Alphabet soup: Decode MACs, PSCs and QICs

Monday, July 31, 2006

Q. On July 1, Medicare transfers claims processing from DMERCs to Medicare Administrative Contractors (MACs). Will this change how we file claims?

A. Some suppliers will have to establish new EDI connections and deal with new contacts on claims matters. Otherwise, you won't see changes in claims submission for now.
The July 1 transition date applies only in Regions A and B, which will now be referred to as Jurisdictions A and B. The MAC contracts for those jurisdictions were awarded to National Heritage Insurance Company and AdminaStar Federal, the current Region B DMERC. MAC implementation in the other two jurisdictions has been delayed. The Jurisdiction D MAC contract has been awarded to Noridian Administrative Services, but Noridian will not assume responsibility for claims administration until sometime this fall. Implementation was delayed because Cigna Government Services filed a protest of the contract award, which was subsequently denied. Cigna also protested the award of the Jurisdiction C contract to Palmetto GBA, the current Region C DMERC, and that protest was upheld. CMS hopes to be able to make the transition in that jurisdiction by the end of 2006. For now, Palmetto will continue to process claims under its DMERC contract.
The transfer of claims administration to the MACs is the final phase in CMS's restructuring of its contracts for DME-related services. That process will result in the redistribution of the functions among three different sets of contractors: MAC, PSC and QIC. Claims processing will be handled by the MACs. PSCs will be responsible for medical review, medical policy development, fraud prevention and investigation, and provider and beneficiary education. The PSCs for the respective MAC jurisdictions are TriCenturion for Jurisdictions A and B, TrustSolutions for Jurisdiction C and IntegriGuard for Jurisdiction D. QIC will hear appeals that formerly were heard by DMERC carrier hearing officers. The QIC contract for all DME jurisdictions has been awarded to Q2Administrators.


Tim Webster is a healthcare attorney with the law firm Brown & Fortunato. Reach him at 806-345-6320 or