Thursday, January 17, 2019
- Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18
- Hospice Quality Reporting Program: Quality Measure User’s Manual
- Qualified Medicare Beneficiary Billing Requirements
- Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
- Glaucoma Awareness Month: Make a Resolution for Healthy Vision
- Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call — January 22
- Comparative Billing Report Webinar on Intensity-Modulated Radiation Therapy Webinar — January 24
- New Electronic System for Provider Reimbursement Review Board Appeals Call — February 5
- Home Health Patient-Driven Groupings Model Call — February 12
- New Part D Opioid Overutilization Policies Call — February 14
Medicare Learning Network® Publications & Multimedia
- 2019 DMEPOS HCPCS Code Jurisdiction List MLN Matters Article — New
- DMEPOS CBP: Quarterly Update MLN Matters Article — New
- NCCI PTP Edits: Quarterly Update MLN Matters Article — New
- Medicare Claims Processing Manual MLN Matters Article — New
- Clinical Lab Fee Schedule: Medicare Travel Allowance Fees MLN Matters Article — New
- New Waived Tests MLN Matters Article — New
- ICD-10 and Other Coding Revisions to NCDs MLN Matters Article — Revised
- Local Coverage Determinations MLN Matters Article — Revised
- Skilled Nursing Facility ABN MLN Matters Article — Revised
- Medicare Preventive Services Educational Tool — Revised
- Remittance Advice: An Overview Booklet — Revised
View this edition as a PDF (PDF)
News & Announcements
Medicare Shared Savings Program: Submit Notice of Intent to Apply by January 18
Time is running out to submit a Notice of Intent to Apply (NOIA) via the Accountable Care Organization (ACO) Management System (ACO-MS) for the July 1, 2019, start date for the redesigned Medicare Shared Savings Program – Pathways to Success. You must submit a NOIA if you intend to apply to the new BASIC track or ENHANCED track of the Medicare Shared Savings Program, to apply for a Skilled Nursing Facility (SNF) 3-Day Rule Waiver, and/or to establish a Beneficiary Incentive Program.
NOIA submissions are due no later than January 18 at noon ET. A NOIA submission does not bind an organization to submit an application; however, you must submit a NOIA to be eligible to apply. Each ACO should submit only one NOIA. ACOs will have an opportunity to make changes to their tracks, repayment mechanisms, and other NOIA information during the application submission period.
Application Submission Period:
- The application submission period for a July 1, 2019, start date will be open from January 22 to February 19, 2019, at noon ET
- Additional resources on the application submission process are now available via the Application Toolkit and Application Types & Timeline webpages
For more information, review the NOIA Guidance (PDF). For questions, email .
Hospice Quality Reporting Program: Quality Measure User’s Manual
Version 3.00 of the Hospice Quality Reporting Program Quality Measure User’s Manual (PDF) is available. The measure specifications for Hospice Visits when Death is Imminent Measure 1 and Measure 2 are included in this new version. Visit the Current Measures webpage for more information.
Qualified Medicare Beneficiary Billing Requirements
Are you in compliance with Qualified Medicare Beneficiary (QMB) billing requirements? People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing. Medicare providers may not bill people in the QMB program for Medicare deductibles, coinsurance, or copays, but state Medicaid programs may pay for those costs. Providers who inappropriately bill individuals enrolled in QMB are subject to sanctions.
Establish processes to routinely identify the QMB status of Medicare beneficiaries prior to billing for items and services:
- Use Medicare 270/271 (HETS) data; see MLN Matters® Article SE1128 (PDF)
- Check your Medicare Remittance Advices (RAs); see MLN Matters Article MM10433 (PDF)
- Check state automated Medicaid eligibility-verification systems
States require providers to enroll in their Medicaid systems for claim review, adjudication, processing, and issuance of Medicaid RAs for payment of Medicare cost-sharing. Check with the states where your beneficiaries reside to determine the enrollment requirements.
Correct billing problems that occur. If you erroneously bill individuals enrolled in the QMB program, recall the charges (including referrals to collection agencies) and refund the invalid charges they paid.
For More Information:
- QMB Program webpage
- Prohibition on Billing Dually Eligible Individuals Enrolled in the QMB Program (PDF) MLN Matters Article
- QMB Program Billing Requirements FAQs (PDF)
- from 2018 Medicare Learning Network call
- Dual Eligible Beneficiaries under the Medicare and Medicaid Programs (PDF) Booklet
Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier
Medicare pays Medicare Diabetes Prevention Program (MDPP) suppliers to furnish group-based intervention to at-risk Medicare beneficiaries:
- Centers for Disease Control and Prevention (CDC)-approved National Diabetes Prevention Program curriculum
- Up to 2 years of sessions delivered to groups of eligible beneficiaries
Find out how to become a Medicare enrolled MDPP supplier:
- Obtain CDC preliminary or full recognition: Takes at least 12 months to obtain preliminary recognition and up to 24 additional months to achieve full recognition; see the Supplier Fact Sheet and CDC website for more information
- Prepare for Medicare enrollment; see the Enrollment Fact Sheet and Checklist
- Apply (PDF) to become a Medicare enrolled MDPP supplier (existing Medicare providers must re-enroll)
- Furnish MDPP services; see the Session Journey Map
- Submit claims to Medicare; see the Billing and Claims Fact Sheet and Billing and Payment Quick Reference Guide
For More Information:
- MDPP Expanded Model (PDF) Booklet
- from Medicare Learning Network call on June 20
- MDPP webpage
- CDC - CMS Roles Fact Sheet
- Contact the MDPP Help Desk at
Glaucoma Awareness Month: Make a Resolution for Healthy Vision
Encourage people with a higher risk for glaucoma to make healthy vision a priority this New Year. Recommend an annual screening if appropriate; Medicare provides glaucoma screening coverage for beneficiaries in at least one high risk group:
- Individuals with diabetes mellitus
- Individuals with a family history of glaucoma
- African-Americans aged 50 and older
- Hispanic-Americans aged 65 and older
For More Information:
- Educational Tool
- Medicare Vision Services (PDF) Fact Sheet
- Initial Preventive Physical Examination (PDF) Educational Tool
- Annual Wellness Visit (PDF) Educational Tool
- National Eye Institute website
Visit the Preventive Services website to learn more about Medicare-covered services.
Provider Compliance
Hospice Election Statements Lack Required Information or Have Other Vulnerabilities — Reminder
After a stratified random sample review of hospice election statements and certifications of terminal illness, the Office of the Inspector General (OIG) reports that more than one-third of hospice General Inpatient (GIP) stays lack required information or had other vulnerabilities.
- Hospice election statements did not always mention – as required – that the beneficiary was waiving coverage of certain Medicare services by electing hospice care or that hospice care is palliative rather than curative
- In 14 percent of GIP stays, the physician did not meet requirements when certifying that the beneficiary was terminally ill and appeared to have limited involvement in determining that the beneficiary’s condition was appropriate for hospice care
Hospices should improve their election statements and ensure that physicians meet requirements when certifying beneficiaries for hospice care. Resources:
- Hospices Should Improve Their Election Statements and Certifications of Illness OIG Report, September 2016.
- Hospice Payment System (PDF) Booklet: Includes a section on the hospice election statement
- Documentation Requirements for the Hospice Physician Certification/Recertification (PDF) MLN Matters Article
- Sample Hospice Election Statement (PDF) MLN Matters Special Edition Article
Upcoming Events
Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates Call — January 22
Tuesday, January 22 from 2 to 3 pm ET
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Do you need to submit data required by the Clinical Diagnostic Test Payment System final rule? Laboratories, including physician offices laboratories and hospital outreach laboratories that bill using a 14X TOB are required to report laboratory test HCPCS codes, associated private payor rates, and volume data if they:
- Have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS), and
- Receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period
This call provides a refresher on how to collect and submit required data. CMS will use this data to set Medicare payment rates effective January 1, 2021.
A question and answer session follows the presentation; however, you may email questions in advance to with “January 22 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call. For more information, visit the PAMA Regulations webpage.
Target Audience: Clinical diagnostic laboratories, including physician offices and hospital outreach laboratories.
Comparative Billing Report Webinar on Intensity-Modulated Radiation Therapy Webinar — January 24
Thursday, January 24 from 3 to 4 pm ET
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Join us for a discussion of the Comparative Billing Report (CBR) on Intensity-Modulated Radiation Therapy (CBR201901), an educational tool for providers who submit Medicare Part B claims for these services. See the CBR - Opens in a new window website for more information.
New Electronic System for Provider Reimbursement Review Board Appeals Call — February 5
Tuesday, February 5 from 1:30 to 3 pm ET
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Do you want to file or manage a Provider Reimbursement Review Board (PRRB) appeal? Learn how to use the new Office of Hearings Case and Document Management System (OH CDMS) to submit new appeals, transfer issues, file position papers, and manage all aspects of your PRRB appeals. For more information, visit the PRRB OH CDMS webpage.
During this call, PRRB staff discuss:
- How to access the system
- Detailed overview of the system and its capabilities
- Frequently asked questions
A question and answer session follows the presentation; however, attendees may email questions in advance to with “Office of Hearings Case and Document Management System Conference Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.
Target Audience: All PRRB appeal stakeholders.
Home Health Patient-Driven Groupings Model Call — February 12
Tuesday, February 12 from 1:30 to 3 pm ET
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During this call, learn about the Patient-Driven Groupings Model (PDGM) that will be implemented on January 1, 2020. CMS will use the PDGM to reimburse home health agencies for providing home health services under Medicare fee-for-service. Topics include:
- Overview of PDGM model
- Walkthrough of payment adjustments, including low utilization payment adjustments, partial payment adjustments, and outliers payments
A question and answer session follows the presentation. For more information, visit the Home Health Prospective Payment System webpage; review the CY 2019 final rule and Overview of the PDGM (PDF).
Target Audience: Home health agencies, administrators, clinicians, and other interested stakeholders.
New Part D Opioid Overutilization Policies Call — February 14
Thursday, February 14 from 1:30 to 3 pm ET
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CMS implemented new opioid policies for Medicare drug plans effective January 1. The new policies include:
- Improved safety alerts when patients fill opioid prescriptions at the pharmacy
- Drug management programs for patients at-risk for misuse or abuse of opioids or other drugs
During this call, CMS experts discuss the new policies and answer questions.
Prior to the call, participants should review the following materials:
- Training materials, including slide decks and tip sheets for prescribers (ZIP), pharmacists (ZIP), and patients (ZIP)
- A Prescriber’s Guide to the New Medicare Part D Opioid Overutilization Policies for 2019 (PDF) MLN Matters Article
- Reducing Opioid Misuse webpage for more information on the CMS strategy
Target Audience: Physicians; physician assistants; nurses; nurse practitioners; dentists and other prescribers; case managers; and other interested stakeholders.
Medicare Learning Network® Publications & Multimedia
2019 DMEPOS HCPCS Code Jurisdiction List MLN Matters Article — New
A new MLN Matters Article MM11085 on 2019 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List (PDF) is available. Learn about the annual updates.
DMEPOS CBP: Quarterly Update MLN Matters Article — New
A new MLN Matters Article MM11097 on Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) – April 2019 (PDF) is available. Learn about fee schedule updates.
NCCI PTP Edits: Quarterly Update MLN Matters Article — New
A new MLN Matters Article MM11126 on Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 25.1 Effective April 1, 2019 (PDF) is available. Learn about Medicare claims processing updates.
Medicare Claims Processing Manual MLN Matters Article — New
A new MLN Matters Article MM10848 on Medicare Claims Processing Manual, Chapter 30 Revisions (PDF) is available. Learn about the revisions for improved formatting and readability.
Clinical Lab Fee Schedule: Medicare Travel Allowance Fees MLN Matters Article — New
A new MLN Matters Article MM11146 on Clinical Laboratory Fee Schedule – Medicare Travel Allowance Fees for Collection of Specimens (PDF) is available. Learn about the billing revisions.
New Waived Tests MLN Matters Article — New
A new MLN Matters Article MM11080 on New Waived Tests (PDF) is available. Learn about claims submission updates.
ICD-10 and Other Coding Revisions to NCDs MLN Matters Article — Revised
A revised MLN Matters Article MM11005 on International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) (PDF) is available. Learn about coding changes.
Local Coverage Determinations MLN Matters Article — Revised
A revised MLN Matters Article MM10901 on Local Coverage Determinations (LCDs) (PDF) is available. Learn about updates to the Medicare Program Integrity Manual.
Skilled Nursing Facility ABN MLN Matters Article — Revised
A revised MLN Matters Article MM10567 on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) (PDF) is available. Learn about the revised CMS-10055 form.
Medicare Preventive Services Educational Tool — Revised
A revised Educational Tool is available. Learn about:
- HCPCS/CPT and ICD-10 Codes
- Who is covered
- Frequency
- What the beneficiary pays
Remittance Advice: An Overview Booklet — Revised
A revised Booklet is available. Learn about:
- Which types are available
- What information is included
- How to view
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