Daily Rules, Proposed Rules, and Notices of the Federal Government
Part F of the Statement of Organization, Functions, and Delegations of Authority for the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS), (
Part F. is described below:
* Section F. 20. (Functions) reads as follows:
* Serves as the focal point for all Agency interactions with health care providers, intermediaries, carriers, and Medicare Administrative Contractors (MACs) for issues relating to Agency fee-for-service (FFS) policies and operations.
* Responsible for policies related to scope of benefits and other statutory, regulatory and contractual provisions.
* Based on program data, develops payment mechanisms, administrative mechanisms, and regulations to ensure that CMS is purchasing medically necessary items and services under Medicare FFS.
* Develops, evaluates and maintains policies, regulations, and instructions that define the scope of benefits and payment amounts for:
1. Hospitals for inpatient services under the inpatient prospective payment system and the long-term care hospital prospective payment system;
2. Inpatient services in hospitals and units excluded from the prospective payment systems;
3. Physicians and non-physician practitioners;
4. Hospital outpatient departments, comprehensive outpatient rehabilitation facilities and ambulatory surgical centers;
5. Clinical laboratory services;
6. Ambulance services;
7. Prescription drugs and blood, blood products and hemophilia clotting factor; and
8. Telemedicine services, rural health clinics, and federally-qualified health centers.
* Formulates CMS policy for development, analysis, and maintenance of new and revised medical codes and medical classification systems (including ICD-9-CM, Healthcare Common Procedure Coding System, Diagnosis Related Groups, and Ambulatory Payment Classifications) and develops common medical coding standards and policy.
* Participates in the development and evaluation of proposed legislation pertaining to assigned subject areas.
* Coordinates with the Office of Clinical Standards and Quality on coverage issues in assigned areas.
* Develops, evaluates, and reviews regulations, manuals, program guidelines, and instructions required for the dissemination of program policies to program contractors and the health care field.
* Identifies, studies and makes recommendations for modifying Medicare policies to reflect changes in beneficiary health care needs, program objectives, and the health care delivery system.
* Develops, evaluates and maintains policies, regulations, and instructions that define the scope of benefits and payment amounts for skilled nursing facilities, home health agencies, hospice, durable medical equipment, orthotics, prosthetics and supplies.
* Develops and evaluates national Medicare policies and principles for applying limitations to the costs of skilled nursing facilities and home health agencies. Develops criteria for exceptions to the cost limitations for skilled nursing facilities. Reviews and makes decisions on requests for such exceptions.
* Analyzes payment data, develops, maintains and updates payments rates for End Stage Renal Disease services and Program of All-Inclusive Care for the Elderly sites.
* Manages designation process for Medicare organ transplant centers, organ procurement organizations and for hospitals seeking out-of-service-area waivers.
* Develops, issues and administers the specifications, requirements, methods, standards, policies, procedures and budget guidelines for Medicare claims processing related activities, including detailed definitions of the relative responsibilities of providers, contractors, CMS, other third-party payers and the beneficiaries of the Medicare program.
* Develops and releases the coding and pricing databases and software for physician, laboratory, Skilled Nursing Facility, Home Health, Inpatient, Outpatient and supplier services in the Medicare claims processing standard systems.
* Develops policies related to the integration of health care services, including policies on ownership and referral arrangements, business relationships and conflict of interest.
* Serves as the CMS lead for management, oversight, budget and performance issues relating to Medicare carriers, fiscal intermediaries, and MACs.
* Functions as CMS liaison for all Medicare carrier, fiscal intermediary, and MAC program issues and, in close collaboration with the regional offices and other CMS components, coordinates Agency-wide contractor activities.
* Manages contractor instructions, workload, and change management process.
* Manages and oversees Medicare contractor provider inquiry, outreach, and education activities including specifying Budget Performance Requirements, allocating and managing budget dollars across contractors, evaluating supplemental budget requests, issuing program instructions and participating in contractor performance evaluation activities.
* In conjunction with the CMS program area experts, develops training programs and materials, and training tools to educate providers, physicians, suppliers and Medicare contractor provider education staff on new initiatives and changes to the Medicare program.
* Develops national provider/supplier education products and training tools for Medicare contractors as well as for provider education provided directly by CMS.
* Supports communication between CMS and the provider/supplier community through facilitation of "open door" and Participating Physician Advisory Committee meetings, other listening sessions and promotes awareness of Agency initiatives by sponsoring exhibit programs at industry conferences.
* Develops system requirements and computer software for select portions of Medicare FFS claims processing systems.
* Develops and implements Medicare FFS program requirements for provider billing and for claims processing systems.
* Implements the Medicare Health Support Program.