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Administrative Procedures And Rules
What will the provider grievance/appeals process look like?
The Medicare appeals process is detailed in the attached link – Medicare Parts A and B Appeals Process.
If providers have concerns or questions related to Medicare, is there an ombudsman or entity they can engage?
You can call CMS at Member Services at 1-877-739-1370. The Office of the Managed Care Ombudsman offers free assistance.
If a provider, air ambulance provider, or health care facility believes a health plan isn’t complying with the dispute resolution process, then they may contact the No Surprises Help Desk at 1-800-985-3059 to submit a question or complaint. Or, they can submit a complaint online. Supporting documentation may be required. CMS will send a confirmation email to the practitioner when CMS receives their complaint to notify them of next steps and let them know if additional information is required.
Is there a Medicare provider directory for behavioral health practitioners?
Medicare has an online provider directory tool that can be accessed at:
https://www.medicare.gov/forms-help-other-resources/find-compare-health-care-providers
Will there be opportunities to engage in the CMS implementation process this year?
Yes. As Medicare Coalition representatives meet with CMS representatives in 2023, we will be soliciting questions and comments from MFTs and counselors on any concerns about implementing rules on Medicare recognition of MFTs and counselors. Further, the Coalition has been holding a series of training sessions this year on Medicare application procedures and coding issues, and regular updates into 2024 and beyond.
How will Medicare recognition of counselors affect the new Counseling Compact and vice versa?
The relationship between CMS regulations and the Counseling Compact is unclear at this time.
Will CMS provide guidance to providers when they treat dual eligibles?
MFTs and counselors must accept assignment for Part B-covered services provided to dually eligible beneficiaries. Assignment means the Medicare Physician Fee Schedule (PFS) amount is payment in full. Special instructions apply when you provide an Advance Beneficiary Notice (ABN) to a dually eligible beneficiary, based on the expectation that Medicare will deny the item or service because it isn’t medically reasonable and necessary or is custodial care.
- You can’t bill the dually eligible beneficiary up front when you provide an ABN. The Medicare Physician Fee Schedule Final Rule will provide more guidance when engaging dual eligibles.
Are Medicare enrolled providers subject to site visits?
Rarely. The National Site Visit Contractor (NSVC) at CMS conducts unannounced site visits for all Medicare Part A and B providers. A site visit helps prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program.
Will practices have to develop or modify their Policy and Procedure (P&P) manuals that meets certain specific Medicare/CMS standards and if so, will a boilerplate checklist or boilerplate/example of P&Ps address the requirements?
CMS expects all Medicare providers to have functional compliance programs to address Medicare requirements of all kinds, including financial, documentation, coding, and quality issues.
