CMS–1500–Revised Time line
CMS
Change Request: 5060 (PDF).
Form CMS-1500 (08/05) will be implemented January 02, 2007. Providers will not be mandated to use the revised Form CMS-1500 (08/05) until April 02, 2007. Providers may contact TFP Data Systems at JRMagdaleno@tfpdata.com to receive copies of the revised form.
The revised implementation time line is (revised June 30, 2006):
January 02, 2007: Health plans, clearinghouses, and other information support vendors should be
ready to handle and accept the revised Form CMS-1500 (08/05).
Note: To circumvent processing delays, providers are encouraged to submit both their NPI and provider identification number (PIN) on the revised Form CMS-1500 (08/05).
January 02, 2007 – March 30, 2007: Providers can use either the current Form CMS-1500 (12/90) version or the revised Form CMS-1500 (08/05) version.
April 2, 2007: The current Form CMS-1500 (12/90) version is discontinued; only the revised Form CMS-1500 (08/05) will be accepted.
Deficit Reduction Act of 2005
9–Day Payment Hold
CMS
Change Request: 5047 (PDF).
Medicare contractors will place a hold on Medicare payments for all claims during the last 9 days of the Federal fiscal year (September 22 through September 30, 2006). These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006. This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements. Payments will not be staggered and no advance payments will be allowed during this 9-day hold.
Medically Unlikely Edits
CMS
Transmittal: 155 (PDF).
Effective January 01, 2007 Medicare contractors will implement CCI edits that will contain a new update for Medically Unlikely Edits (MUEs). MUEs represent limits on the units of service that a healthcare provider can bill a particular CPT/HCPCS code per Medicare beneficiary per day. Claims exceeding these limits will be automatically denied.
Lab and Pathology codes in the CPT 80000 series will not be included in this release, with the exception of HCPCS “G” codes for PAP Smear and Prostate Cancer screening.
RARC & CARC Update
CMS
Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update
The November 2005 through February 2006 updates have been posted.
The following code table reflects new remark codes:
| New
Code |
Current Narrative |
| N365 | This procedure code is not payable. It is for reporting/information purposes only. |
| N366 | Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice. |
| N367 | The claim information has been forwarded to a Health Savings Account processor for review. |
| N368 | You must appeal the determination of the previously adjudicated claim. |
| N369 | Alert: Although this claim has been processed, it is deficient according to state legislation/regulation. |
The following code table reflects new reason codes:
| New
Code |
Current Narrative | As of: |
| 193 | Original payment decision is being maintained. This claim was processed properly the first time. | February 2006 |
| 194 | Payment adjusted when anesthesia is performed by the operating physician, the assistant surgeon or the attending physician. | February 2006 |
| 195 | Payment denied/reduced due to a refund issued to an erroneous priority payer for this claim/service. | February 2006 |
Frequency Restriction for Obstetric Panel
California — Medi-Cal
Medi-Cal Update: Obstetrics Bulletin 385
Effective for dates of service on or after September 01, 2006, reimbursement of CPT-4 code 80055 (obstetric panel) is restricted to once in nine months for the same provider. The provider may be reimbursed for a second or subsequent obstetric panel within the nine-month period if there is documentation to justify medical necessity or documentation of a different pregnancy.
NPI Registration
California — Medi-Cal
Medi-Cal Update: NPI Update.
Beginning September 2006, Medi–Cal providers will be able to register their National Provider Identifier (NPI) with the California Department of Health Services (CDHS) through an automated collection system. A new NPI Web page will appear on the Medi-Cal Web site that will contain the link to the NPI registration tool.
HIPAA mandates the use of an NPI beginning May 23, 2007. Providers can authorize the automatic update of existing agreements on file with their NPI information. The collection tool includes a list of agreement forms that contain the current Medi-Cal provider number.
Providers who have more than one active Medi-Cal or CHDP provider number must log in separately for each provider number in order to register their single or sub part NPI. Providers with more than one NPI for a single Medi-Cal or CHDP provider number can register only one NPI through the NPI registration tool.