- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 4: Getting Ready to Bill Medicare
Registration of the Medicare Patient
When a Medicare beneficiary receives hospital or other medical services, he/she is generally registered at the facility.
It is possible that the patient may present one, or even all, of the following cards:
- A red, white, and blue Medicare card
- A Medicare Advantage subscriber card
- A Medicare supplemental card (Medigap)
- A Medicaid card
- Any other insurance cards, e.g., through a current or former employer (including GHP HMOs), automobile insurance, etc.
Because the patient may present their Medicare card as well as any other insurance card he/she may have, it is important that the registration staff (and billing staff) understand all of the rules and regulations that help determine in which plan(s) the beneficiary is currently enrolled. Of those that are currently in effect, the provider must determine which is the appropriate primary payer and in what order each plan pays. Patients may enter a facility and advise the registrar which plan is primary, but ultimately it is the provider’s responsibility to make this decision and communicate it to the beneficiary.
The provider must verify a patient’s eligibility in order to submit the claim to Medicare. Providers may obtain this eligibility information directly from the patient and verify the information using the Medicare eligibility data available in the CWF, HETS, or NGSConnex. This information can also be obtained through the National Government Services IVR system. Providers should obtain and verify the required information from Medicare beneficiaries upon admission.
They must ascertain if the patient is a member of a MAO. Providers should check HETS, NGSConnex, or IVR records for all of their patients to determine whether that individual belongs to an MAO. The records will indicate if the beneficiary is enrolled, the start and end date of the MAO coverage, the type of MAO, and the MAO identification code.
- Risk-based MAOs are indicated by Opt. Code = C. Claims for risk-based MAOs must be sent to the private insurance carrier.
- Cost-based MAOs are indicated by Opt. Code = 1. Claims for cost-based MAOs are sent to your A/B MAC.
Note: The provider should contact the MAO directly to determine bill submission policies.
Providers can search for MAO addresses on the CMS website.
If the patient indicates he/she is not a member of an MAO, providers must ask him/her if he/she has other coverage that may be primary to Medicare in order to determine which insurer to bill first.
Refer to CMS IOM Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.1 for questions to ask Medicare beneficiaries.
Most providers refer to their internal form as their MSP questionnaire, which could either be hard copy or on the provider’s system. The provider should verify MSP information prior to submitting a bill to Medicare. This means confirming that the information previously furnished about the presence or absence of another payer that may be primary to Medicare is correct, clear, and complete, and that no changes have occurred. Providers should document the patient’s responses, positive or negative, even if the patient cannot remember the exact date of a particular event.
In addition, providers should research CWF to determine if the patient has other insurance files on record. The provider would then review all of the information and determine which insurer is primary. The pages in CWF, accessed through the FISS DDE Beneficiary Inquiry Menu 10, are titled MAPs. The CWF page containing MSP information is titled MAP1759.
Once it is determined that Medicare is the primary payer, the provider must ask the patient if he/she was an inpatient in any hospital or SNF during the prior 60 days. If so, the provider must ascertain the number of days of hospitalization the beneficiary used in the current benefit period. Maintain the name and address of the prior stay provider until payment is received. National Government Services may need to ask for this information if a bill has not been received from a prior provider or if additional development is needed. Calculate the applicable deductible, coinsurance, and eligibility where possible based upon internal records and information obtained from the beneficiary. If the patient indicates he/she was not an inpatient within the last 60 days, apply the inpatient deductible to the current stay if it is covered. National Government Services will determine the accuracy of the bill data after receipt of the claim. The remittance advice received from National Government Services reflects the amount of deductible and coinsurance applied. If this amount is different from what was billed, the provider should adjust their internal records accordingly.
If the provider experiences significant problems obtaining information regarding Medicare entitlement or benefits, in order to accurately prepare bills the provider may contact National Government Services for assistance. However, these requests should be on an infrequent basis. National Government Services may temporarily refuse assistance if a pattern of abuse is discovered. Situations that may require intermediary assistance are when:
- the patient dies following admission. It may be necessary to file timely with his/her estate;
- the patient is not in a physical or mental condition to discuss his/her entitlement and no other person with knowledge of his/her affairs is available;
- the provider has reason to believe the beneficiary may need his/her lifetime reserve days. The beneficiary’s signature must be obtained if the available lifetime reserve days are not to be used for this admission and other financial arrangements must be made;
- the provider suspects that the beneficiary may have exhausted his/her Medicare benefits, and timely confirmation is needed in order to file for possible supplemental benefits;
- the patient has experienced repeated admissions during the same spell of illness, and the provider is at a loss in explaining available benefits to the beneficiary.
Revised 1/2021