What is a Medicare Administrative Contractor & Why Should I Care?

What is a Medicare Administrative Contractor & Why Should I Care?

Are you a provider offering Medicare hospital and/or outpatient services? Are you applying to be a Medicare provider? Or are you a Medicare beneficiary filing an appeal? If you answered yes to any of the above questions, it is important you know who serves as your regional Medicare Administrative Contractor (MAC) and what a MAC does.

Which regional MAC covers California?
Noridian Healthcare Solutions is the Medicare Administrative Contractor for California and is responsible for processing all Medicare fee-for-service Part A and B claims. Palmetto GBA previously held the contract. On August 26, however, Medicare Part A claims processing services switched to Noridian, and Part B claims services changed over on September 16.

In the past, the Centers for Medicare and Medicaid Services (CMS) contracted with 23 fiscal intermediaries (FI) and 17 carriers across the nation to process Medicare Part A and B fee-for-service claims respectively. As a result of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), however, CMS was authorized to make Medicare’s administrative systems more efficient, competitive and performance-based. Consolidating the intermediaries’ and carriers’ administration into one entity, now called A/B Medicare Administrative Contractors, or A/B MACs, was one of the changes. CMS is now contracting with 10 A/B MACs covering various geographic regions across the country. California, along with Nevada, Hawaii, and the U.S. territories of American Samoa, Guam and the Northern Mariana Islands, are under Jurisdiction E (previously called Jurisdiction 1). There are also MACs for handling durable medical equipment, home health, and hospice claims.

What do MACs do?
MACs are the primary point of contact for:

  • Provider enrollment
  • Medicare coverage and billing requirements
  • Training for providers
  • Receipt, processing and payment of fee-for-service claims

Medicare providers are assigned to the MAC serving their geographical region.

In addition to processing Medicare Part A and B claims, MACs also play an important role in Medicare Part A and B appeals. If a Part A or Part B claim is denied or not handled the way you think it should be, you can appeal the decision. There are up to 5 levels in the appeals process, and the MACs provide a review at the 1st level, called a Redetermination. Very few people do this, but more than half of appealed claims bring positive results for the provider” and beneficiary. See our Medicare Appeals section for more information on the appeal process and how to start an appeal for Medicare Parts A, B, C (Medicare Advantage) and D.

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Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.