claims for test strips and/or lancets complied with certain Medicare documentation requirements. Specifically, Noridian did not have system edits to identify, and review when necessary, high utilization claims. In addition, Noridian did not have system edits to identify suppliers’ claims with overlapping service dates for the same beneficiary. This billing pattern caused Noridian to allow payment for claims when beneficiaries had not nearly exhausted previously dispensed test strips and/or lancets.
What is Medicare and Medicaid?
The Medicare program, established by Title XVIII of the Social Security Act (the Act) in 1965, provides health insurance coverage to people aged 65 and over, people with disabilities, and people with end-stage renal disease. The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program.
What is OAS in HHS?
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others . Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.
What is the purpose of the Office of Evaluation and Inspections?
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations.
What is the Office of Investigations?
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.
What is the Office of Counsel to the Inspector General?
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities.
What is Medicare Part B?
Pursuant to sections 1832(a)(1), 1861(s)(6), and 1861(n) of the Social Security Act, Medicare Part B covers home blood-glucose test strip and lancet supplies (test strips and lancets) that physicians prescribe for diabetics. The Centers for Medicare & Medicaid Services (CMS) contracts with four durable medical equipment Medicare administrative contractors (DME MAC) to process and pay Medicare Part B claims for test strips and/or lancets. The amount allowed for payment is equal to the lesser of the Medicare fee schedule amount or the amount charged by a DME supplier. Medicare pays the beneficiary or the supplier the amount allowed for payment, less the beneficiary share (i.e., deductibles and coinsurance).
When do you have to contact the beneficiary before refilling a DME?
The Medicare Program Integrity Manual (the Manual), Pub. No. 100-08, chapter 4, section 4.26.1, states that, when a DME supplier refills an original order, the supplier must contact the beneficiary before dispensing the refill. Further, the Manual states: “For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product.”
What is Medicare and Medicaid?
The Medicare program, established by Title XVIII of the Social Security Act (the Act) in 1965, provides health insurance coverage to people aged 65 and over, people with disabilities, and people with end-stage renal disease. The Centers for Medicare & Medicaid Services (CMS) administers the Medicare program.
What is the purpose of the Office of Evaluation and Inspections?
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations.
What is the Office of Counsel to the Inspector General?
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities.
What is Medicare Part B?
Pursuant to sections 1832(a)(1), 1861(s)(6), and 1861(n) of the Act, Medicare Part B covers home blood-glucose test strip and lancet supplies (test strips and lancets) that physicians prescribe for diabetics, whether they are insulin-treated or non-insulin-treated. The patient, using
How long do DME suppliers have to keep proof of delivery?
The Manual, chapter 4, section 4.26, requires that DME suppliers maintain proof-of-delivery documentation in their files for 7 years.
Why did Palmetto GBA make improper payments to DME suppliers?
CGS and Palmetto GBA made improper payments to DME suppliers because CGS and Palmetto GBA did not have controls to ensure that claims for test strips and/or lancets complied with certain Medicare documentation requirements. Specifically, they did not have system edits to identify, and review when necessary, high utilization claims. (CGS did have edits for test strips and/or lancets that rejected claims submitted without the required modifier and an appropriate diagnosis code.) In addition, CGS and Palmetto GBA did not have system edits to identify suppliers’ claims with overlapping service dates for the same beneficiary. This billing pattern caused them to allow payment for claims when beneficiaries had not nearly exhausted previously dispensed test strips and/or lancets.
