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Posting Date: 01/19/2021
Coordination of Benefits Trading Partners
Section 2: Medicare Basics Coordination of Benefits Trading Partners COBC exclusively crosses over all claims to trading partners. “Trading partner” is defined as an issuer of an insurance policy that supplements Medicare or a state agency [...]
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Posting Date: 04/27/2015
Fraud and Abuse
Section 3: Fraud and Abuse Fraud and Abuse Table of Contents Fraud and Abuse Examples of Fraud Examples of Abuse [Return to Top] Fraud and Abuse Fraud occurs when there is an intentional deception or misrepresentation that an [...]
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Posting Date: 02/27/2014
Benefit Integrity
Section 3: Fraud and Abuse Benefit Integrity Providers have an obligation, under law, to conform to the requirements of Medicare. A key to avoiding fraud and abuse is the integrity of the provider as an entity and of each individual that is [...]
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Posting Date: 04/27/2015
Fundamentals of Medicare: Program Safeguard Contractor/Zone Program Integrity Contractor
Section 3: Fraud and Abuse Program Safeguard Contractor/Zone Program Integrity Contractor The primary goal of the PSC/ZPIC is to: identify cases of suspected fraud; develop them thoroughly and in a timely manner; and take immediate [...]
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Posting Date: 04/28/2015
Office of Inspector General
Section 3: Fraud and Abuse Office of Inspector General Table of Contents Office of Inspector General Compliance Programs Benefits of a Compliance Program Elements of A Compliance Program OIG Compliance Guidance Self-Discovery [...]
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Posting Date: 11/18/2020
Fraud and Abuse/Compliance Resources
Section 3: Fraud and Abuse Fraud and Abuse/Compliance Resources CMS Resources CMS IOM Publication 100-08, Program Integrity Manual OIG website OIG Fraud Prevention and Detection NGS Fraud and Abuse Resources Reviewed 6/4/2024
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Posting Date: 01/18/2022
Appeals Process
Section 3: Fraud and Abuse Appeals Process Table of Contents Appeals Process The Five Levels of Appeal Appeals Request Process First Level—Redetermination Second Level—Reconsideration Third Level—Administrative Law Judge [...]
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Posting Date: 04/28/2015
Comprehensive Error Rate Testing Process
Section 3: Fraud and Abuse Comprehensive Error Rate Testing Process Table of Contents Comprehensive Error Rate Testing Process What is CERT? Who Performs CERT? How Does It Work? CERT Information Available from CMS [Return to Top] [...]
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Posting Date: 04/28/2015
Registration of the Medicare Patient
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 [...]
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Posting Date: 11/07/2024
MLN Connects® Newsletter: November 7, 2024
MLN Connects® Newsletter: November 7, 2024 Final Rules Physician Fee Schedule CY 2025 Final Rule Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Payment System CY 2025 Final Rule ESRD Prospective Payment [...]
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Posting Date: 04/13/2023
Top Tobacco Counseling Claim Errors
Top Tobacco Counseling Claim Errors Reason Code(s) Description Avoiding/Correcting This Error OA-18 A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a [...]
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Posting Date: 04/25/2024
Skin Substitutes
Skin Substitutes CMS provides pricing for some wound care products; however, there are many that do not have established pricing. When a skin substitute/wound care product does not have established pricing, the pricing for the item will be [...]
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Posting Date: 04/28/2015
Common Working File
Section 4: Getting Ready to Bill Medicare Common Working File The CWF was developed in 1989 as a means to maintain all of the records for each Medicare beneficiary. These records are a detailed account of each Medicare beneficiary’s status [...]
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Posting Date: 04/28/2015
Fiscal Intermediary Standard System
Section 4: Getting Ready to Bill Medicare Fiscal Intermediary Standard System National Government Services utilizes FISS to process claims and maintain Medicare beneficiary information. Providers have access to this information through a [...]
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Posting Date: 04/28/2015
Advance Beneficiary Notice of Noncoverage
Section 4: Getting Ready to Bill Medicare Advance Beneficiary Notice of Noncoverage An ABN is a written notice a provider gives to a Medicare beneficiary before items or services are furnished, when the provider believes that Medicare [...]
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Posting Date: 11/11/2024
Prepare and Submit a Medicare Tertiary Claim
Table of Contents Prepare and Submit a Medicare Tertiary Claim Step 1: Determine When a Claim(s) Must be Submitted to Medicare Step 2: Check for MSP Insurer Information in Medicare’s Records Step 3: Prepare and Submit Medicare Tertiary [...]
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Posting Date: 08/30/2022
Use National Government Services Self-Service Tools to Maximize your Workload
Use National Government Services Self-Service Tools to Maximize your Workload Our PCC telephone lines are busiest at the beginning and end of each month, and this creates long wait times for providers trying to resolve claim payments, denials, [...]
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Posting Date: 11/07/2022
Common Denials Guide for Diabetes Self-Management Training and Medical Nutrition Therapy
Common Denials Guide for Diabetes Self-Management Training and Medical Nutrition Therapy National Government Services, MAC for Jurisdiction K and Jurisdiction 6, continues to provide you with resources to help reduce the burden of claim [...]
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Posting Date: 07/21/2022
Non-Appealable Situations with Medicare Advantage Plans - Make Sure Your Staff is Aware
Non-Appealable Situations with Medicare Advantage Plans - Make Sure Your Staff is Aware When a Medicare Beneficiary enrolls in a MA Plan, that MA plan takes the place of Traditional Medicare benefits. National Government Services is [...]
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