|City and County of San Francisco
Department of Public Health
POPULATION HEALTH AND PREVENTION
COMMUNITY BEHAVIORAL HEALTH SERVICES
1380 Howard Street, 5th Floor
San Francisco, CA 94103
POLICY/PROCEDURE REGARDING: Physician Responsibilities for Medicare/MediCal Reimbursement
|Issued By: Jo Ruffin, LCSW
Deputy Director of Health for Mental Health
Date: October 16, 1997
Reference: Medicare Regulation
(New Policy Procedure)
This policy, issued by CBHS, serves to inform and reinforce current law and regulation regarding physician responsibilities for Medicare and MediCal reimbursement. The directives included in this policy are intended for physicians providing service at civil service, contract and/or sub-contract providers.
II. Policy Statement/Procedure
Medicare/MediCal Regulations require:
A. Physician Identification:
I. Medicare PIN and UPIN
MEDICARE issues two different Physician identifying numbers: PIN (Provider Identifying Number) and UPIN (Unique Physician Identification
Number). The Medicare PIN is used on Medicare claims to identify the
physician providing the service; and, the UPIN is required for doctor ordered or referred services, such as Medication or Laboratory Procedures. The Medicare PIN is issued by the carrier; whereas the UPIN is issued by HCFA (Health Care Finance Administration). Both are issued at the same time on the same application sent to Medicare. All physicians must obtain a UPIN and PIN even though they do not bill Medicare directly.
HCFA, Medicare, and Federal agencies are in the process of developing a single National Provider Identifier (NPI) for Medicare certified physicians. The NPI is scheduled to be issued in late 1998 and will replace Medicare PIN and UPIN.
Currently, Medicare claims submitted for reimbursement must include a Provider Identifying Number (PIN). This code begins with an alpha character and is followed by five numerals and identifies the physician as the provider of services. In addition, a UPIN is required for physician ordered services being claimed to Medicare.
The following policy statement and procedure is effective immediately:
Services claimed to Medicare must include the physician's PIN or UPIN. As CBHS provides the billing service on behalf of physicians, these identifiers must be current and on file. CBHS Provider Relations will maintain a current Provider Database which will contain Medicare PIN and UPIN information. Physiscians who do not currently have a Medicare PIN or UPIN must complete a Medicare Health Care Provider/ Supplier Enrollment Application (Attachment 1). In addition, Physicians are required to complete a BIS Staff ID Form (Attachment 2) in order to enter services into the billing and information system. Completed forms are sent by mail to: DPH - CBHS, Billing and Information Systems, 1380 Howard Street, 3rd Fl., S. F., CA 94103.
II. Medi - Cal PIN
To receive payment for medical services or supplies furnished to Medi-Cal patients, a provider must be approved for participation by the Department of Health Services (DHS). The DHS Provider Enrollment Unit assigns each provider a unique nine character identification number. This number identifies the provider through the Medi-Cal claims processing system.
Services claimed to Medi-Cal must include the physician's Medi-Cal PIN. As CBHS provides the billing service on behalf of physicians, these identifiers must be current and on file. CBHS Provider Relations will maintain a current Provider Database containing Medi-Cal PIN information. If not currently approved for participation, a provider should contact: CA Dept. of Health Services, Provider Enrollment, (916) 323-1945, P. O. Box 942732, Sacramento, CA 94234-7320. In addition, Physicians are required to complete a BIS Staff ID Form (Attachment 2) in order to enter services into the billing and information system. Completed forms are sent by mail to: DPH - CBHS, Billing and Information Systems, 1380 Howard Street, 3rd Fl., S. F., CA 94103.
Organizational Provider SD/MC Certification
DMS Provider sites, except for Inpatient and Outpatient Hospital Services operating under the hospital license, must be certified according to the standards of the Short-Doyle/Medi-Cal Manual for Rehabilitation Option and Targeted Case Management in order to bill for Medi-Cal services (DMS Policy Manual Number 2.01-2). Each certified Provider site is assigned its own unique provider number, a Medicaid Authorization Provider PIN. Claims for eligible services provided by staff at a certified Provider site require this authorization number.
B. Limited Visits:
The Medicare fiscal intermediary has established a general protocol that limits the reimbursement for physician visits to 20 physician visits per year on average. Additional visits are subject to demonstrating medical necessity through documentation.
CBHS will monitor physician visits (number and location) through the Information System to ensure they do not exceed 20 visits per year. The purpose of such monitoring is, when applicable, to maximize reimbursement by Medicare as the primary payor source at SF City and County and contract agencies.
MediCal reimbursement for physician visits will be monitored and managed through the outpatient consolidation authorization and reauthorization medical necessity criteria.
C. Documentation: Client Death
Claims submitted for services provided after a client death will be denied by Medicare and MediCal. In the event of a client death, claims may be submitted for services rendered only prior to the date of death (no billable case management afterward). Upon notification of a client death, the case must be closed by the client's case coordinator/manager within 2 weeks.
Contact Person: Maria Poulo, Billing Manager, (415) 255-3536
Administrative Manual Holders
Quality Management Staff
All CBHS Programs
All CBHS/Contract Physicians