CMS Pub. 100-04, ch. 1, § 20

A. The Process of Moving Providers from FIs to MACs

1. The General Case

An existing Medicare provider with a claims history will remain in its current workload

assignment. As each MAC contract is awarded, the new MAC will take over workload

from the carriers and FIs that serviced the state(s) in the given MAC jurisdiction. The

Part A and Part B workload segments for each of the states in the given MAC jurisdiction

will be moved one-by-one in the 12 months following the final award. The specific

requirements associated with workload transfers will be directed through formal CMS

transmittals.

A new provider (also known as an “initial enrollment”) will be assigned to the FI or

MAC that covers the state where the provider is located, unless the assignment is directed

to a non-geographic workload by §20B below.

A special exception exists for a “Multi-Provider Complex/Sub-Unit” relationship (ref: 42

CFR 483.5(b)). An initial enrollment for a sub-unit will be assigned to the FI or MAC

that currently serves the existing parent hospital – even if the parent hospital is not

presently billing in accordance with the “geographic assignment rule.” Each such case is

fact-specific and will be treated on an individual basis.

2. Out of Jurisdiction Providers

An “out-of-jurisdiction provider” (OJP) is a provider that is not currently assigned to the

A/B MAC or FI in accordance with §§B.1-5 below (including the geographic assignment

rule.) For example, an individual, freestanding provider located in Maine, but currently

assigned to the Wisconsin FI, would be an OJP.

Many legacy Part A workload segments may include a number of OJPs. Examples of

how an OJP may have been assigned to the given Part A segment include:

a. Individual “provider nominations.” (Note MMA §911 repealed the

provider nomination provisions of the Act.);

b. Chains being granted “single FI” status; and

c. Legacy-world regional and national FIs for specific provider types

such as FQHCs, RHCs, and ESRD facilities.

New MACs will initially service some OJPs until CMS undertakes the final reassignment

of all OJPs to their destination MACs based on the geographic assignment rule and its

exceptions.

CMS will start the overall transfer of OJPs to their final destination MACs after all 15

A/B MACs have been implemented. Each move will be dependent on the then-current

implementation status of the systems that support the cost report audit, claims processing,

and provider enrollment functions at the departure and destination MACs.

Some providers will need to submit or update their Medicare enrollment record before

being reassigned.

B. The Settled MAC Environment

The “settled MAC environment” refers to the period after all OJPs have been moved to

their destination MACs.

1. Home Health & Hospice

All home health and hospice (HH&H) providers will be assigned to the MAC contracted

by CMS to administer HH&H claims for the geographic locale in which the provider is

physically located.

2. Durable Medical Equipment

Each supplier of durable medical equipment, prosthetics, orthotics, and supplies

(DMEPOS) will submit claims to the DME MAC contracted by CMS to administer

DMEPOS claims for the geographic locale in which the beneficiary permanently resides.

3. Qualified Railroad Retirement Beneficiaries Entitled to Medicare

Physicians and other suppliers (except for DMEPOS suppliers) will continue to enroll

with and bill the contractor designated by the Railroad Retirement Board (under Section

1842(g) of The Act) for Part B services furnished to these beneficiaries. Suppliers of

DMEPOS will bill the DME MACs.

4. Specialty Providers and Demonstrations

Specialty providers, and providers involved with certain demonstrations, will submit

claims to a specific MAC designated by CMS. Examples of specialty providers and their

corresponding MACs are:

Specialty Service MAC

Jurisdiction

Centralized Billing for Mass Immunizers 4

Indian Health Services/Federally Recognized Tribal

Providers

(Refer to Chapter 19 of this manual.)

4

Low Vision Demonstration 5, 10, 11, 13, and

14

Veterans Affairs Medicare Equivalent Remittance Advice

Project 4

Home Health Third Party Liability Demonstration Project 14

Independent Organ Procurement Organizations 10

Religious Non-medical Health Care Institution (RNHCI) 10

Histocompatibility Lab 10

5. The Geographic-Assignment Rule

Medicare providers, physicians, and suppliers will generally be assigned to the A/B MAC

that covers the state where the provider is located. This includes FQHCs, RHCs, and

ESRD facilities.

An exception exists for qualified chain providers (QCPs). A QCP may request that its

member providers be serviced by a single A/B MAC - specifically, the A/B MAC whose

jurisdiction includes the QCP’s home office. See 42 CFR 421.404 for QCP criteria and

additional information.

A few providers that meet the “provider-based” criteria of 42 CFR 413.65 may present an

additional exception to the geographic-assignment rule. Provider-based entities (other

than HH+H providers) will be assigned to the MAC contracted by CMS to administer

claims for the Medicare benefit category applicable to the provider’s covered services for

the geographic locale in which the main (“parent”) provider is physically located.