December 6, 2012
Cassandra M. Wineglass
The Health Care Industry continues to grow daily and provide benefits for those who are
in need of employment or just want to be educated on the topic there of. With the world and the
fast paste we live in it is extremely important to find your area of need and focus. My area of
focus just so happens to be Health Care Information. For this week’s assignment, I targeted the
area of Medicare Part B. This area of operation was created to enroll institutional providers that
wish to bill for services offered by Medicare. Here we find the review and processesing of the
the CMS 855 B. There are several providers that are allowed to complete this application.
Ambulance Service Supplier, Ambulatory Surgical Center, Clinic/Group Practice, Independent
Clinical Laboratory, Independent Diagnostic Testing Facility(IDTF), Intensive Cardiac
Rehabilitation Supplier, Mammography Center, Mass Immunization (Roster Billing Only), Part
B Drug Vendor, Portable X-Ray Supplier, and Radiation Therapy Center are just to name a few.
Extensive training is given to ensure that you learn the different types of applications needed to
enroll Institutional Providers. Physicians and Non-Physician Practitioners are processed with the
application called the CMS 855 I & R. These applications are set in place for a provider to
complete and ensure Medicare approval. The applications are either given what is called a
Provider / Medicare Identification Number, or make recommendations for approval. In addition
To reviewing the application, CMS has set in place provider standards that must be adhered
to. There are 30 set in place, but I will only name a few. These standards can be viewed by
anyone at http://www.hqaa.org/docs/30supplierstandardsabv.pdf. “A supplier must be in
compliance with all applicable Federal and State licensure and regulatory requirements
and cannot contract with an individual or entity to provide licensed services.”
(http://www.hqaa.org/docs/30supplierstandardsabv.pdf) All applications must
be signed by what is called an Authorized Official. He or she must be someone who can legally
bind a company.” A supplier has to maintain a physical facility on an appropriate site. CMS or
it agents must be allowed to conduct on site inspections to ascertain compliance.”
An onsite inspection takes place to ensure that the provider is located at the address submitted in
section 4A of the application. Several pictures over the area are taken for address verification.
standards. Pictures taken are sent to analyst for review. There are lists of questions asked during
the survey. It is the responsibility of the analyst to ensure complete documentation of the
answers given before a final determination is reached. Once a provider number is issued CMS
has set in place what is called a Revalidation Process. This process takes place every three to four
years to ensure that the provider is still in good standing. If the provider is non-compliant they
are either inactivated or revoked from the Medicare Program. A reactivation of the provider
number or PTAN (Provider Transaction Number) is the simply way to regain access to the
number again. They will have to go back through the entire application process. If the number is
revoked it is a strong possibility the provider will have to sit out of the Medicare program for a
minimum of a year or more. The number of years given are all based on a case-by-case basis.
For this week’s assignment I had the opportunity to review a young lady by the name of
Angela Spradley who has been with Palmetto GBA(Blue Cross Blue Shield) for the last 5 years.
We were able to discuss her role as a Provider Enrollment Analyst. The following is a questions...