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Frequently Asked Questions (FAQ's)

- Medicare


{short description of image}What are the differences between "Participating" and "Nonparticipating" providers with Medicare?

{short description of image}What is Medigap?

{short description of image}What is the difference between Medigap and complementary crossover insurers?

{short description of image}What Is Medicare complementary claim crossover and how does it work?

{short description of image}What is the difference between an assigned and a non-assigned claim?

{short description of image}Where can I find information about Medicare's signature requirements for medical records and whether or not the use of a signature stamp is acceptable?

{short description of image}How do I file a claim when Medicare is the secondary insurer?

{short description of image}How many services should be listed on the claim when using the modifier 50?

{short description of image}What are returned unprocessable claims (RUC)?

{short description of image}How do I correct returned unprocessable claims?

{short description of image}Where can I find a copy of the "Request for Review Form?

{short description of image}What is the CMS - Center for Medicare/Medicaid Internet site?


{short description of image}What are the differences between "Participating" and "Nonparticipating" providers with Medicare?

A participating provider has signed a participation agreement with Medicare to submit only assigned claims and follow all the regulations for assigned claims. The provider has agreed to accept as payment the Medicare allowed amount for a given service. With a participating provider the beneficiary's responsibility will usually be 20% of the Medicare approved amount.

A nonparticipating provider has not signed a participation agreement with Medicare and can submit either assigned or non-assigned claims. This can be done on a claim-by-claim basis. A nonparticipating provider must follow all the regulations that apply to the type of claim submitted.

A nonparticipating provider can charge a Medicare beneficiary up to 115% of what Medicare would normally allow for certain services on non-assigned claims. The beneficiary would be responsible for 20% of the Medicare approved amount plus the difference between the approved amount and the doctor's charge. Additionally, the Medicare allowed amount for nonparticipating providers is 5% less than what is allowed for participating providers on most services, whether the claim is assigned or non-assigned.

Participation agreements are mailed out each year in the fee schedule. Changes to participation status should be made in writing and submitted to Provider Enrollment between December 1 and December 31 each year.

NOTE: These dates may fluctuate slightly based on the Centers for Medicare and Medicaid Services (CMS) instructions.

{short description of image}What is Medigap?

The term "Medigap" refers to Medicare supplemental insurance. It is private health insurance designed specifically to supplement Medicare benefits by filling in some of the "gaps" in Medicare coverage. Examples of some of these gaps are: deductible, co-insurance, and noncovered services. A health plan offered by a company or labor organization for current or former employees does not qualify as a Medigap policy.

For participating providers, when Medigap information is provided correctly, Medicare will automatically advise the Medigap insurer of Medicare's approved amount and payment for the billed services. Nonparticipating provider claims will not be crossed over to Medigap insurers.

A list of Georgia Medigap Insurers can be found at:
http://www.gamedicare.com/common/cob.htm

{short description of image}What is the difference between Medigap and complementary crossover insurers?

The complementary crossover process is totally automatic and does not require or permit any clerical intervention. The automated crossover system is not the same as the Medigap program in that, with the Medigap program, participating providers must manually enter the policyholder, policy number and policy name on the assigned claim. The Medigap fields can be found on the HCFA 1500 form in Items 9 a-d or in the equivalent electronic fields.

{short description of image}What Is Medicare complementary claim crossover and how does it work?

Medicare currently has contractual arrangements with supplemental insurers to automatically crossover claims payment information for their policyholders. An eligibility file furnished by the supplemental insurer is used to drive the process rather than information found on the claim. These eligibility files are matched, based on the Health Insurance Claim (HIC) number, against Medicare’s internal eligibility file. If a match occurs, the beneficiary’s record is flagged, indicating to which company we will cross claim payment information.

Each supplemental insurer is given the opportunity to specify criteria related to the claims the insurer wants Medicare to crossover. Examples of claims most often excluded from the crossover process are:

· Totally denied claims;

· Claims denied as a duplicate or denied for missing information;

· Adjustment claims;

· Claims reimbursed at 100 percent; and

· Claims for dates of service outside of the supplemental policy’s effective date and end date.

As claims are processed, the beneficiary’s eligibility record is checked by the system to determine whether or not the claim should be considered for crossover. If the beneficiary’s eligibility is flagged for crossover, the claim is then checked by the system to determine whether or not the claim meets the crossover criteria requested by the insurer. If the claim is not excluded, it is marked for crossover to the appropriate supplemental insurer. An electronic claims payment record is then created and forwarded to the requesting insurer. This eliminates the need for you to file claims for the patient’s supplemental benefits.


It is important to note the following:

Medicare cannot add, change or delete any eligibility information furnished by an insurer; and

The crossover process is totally automatic and does not require or permit any clerical intervention.

{short description of image}What is the difference between an assigned and a non-assigned claim?

An assigned claim means the provider will accept the Medicare allowed amount as full payment for a given service. Medicare will make payment directly to the provider. The patient is responsible for the co-insurance, which is the difference between the Medicare allowed amount and the amount Medicare paid directly to the provider. The co-insurance is usually 20% of the allowed amount.

For example, if Medicare approves payment to the provider for $100.00, Medicare would pay 80% ($80.00). It is the patient's responsibility to pay the difference between what Medicare allowed and what Medicare paid. In this case, the patient would pay $20.00 (20% of the Medicare allowed amount), unless the have a secondary or supplemental insurance.

A non-assigned claim means the provider will not accept the Medicare allowed amount as full payment. Medicare will make payment to the patient. Most services are subject to "limiting charge" regulations. The provider cannot charge the patient more than 115% of the Medicare allowed amount for services subject to limiting charge. It is the patient's responsibility to pay the full billed amount to the provider for services that are not subject to limiting charges (such as non-covered Medicare services).

{short description of image}Where can I find information about Medicare's signature requirements for medical records and whether or not the use of a signature stamp is acceptable?

The Centers for Medicare and Medicaid Services (CMS) has revised the Medicare Program Integrity Manual. The complete Medicare Program Integrity Manual can be viewed online at http://www.cms.hhs.gov/manuals/108_pim/pim83toc.asp .Medicare requires a legible identity for services provided or ordered. The method used (e.g. hand written, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Medicare will not deny a claim on the sole basis of type of signature submitted. Providers using alternative signature methods (e.g. a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods. For example, a rubber stamped signature is much less secure than other modes of signature identification. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods. All State licensure and State practice regulations continue to apply. Where State law is more restrictive than Medicare, the contractor needs to apply the State law standard. The signature requirements described here do not assure compliance with Medicare conditions of participation. Note that this instruction does not supersede the prohibition for Certificates of Medical Necessity (CMN). CMNs are a term of art specifically describing particular Durable Medical Equipment forms. As stated on CMN forms, "Signature and date stamps are not acceptable" for use on CMNs. No other forms or documents are subject to this exclusion.

{short description of image}How do I file a claim when Medicare is the secondary insurer?

The CMS-1500 Claim Form must be completed indicating the name and policy number of the beneficiary's primary insurance company in Items 11-11c. A copy of the primary insurer's Explanation of Benefits (EOB) must be submitted with the claim form and should include the name and address of the primary insurance company, the name of the subscriber and policy number, name of the provider of services, itemized charges for all procedure codes reported, an explanation of any denial or payment codes, and the date(s) of service.

{short description of image}How many services should be listed on the claim when using the modifier 50?

The modifier 50, bilateral services, is used when the service being provided is being provided bilaterally. Remember when you use the modifier 50 the number of services should be "1", not "2". The modifier 50 means both sides (Right and Left). There is no need to use modifier 50 and the modifiers RT and LT.

Example:

20601- Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g. shoulder, hip, knee joint, subacromial bursa)

  Date CPT/HCPCS Code/Modifier Billed Amount Number of Service
Correct 05012004 20601-50 300.00 1
         
Incorrect 05012004 20601-50RTLT 300.00 2
Incorrect 05012004 20601-50RT 300.00 2
Incorrect 05012004 20601-50LT 300.00 2

{short description of image}What are returned unprocessable claims (RUC)?

Both paper and electronic claims will be returned to you as unprocessable (Returned Unprocessable Claims [RUC]) if the claim contains certain incomplete or invalid information. An incomplete claim is a claim submitted with missing required information (for example; no UPIN). An invalid claim is a claim that contains complete and necessary information; however, the information is illogical or incorrect. No appeal rights are afforded to RUC, as no "initial determination" can be made, thus rendering the claim unprocessable.

{short description of image}How do I correct returned unprocessable claims?

You must resubmit a corrected claim to Medicare for reprocessing. Do not request a rejected claim be reviewed. You cannot bill the beneficiary for the services.

{short description of image}Where can I find a copy of the "Request for Review Form?

The "Request for Review Form" is located at http://www.cms.hhs.gov/forms/cms1964.pdf

Medicare regulations allow providers and beneficiaries who are dissatisfied with Medicare’s determination to request that the determination be reconsidered. Through the appeals process, Medicare seeks to ensure that the correct payment is made or a clear and adequate explanation is given supporting nonpayment.

A physician or supplier providing items and services payable under Medicare Part B may appeal an initial determination if he or she:

  • Accepted assignment;
  • Did not accept assignment on the claim that denied and the claim was denied as not reasonable and necessary;
  • The beneficiary did not know or could not have been expected to know that the service would not be covered, requiring the provider/supplier to refund the beneficiary any payment received for the services; OR,
  • Did not accept assignment, but is acting as the authorized representative of the beneficiary, and indicates this in the appeal. (Attaching a copy of the beneficiary’s Medicare Summary Notice [MSN] indicates the provider/supplier is authorized to act on the beneficiary’s behalf.)

Effective March 1, 2001, any implied request for a review or an appeal request that does not meet the following requirements will be returned.

For Part B appeals, the Medicare regulation states that any party who is dissatisfied with the initial determination may request the carrier review such determination. Effective January 1, 2003, a request for review must be filed within four months after the date of the notice of the initial determination. Medicare can not accept an appeal for which no initial determination has been made. Again, the request for review must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of an appeal request outlined below.

  • A request for a review may be filed on CMS-1964, Request for Review of Part B Medicare Claim; (a copy of Form CMS-1964 is located on the CMS.gov web site at www.cms.gov/forms/cms1964.pdf
  • A request for a review may be a signed written statement from the provider or supplier expressing disagreement with the initial determination or indicating that the review or a reexamination should be made;
  • A request for a review may be filed on the provider's or supplier's letterhead or on a Physician/Supplier Inquiry Form (this form may be requested by calling the Provider Inquiry Line at 1 877 567-7271).

The review request must include the following information:

  • Beneficiary name;
  • Medicare Health Insurance Claim (HIC) number;
  • Name and address of provider/supplier of item/service;
  • Date of initial determination;
  • Date(s) of service for which the initial determination was issued (dates must be reported in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form); and
  • Which item(s), if any, and/or service(s) are at issue in the appeal.
  • The provider remit, should accompany your review request along with any pertinent data which should be considered as additional information (information not submitted with your initial claim). It is not necessary to send another HCFA-1500 claim form - any corrected information should be included with your written request.

Medicare will not accept implied request for reviews from providers, suppliers, states, or any party authorized to act on behalf of the Medicaid State Agency. Any Provider Remittance Advice, listings, or computer printouts that are not signed and/or do not express a disagreement with a specified initial determination will be returned to the sender.

Providers and suppliers are responsible for submitting documentation, if any, that supports the reason for the appeal. This documentation may be supplied with the appeal request or at the request of the carrier. Failure to submit documentation in a timely manner may result in processing delays.

{short description of image}What is the CMS - Center for Medicare/Medicaid Internet site?

http://www.cms.hhs.gov/


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