You will find tips on Medicare claims filing posted frequently on this page, and you can access an always-growing archive of the tips.

 

If your physician practice is non-participating, you are legally bound by the assignment agreement if you submit a Medicare claim with Item 27 marked "Yes"—even if you intended that the claim be non-assigned.

Have you ever experienced an initial-claims-filing backlog in your practice?  Or have you ever discovered a very old claim that has never been filed?

You’ll be glad to know that Medicare gives you a longer period to file a new claim than most any other insurance carrier—between 15 and 27 months.  However, filing an assigned claim more than one year after the date of service will cost you:  see “payment penalty” tip.

Use this chart to keep track of timeliness:

Although your Medicare claim is still timely more than one year after the date of service, you'll want to keep a tight control so you won't exceed one year.  You may file your assigned claim within the timeliness limits, but if Medicare receives your claim more than one year after the date of service, Medicare reduces its payment amount (not the allowed amount) by 10%.

Note that you may not collect the reduction amount from your patient (or from your patient’s Medigap or other insurance.)

Your patient receives the following message on the Medicare Summary Notice:

            Payment was reduced for late filing.

Do you ever have difficulty obtaining a UPIN (Unique Provider Identification Number) from a referring or ordering doctor?  There is an online database which is updated from CMS listings, but it is not maintained by CMS and thus is not guaranteed to be complete.

Go to http://www.cpg.mcw.edu/www/upin.html, click on your state, and enter the physician's last name.

If you have questions on the proper use of UPINs, study items 17 and 17a in the HCFA-1500 claim form instructions.  (See Tip # 1.)

back to top of index

When Medicare determines that it is not (or it may not be) the primary payer, you may receive a letter from the COB (Coordination of Benefits) contractor. This contractor now handles all Medicare Secondary Payer (MSP) research nationwide.

Your local Medicare carrier will continue to process MSP claims but will no longer investigate them, and you can prevent some MSP problems by reporting information yourself. Be sure your staff knows to notify the COB contractor about potential MSP situations, changes in a beneficiary's insurance coverage or employment, and general MSP questions and concerns.

You can reach the COB contractor's customer call center at 800-999-1118 Monday through Friday, 8 am to 8 pm EST.

back to top of index

Can you staff recognize Railroad Medicare beneficiaries before you file a claim? All Railroad Medicare HICNs (Health Insurance Claim Numbers) begin with a letter followed by 6 or 9 numbers; regular Social Security Administration Medicare numbers end with a letter.

If you file a Railroad Medicare claim with your regular Medicare carrier by mistake, the carrier will deny the claim and notify you that it has forwarded the claim to Railroad Medicare.  Avoid doubling your claim processing time by ensuring that your staff carefully screens Medicare cards at patient registration and clearly identifies Railroad Medicare patients.

Go to http://www.pgba.com, choose "Providers", then "Railroad Medicare" for more Railroad Medicare information.

back to top of index

Unlike a Railroad Medicare number (easily recognizable since it begins with a number), a UMWA Medicare HICN (Health Insurance Claim Number) is a regular Social Security Administration Medicare number which ends with a letter.  However, since UMWA Medicare claims cannot be paid by your regular Medicare carrier, it's important for your staff to learn how to identify a UMWA Medicare patient at initial registration.

UMWA The Funds is a Health Care Prepayment Plan (HCPP) and administers payment for Medicare Part B services on behalf of Medicare-eligible Funds' beneficiaries.  These patients should present a The Funds card as well as the Medicare card:  train your staff to recognize the UMWA card and flag the patient's claims for submission to UMWA Medicare.

If you send a UMWA Medicare patient's claim to your local carrier by mistake, the carrier will deny the claim and notify you that it has forwarded the claim to UMWA Medicare.  Avoid doubling your claim processing time by ensuring that your staff carefully screens Medicare cards at patient registration and clearly identifies UMWA Medicare patients.

Go to http://www.umwafunds.org for more UMWA Medicare information.

back to top of index

CMS has designated three place-of-service (POS) codes 
for use with two sets of nursing facility procedure codes.  Inpatient and outpatient consultations can also be performed in nursing facilities.  

When you provide services to patients in any level of nursing facility, you must determine and document your patient's level of service on your date of service so that you can choose the correct procedure and POS codes.  Remember that any facility may provide one, two, or all three levels of care.

Use this chart to code POS correctly:
          NP = new patient 
          EP = established patient
          ICF = intermediated care facility
          LTCF = long-term care facility

back to top of index

Are you non-participating?  If so, Medicare will not automatically send your claims to the patients' Medigap insurers (even if you complete Items 9 through 9d of the claim form):  the Medigap crossover process is only for participating physicians and suppliers.  Non-participating physicians and suppliers should not enter any information in Items 9 through 9d.

If you participate with Medicare, the Medigap crossover process is one of the advantages of participation:  you file one claim and receive payment from two carriers.  

If your patient requests that you file the Medigap claim, Medicare requires that you do so.  Your patient must agree to this process by signing Item 13 or by signing a separate Medigap authorization that you keep on file.  

Participating physicians and suppliers complete the Medigap section of the claim form as follows:

Item 9—Enter the word SAME if the Medigap enrollee is the Medicare patient, as is usually the case.  If the Medigap enrollee is not the patient, enter the last name, first name, and middle initial of the Medigap enrollee.

Item 9a—Enter the policy and/or group number of the Medigap enrollee preceded by MG or MGAP or Medigap.

Item 9b—Enter the Medigap enrollee's eight-digit birth date (MMDDCCYY) and sex.

Item 9c—Enter the claims processing address of the Medigap insurer.  Use an abbreviated street address, two-letter state postal code, and zip code copied from the Medigap identification card:  e.g., 1275 Anywhere St MD 21204.

Item 9d—Enter the Medigap insurance program or plan name, unless you have the Other Carrier Name and Address (OCNA) number from a listing published by the carrier.  (Note: Eventually a nine-digit PayerID will replace the OCNA number.)

If you have the OCNA number:

Be sure that your correct tax ID number is in 
Item 25.

back to top of index

 

If you file an assigned claim, the Medicare carrier may forward claim payment/denial information to a secondary insurer—not a Medicaid or a Medigap plan.  These crossovers are called "complimentary" or "automatic" and can occur even if you enter no secondary insurer information on your claim.

There is really no way for you to be sure whether or not this crossover will happen:  each secondary insurer chooses the type of claim it will receive (all claims vs. only allowed claims, etc.), and it's the secondary insurer's responsibility to notify the carrier of its policyholder changes, additions, and deletions.

Your responsibility is to handle properly any payment you may receive from a secondary insurer.  If you have already received your full allowed amount from Medicare/Medigap/Medicaid/patient payments, and you then receive a secondary insurance payment, you must refund the correct amount to the correct party.

back to top of index

  Tip # 11:  Advance Beneficiary Notice

Are you confused about Medicare’s requirements for obtaining a patient’s signature and agreement to pay you for services that Medicare might not approve?  Medicare now calls this document an “Advance Beneficiary Notice” (ABN) instead of using the former “Waiver of Liability” phrase.

For a current, detailed explanation of the ABN (and to download the ABN form), click here to access the “Advance Beneficiary Notice Quick Reference Guide” from the MedLearn page of the CMS (Centers for Medicare and Medicaid Services) web site.  I recommend that you study this material thoroughly since failing to follow this set of rules may mean that you cannot be paid by Medicare or by your patient for services you have provided.

Be sure to download the correct form―CMS-R-131-G (General Use)―not the form for laboratories.   You cannot modify this form!  You can only complete it properly for each patient.

 

If you are a non-participating physician practice, you are legally bound by the assignment agreement if you submit a Medicare claim with Item 27 marked "Yes"—even if you intended that the claim be non-assigned.

Provide your claims filing staff with complete training on this point, and be sure for each patient encounter that you give clear instructions whether to accept assignment or not.

back to top of index