-
Posting Date: 01/19/2021
The Hospice Benefit
Section 2: Medicare Basics The Hospice Benefit Table of Contents The Hospice Benefit Requirements for Coverage Hospice Benefit Days and Costs Hospice Services Noncovered Hospice Services [Return to Top] The Hospice Benefit [...]
Read More -
Posting Date: 05/31/2024
Medicare Part B Medical Insurance
Section 2: Medicare Basics Medicare Part B—Medical Insurance Table of Contents Medicare Part B—Medical Insurance Part B Costs Medicare Deductible, Coinsurance and Premium Rates Covered Part B Services Covered Physicians’ Services [...]
Read More -
Posting Date: 01/19/2021
Fundamentals of Medicare - Medicare Program Exclusions
Section 2: Medicare Basics Medicare Program Exclusions No payment can be made under Medicare Part A or Medicare Part B for certain items and services. The list below includes the general Medicare program exclusions. For details regarding [...]
Read More -
Posting Date: 01/19/2021
Medicare Advantage Organizations
Section 2: Medicare Basics Medicare Advantage Organizations Table of Contents What are Medicare Health Plans? Medicare Managed Care Plans [Return to Top] What are Medicare Health Plans? Medicare health plans provide different ways [...]
Read More -
Posting Date: 01/19/2021
Medicare Secondary Payer
Section 2: Medicare Basics Medicare Secondary Payer Table of Contents Medicare Secondary Payer MSP Provisions MSP Billing - General Benefits Coordination & Recovery Center Contacting the BCRC [Return to Top] Medicare [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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
Read More -
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 [...]
Read More -
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] [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More -
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 [...]
Read More