Indian Health Service Part A and Part B Updated January 2021 Contents Introduction ..................................................................................................................... 1 Introduction to Medicare ................................................................................................. 2 Overview ...................................................................................................................... 2 Four parts of Medicare ................................................................................................. 2 Deductibles, coinsurance and premiums ..................................................................... 3 Lifetime reserve days (LTR) ......................................................................................... 3 Railroad retirement beneficiary ................................................................................... 5 Mandatory electronic claim submission ........................................................................ 5 Timely filing requirements ............................................................................................ 5 Definitions .................................................................................................................... 6 Hospital ..................................................................................................................... 6 Critical access hospital (CAH) .................................................................................. 7 Federally qualified health center (FQHC) ................................................................. 7 Provider-based and freestanding entities ................................................................. 8 Physician .................................................................................................................. 8 Non-physician practitioner (NPPs) ............................................................................ 8 Grandfathered tribal federally qualified health centers ................................................. 9 Medical necessity ....................................................................................................... 11 Definition of limited coverage ..................................................................................... 11 NCDs ......................................................................................................................... 11 LCDs .......................................................................................................................... 11 Reasons for non-coverage ......................................................................................... 12 Medicare statutory exclusions .................................................................................... 12 Exclusions from coverage ....................................................................................... 12 Routine services and appliances ............................................................................... 13 Services related to and required as a result of services that are not covered under Medicare .................................................................................................................... 13 Provider enrollment ....................................................................................................... 14 NPI ............................................................................................................................. 14 Enrollment forms ........................................................................................................ 14 Supporting documents ............................................................................................... 15 Enrollment application cover sheets ........................................................................... 15 Provider Enrollment, Chain and Ownership System (PECOS) ................................... 15 Internet-based Pecos ................................................................................................. 15 Application fee and screening process ....................................................................... 16 Screening process ..................................................................................................... 16 Application fee ............................................................................................................ 17 Hardship exceptions .................................................................................................. 18 Returned applications ................................................................................................ 19 Application processing ............................................................................................... 19 Contact person ........................................................................................................... 19 Changing Tax ID ........................................................................................................ 19 Individual practitioners ............................................................................................... 20 Physician assistants (PAs) ......................................................................................... 20 Contracted radiologists .............................................................................................. 20 Reciprocal billing and fee-for-time compensation arrangements (formerly locum tenens arrangements) ................................................................................................ 20 Mobile mammography units ....................................................................................... 21 Medical students ........................................................................................................ 22 Part B do not forward (DNF) initiative ......................................................................... 22 Electronic data interchange ........................................................................................... 23 Electronic claims ........................................................................................................ 23 Electronic remittance advice ...................................................................................... 23 Patient registration/screening ........................................................................................ 24 Eligibility inquiry resources ......................................................................................... 25 Interactive voice recognition (IVR) system ................................................................. 26 Hospice ...................................................................................................................... 26 Part A ......................................................................................................................... 26 Part B ......................................................................................................................... 26 Home health ............................................................................................................... 27 MSP .............................................................................................................................. 28 MSP questionnaire (MSPQ) ....................................................................................... 28 Recurring outpatient services ..................................................................................... 29 Beneficiary signature ................................................................................................. 29 Retention of MSPQ .................................................................................................... 30 Tribal self-funded insurance ....................................................................................... 30 Part A MSP adjustments ............................................................................................ 30 Benefits Coordination & Recovery Center (BCRC) .................................................... 31 References ................................................................................................................. 31 Medicare Part A hospital insurance .............................................................................. 32 IPPS/DRG .................................................................................................................. 32 Inpatient hospital coverage conditions .................................................................... 33 Definition of inpatient .............................................................................................. 33 Benefit period.......................................................................................................... 34 LTR days ................................................................................................................ 34 Counting an inpatient day ....................................................................................... 34 Inpatient services .................................................................................................... 35 Appropriate short inpatient hospital stays ............................................................... 35 Documentation requirements for Medicare inpatient admissions ............................... 36 Inpatient admission procedures ................................................................................