LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

Jurisdiction 15 A/B MAC EDI Enrollment

Attention: Please Read and Accept Before Completing EDI Enrollment

CGS will obtain an EDI Enrollment form for each provider prior to electronic transfer of data and issuance of system passwords/billing numbers to protect the security of transferred data. CGS will obtain a new EDI Enrollment package or a written and signed statement from a previously enrolled provider if the provider reports a change in the clearinghouse, billing agent, or other third party agent; termination of use of such an agent; intent to begin to submit/receive additional EDI transactions, or if the provider will begin to use a different software for submission of EDI transactions.

As instructed by CMS, please be aware of the following requirements, as outlined in IOM 100-04, Ch. 24, §40.2.2.3External PDF

A/B MACs and DME MACs, or other contractors if designated by CMS must notify each provider that applies for permission to obtain eligibility data electronically that:

  • They are permitted to view Medicare eligibility data only for patients currently being treated by or who have requested treatment or supplies from that provider;
  • A provider cannot authorize a billing agent or clearinghouse to submit or obtain data from an A/B MACs and DME MACs that the provider is not entitled to personally submit or obtain;
  • A request for personally identifiable information for any other Medicare beneficiaries would be a violation of Medicare and HIPAA privacy requirements, and subject to the applicable penalties for such violations.
  • A/B MACs and DME MACs must notify each billing service and clearinghouse/VAN/NSV at the time of their application for access to Medicare eligibility data and by also posting information on their web site that:
  • Their access is limited to submission of transactions and receipt of transactions for those providers that are their clients, but only if those providers authorized the billing agent and/or clearinghouse/VAN/NSV to submit or receive each transaction.
  • A billing agent or clearinghouse/VAN/NSV that has provider authorization to submit claim data for a provider cannot obtain eligibility data for that provider unless that was specifically authorized by the provider.
  • Likewise, the billing agent or clearinghouse/VAN/NSV cannot be sent remittance advice transactions for a provider unless specifically authorized to do so by that provider.

IOM 100-04, Ch. 24, §40.2.2.4
D. Providers must be notified that:

  • They may obtain eligibility data only for the approved use of preparing accurate Medicare claims;
  • Access to eligibility data is limited to individuals within a provider's organization who are involved in claim preparation and submission; and
  • they and their authorized third party agents must agree not to request eligibility data for a beneficiary unless the provider has been contacted by the beneficiary, a personal representative of a beneficiary such as a relative or friend, or a health care provider currently treating the beneficiary concerning provision of health care services or supplies to the beneficiary.

The Benefits of EDIPDF

Availability of free software:

Availability of batch claims status inquiries.The information must be updated on a regular basis.

IOM 100-04, Ch. 24, §40.2.4.1

CGS provides information available to potential user for each EDI transaction supported by Medicare with detailed information within:

IOM 100-04, Ch. 24, §40.2.4.6

A/B MACs, DME MACs, and CEDI Web pages must include a link to the CMS Web site, which provides record formats and transactions information. If the information is available on the CMS Home page, A/B MACs, DME MACs, and CEDI should link to it rather than duplicating development and maintenance.

IOM 100-04, Ch. 24, §40.2.5

A/B MACs, HIPAA Eligibility Transaction System (HETS) ASC X12 270/271 eligibility and CEDI must make EDI information available to new users that describe the various steps in the testing process (see §30 and §60) and discloses: http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/index.htmlExternal Website

HETS (HIPAA Eligibility Transaction System) – A Centers for Medicare & Medicaid Services (CMS) system, based on the HIPAA 270/271 transaction.

HETS requires the provider to obtain an IP connection from an authorized Network Service Vendor.

MCARE Help Desk
mcare@cms.hhs.gov
1-866-324-7315

CMS HETS Web pageExternal Website

The Help Desk contact information, including telephone number, email address, and website to help with:

Using Electronic Data Interchange Services

CGS has prepared this packet for Jurisdiction 15 A/B MAC submitters. J15 includes the Part A & Part B contracts for Kentucky and Ohio and Region B for Home Health and Hospice (HHH).

Please visit the CGS website or contact the CGS Help Desk for EDI support:

  • Ohio/Kentucky Part B: 1-866-276-9558 Option 2
  • Ohio/Kentucky Part A: 1-866-590-6703 Option 2
  • Home Health/Hospice: 1-877-299-4500 Option 2

When submitting completed forms, please allow a processing time of approximately 7 Calendar days. Remember – CGS cannot process incomplete applications or agreements! Please fill in all appropriate blank.

If you are a provider waiting for a provider number, please wait before submitting any EDI forms! You must be assigned your provider number before completing any of the paperwork below. To apply for a provider number, please call the Provider Customer Service toll-free at the following phone number:

  • Ohio/Kentucky Part A: 1-866-590-6703
  • Ohio/Kentucky Part B: 1.866.276.9558
  • Home Health and Hospice: 1.877.299.4500

The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations. All initial claims for reimbursement from Medicare must be submitted electronically, with limited exceptions.

For more information on CGS EDI options, please visit our website at https://www.cgsmedicare.com The CMS Electronic Billing & EDI Transactions Web page at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/index.htmlExternal Website also includes detailed information on EDI and the Administrative Simplification provision.

Please join theListServ Notification Service to receive EDI news electronically!

IOM 100-09, Ch. 6, §20.4.3

Contractors shall offer training that is tailored to the needs of new Medicare providers and billing staff. Medicare Learning Network® products or content shall be used to the extent practicable. (See section 20.4 of this chapter.)This training shall deal with fundamental Medicare policies, programs, and procedures and shall concentrate on and feature information on billing Medicare.

IOM 100-09, Ch. 6, §20.4.5.4

Contractors shall conduct training for providers or their staff in electronic claims submission. The contractor shall conduct training activities for providers to educate them on, and expand their use of, Medicare billing software and the EDI transactions supported by Medicare.

Medicare Electronic Data Interchange (EDI) Enrollment Agreement

  1. The provider agrees to the following provisions for submitting Medicare claims electronically to CMS or to CMS' A/B Mac's or CEDI:
    1. That it will be responsible for all Medicare claims submitted to CMS or a designated CMS contactor by itself, its employees, or its agents;
    2. That it will not disclose any information concerning a Medicare beneficiary to any other person or organization, except CMS and/or its A/B MAC's, DME MACS or CEDI or another contractor if so designated by CMS without the express written permission of the Medicare beneficiary or his/her parent or legal guardian, or where required for the care and treatment of a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to Medicare, or as required by State or Federal law;
    3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their written authorization to do so, and to certify that required beneficiary signatures, or legally authorized signatures on behalf of beneficiaries, are on file;
    4. That it will ensure that every electronic entry can be readily associated and identified with an original source document. Each source document must reflect the following information:
      1. Beneficiary's name;
      2. Beneficiary's Medicare beneficiary identifier;
      3. Date(s) of service;
      4. Diagnosis/nature of illness; and
    5. That the Secretary of Health and Human Services or his/her designee and/or the A/B MAC, DME MAC, CEDI or other contractor if designated by CMS has the right to audit and confirm information submitted by the provider and shall have access to all original source documents and medical records related to the provider's submissions, including the beneficiary's authorization and signature. All incorrect payments that are discovered as a result of such an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal regulations, and CMS guidelines;
    6. That it will ensure that all claims for Medicare primary payment have been developed for other insurance involvement and that Medicare is the primary payer;
    7. That it will submit claims that are accurate, complete, and truthful;
    8. That it will retain all original source documentation and medical records pertaining to any such particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid;
    9. That it will affix the CMS-assigned unique identifier number (submitter identifier) of the provider on each claim electronically transmitted to the A/B MAC, CEDI or other contractor if designated by CMS;
    10. That the CMS-assigned unique identifier number (submitter identifier) or NPI constitutes the provider's legal electronic signature and constitutes an assurance by the provider that services were performed as billed;
    11. That it will use sufficient security procedures (including compliance with all provisions of the HIPAA security regulations) to ensure that all transmissions of documents are authorized and protect all beneficiary-specific data from improper access;
    12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of such claims is a claim for payment under the Medicare program, and that anyone who misrepresents or falsifies or causes to be misrepresented or falsified any record or other information relating to that claim that is required pursuant to this agreement may, upon conviction, be subject to a fine and/or imprisonment under applicable Federal law;
    13. That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries, or any information obtained from CMS or its A/B MAC, DME MAC, CEDI or other contractor if designated by CMS shall not be used by agents, officers, or employees of the billing service except as provided by the A/B Mac, DME MAC or CEDI (in accordance with §1106(a) of the Social Security Act (the Act);
    14. That it will research and correct claim discrepancies;
    15. That it will notify the A/B Mac, CEDI, or other contractor if designated by CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form.
  2. The Centers for Medicare & Medicaid Services (CMS) agrees to:
    1. Transmit to the provider an acknowledgment of claim receipt;
    2. Affix the A/B Mac, DME MAC, CEDI or other contractor if designated by CMS number, as its electronic signature, on each remittance advice sent to the provider;
    3. Ensure that payments to providers are timely in accordance with CMS's policies;
    4. Ensure that no A/B MAC, CEDI, or other contractor if designated by CMS may require the provider to purchase any or all electronic services from A/B MAC, CEDI, or from any subsidiary of A/B MAC, CEDI, other contractor if designated by CMS, or from any company for which the A/B MAC, CEDI has an interest. The A/B MAC, CEDI, or other contractor if designated by CMS will make alternative means available to any electronic biller to obtain such services;
    5. Ensure that all Medicare electronic billers have equal access to any services that CMS requires Medicare A/B MAC, CEDI, or other contractors if designated by CMS to make available to providers or their billing services, regardless of the electronic billing technique or service they choose. Equal access will be granted to any services the A/B MAC, CEDI, or other contractor if designated by CMS sells directly, or indirectly, or by arrangement;
    6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form;

      Note: Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by CMS under this document.

This document shall become effective when signed by the provider. The responsibilities and obligations contained in this document will remain in effect as long as Medicare claims are submitted to the A/B Mac, DME MAC, CEDI, or other contractor if designated by CMS. Either party may terminate this arrangement by giving the other party thirty (30) days written notice of its intent to terminate. In the event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of mailing, as established by the postmark or other appropriate evidence of transmittal.

Attestation

The Trading partner has executed Business Associate Agreements (contracts), as mandated by HIPAA and ARRA/HITECH, with each of its business associates. Moreover, the trading partner attests that it has full responsibility, as mandated by HIPAA and ARRA/HITECH, for notification of breaches of protected health information caused by the trading partner or its business associates.

Accept

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved