Posted in #Medicare, Training

Do you know what is your Local CMS MAC?

As a provider you see Medicare patients and file their claims to Medicare every day, but do you know who is the one the processes those claims?

Well, the short answer is your Local CMS MAC.

What is a Local MAC? MAC stands for Medicare Administrative Contractor- a private healthcare insurer that processes the fee-for-services claims for Medicare Part A/B beneficiaries, Home Health, and DME claims.

According to CMS.gov as of 2019 there are 13 Medicare A/B MACs and 4 DME MACs. They are responsible for processing  claims for ” nearly 68% of Medicare population”.

MACs provide LCDs- Local Coverage Determinations for services that are done by you-provider.  By contacting your local MAC you can find out if a service or medication is covered or not. This step will help you reduce the number of your unnecessary denials and decrease the amount of days in your A/Rs.  

I am located in New York, so my local MAC is for Jurisdiction K- Medicare Part B claims ONLY.  The company that provides LCDs and processes my claims is NGS or National Government Services. 

Below are the most current A/B MAC + DME MAC jurisdictions.


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Posted in Insurance, Training, Updates

MVP Plans (NY) Cardiovascular and Ophthalmology TC Reimbursement Policy 2021

Full Name of this policy is: Multiple Procedure Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures Payment Policy

Effective Date is February 03/2021

This policy will follow the reimbursement standards set forth by the CMS, under the MVP Multiple Procedure Payment Reduction (MPPR) policy. The MPPR policy regarding diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPR policy applies independently to cardiovascular and ophthalmology services. The MPPR policy applies to TC-only services, and to the TC of global services.

For cardiovascular services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 75% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.

For ophthalmology services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 80% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same group NPI) to the same patient on the same day. The MPPR policy does not apply to the professional component.

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR7848 respectively. CR7848 is available at http://www.cms.gov/Regulations[1]and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

Source: MVP provider fax announcements.

Posted in Insurance, Updates

Empire BCBS New Reimbursement Policy for services provided by NP or/and PA

Empire Introduces a new reimbursement policy Effective Date 09/01/2020 for services done by Nurse Practitioner and Physician Assistant Providers.

Unless indicate otherwise by state, federal, or CMS contracts and/or requirements; Empire BCBS will reimburse NPs and PAs for services done on DOS 09/01/2020 and thereafter.

The reimbursement is based upon the following:

1. The services performed by NP or PA are in the scope physician’s office

2. The service is considered a physician’s services

3. A payment reduction consistent with CMS reimbursement

The services furnished, should be billed under the NP or PA own NPI number.

Modifier: SA

Please click here to visit the complete new reimbursement policy.