CMS Pub. 100-04, ch. 1, § 01

Generally, this chapter describes policy applicable to Medicare fee-for-service claims, or

what is known as the original or traditional Medicare program. See the Medicare

Managed Care Manual for services to enrollees in managed care plans.

Unless specified otherwise the instructions in this chapter apply to both providers and

suppliers, and to the contractors that process their claims.

In this chapter the terms provider and supplier are used as defined in 42 CFR 400.202.

• Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive

outpatient rehabilitation facility, a home health agency, or a hospice that has in

effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency,

or a public health agency that has in effect a similar agreement but only to furnish

outpatient physical therapy or speech-language pathology services, or a

community mental health center that has in effect a similar agreement but only to

furnish partial hospitalization services.

• Supplier means a physician or other practitioner, or an entity other than a provider

that furnishes health care services under Medicare. A supplier must meet certain

requirements and enroll as described in Chapter 10 of the Medicare Program

Integrity Manual. A provider that meets the applicable conditions may also enroll

as a supplier of a particular service and may bill separately for that service where

Medicare payment policy allows separate payment for the service.

In this chapter and in subsequent chapters of Pub. 100-04, the terms ‘institutional claim’

and ‘professional claim’ are defined by the submission format of the claim.

• Institutional claim means any claim submitted using the Health Insurance

Portability and Accountability Act (HIPAA) mandated transaction ASC X12 837

institutional claim or the paper Form CMS-1450.

• Professional claim means any claim submitted using the HIPAA mandated

transaction ASC X12 837 professional claim or the CMS-1500 paper claim form.