Provider Responsibility

According to the Medicare Claims Processing Manual, Chapter 30, Section 40.1, providers and suppliers are responsible for knowing the rules and regulations that apply to all services billed by the provider to the Medicare program.

In accordance with regulations at 42 CFR 411.406, evidence that the provider, practitioner or other supplier did, in fact, know or should have known that Medicare would not pay for a service or item includes:

• A Medicare contractor's prior written notice to the provider, practitioner or other supplier of Medicare denial of payment for similar or reasonably comparable services or items
• Medicare's general notices to the medical community of Medicare payment denial of services and items under all or certain circumstances (such notices include, but are not limited to, manual instructions, bulletins, contractors' written guides, and directives)
• Provision of the services and items was inconsistent with acceptable standards of practice in the local medical community (refer to §40.1.3 and §40.1.4)

If any of the circumstances described above exists, a provider, practitioner or other supplier is held to have knowledge.

The provider is responsible to know the rules and regulations that are made available through publications from the Medicare carriers and fiscal intermediaries, which include, but are not limited to, the Medicare publications, articles and email updated published on the Palmetto GBA websites.   

Resources:

• Beneficiary Notices Initiative (BNI) CMS website
• Medicare Claims Processing Manual, Chapter 30, Section 40.1 (PDF)