Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1279 Date: JUNE 29, 2007

Transcription

1 anual ystem Pub edicare laims Processing epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 1279 ate: JUN 29, 2007 hange equest 5613 ubject: harges for issed ppointments. UY O NG: s policy is to allow physicians and suppliers to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non-edicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician s or supplier s missed appointment policy applies equally to all patients (edicare and non-edicare), then the edicare law and regulations do not preclude the physician or supplier from charging the edicare patient directly. New / evised aterial ffective ate: October 1, 2007 mplementation ate: October 1, 2007 isclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =V, N=NW, =LT-Only One Per ow. /N/ N PT/TON/UBTON/TTL 1/Table of ontents 1/ /harges for issed ppointments. UNNG: No additional funding will be provided by ; contractor activities are to be carried out within their Y 2007 operating budgets. V. TTNT: Business equirements anual nstruction *Unless otherwise specified, the effective date is the date of service.

2 ttachment Business equirements Pub Transmittal: 1279 ate: June 29, 2007 hange equest: 5613 UBJT: harges for issed ppointments ffective ate: October 1, 2007 mplementation ate: October 1, GNL NOTON. Background: 's policy is to allow physicians and suppliers to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non-edicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (edicare and non-edicare), then the edicare law and regulations do not preclude the physician or supplier from charging the edicare patient directly. B. Policy: 's policy is to allow physicians and suppliers to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non-edicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (edicare and non-edicare), then the edicare law and regulations do not preclude the physician or supplier from charging the edicare patient directly.. BUN QUNT TBL Use hall" to denote a mandatory requirement Number equirement esponsibility (place an X in each applicable column) edicare contractors/carriers shall allow physicians and suppliers to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non- edicare patients for missed appointments With respect to Part providers, edicare intermediaries shall allow hospital outpatient departments to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non-edicare patients for missed appointments. n the event, however, that a hospital inpatient / B X X X hared-ystem aintainers V W OT

3 misses an appointment in the hospital outpatient department, it would violate for the outpatient department to charge the beneficiary a missed appointment fee.. POV UTON TBL Number equirement esponsibility (place an X in each applicable column) ontractors shall post this entire instruction, or a direct link to this instruction, on their Web site and include information about it in a listserv message within 1 week of the release of this instruction. n addition, the entire instruction must be included in your next regularly scheduled bulletin. ontractors are free to supplement it with localized information that would benefit their provider community in billing and administering the edicare program correctly. / B X X X hared-ystem aintainers V W OT V. UPPOTNG NOTON. or any recommendations and supporting information associated with listed requirements, use the box below: Use "hould" to denote a recommendation. X-ef equirement Number ecommendations or other supporting information: B. or all other recommendations and supporting information, use this space: V. ONTT Pre-mplementation ontact(s): red Grabau Post-mplementation ontact(s): red Grabau V. UNNG. or iscal ntermediaries, arriers, and the urable edical quipment egional arrier (), use only one of the following statements: No additional funding will be provided by ; contractor activities are to be carried out within their Y 2007 operating budgets.

4 B. or edicare dministrative ontractors (), use the following statement: The contractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work (OW). The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by , and request formal directions regarding continued performance requirements.

5 edicare laims Processing anual hapter 1 - General Billing equirements Table of ontents (ev. 1279, ) harges for issed ppointments

6 harges for issed ppointments (ev. 1279; ssued: ; ffective: ; mplementation: ) 's policy is to allow physicians and suppliers to charge edicare beneficiaries for missed appointments, provided that they do not discriminate against edicare beneficiaries but also charge non-edicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (edicare and non-edicare), then the edicare law and regulations do not preclude the physician or supplier from charging the edicare patient directly. The amount that the physician or supplier charges for the missed appointment must apply equally to all patients (edicare and non-edicare), in other words, the amount the physician/supplier charges edicare beneficiaries for missed appointments must be the same as the amount that they charge non-edicare patients (whatever amount that may be). With respect to Part providers, in most instances a hospital outpatient department can charge a beneficiary a missed appointment charge without violating its provider agreement and Because applies only to inpatient services, it does not restrict a hospital outpatient department from imposing charges for missed appointments by outpatients. n the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate for the outpatient department to charge the beneficiary a missed appointment fee. edicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers. harges to beneficiaries for missed appointments should not be billed to edicare. f contractors receive any claims for missed appointment charges, the following reason code and N messages should be used to deny the claims eason ode 204: This service/equipment/drug is not covered under the patient s current benefit plan. N messages: edicare doesn t pay for missed appointments edicare no paga por citas médicas a las que no se presentó.