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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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

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 [...]

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] [...]

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 [...]

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 [...]

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 [...]

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 [...]

NGSConnex

Section 4: Getting Ready to Bill Medicare NGSConnex NGSConnex is a self-service web application developed by National Government Services that offers providers and suppliers to access to information at their fingertips via the Internet. [...]

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 [...]

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 [...]

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 [...]

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 [...]

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, [...]

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 [...]

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 [...]

Determine if Medicare is Primary or Secondary for a Beneficiary's Services

Table of Contents Determine if Medicare is Primary or Secondary for a Beneficiary's Services Step 1: Collect MSP Information from the Beneficiary During an MSP Screening Process Step 2: Check for Open MSP Records for a Beneficiary in [...]

Fundamentals of Medicare

Track the Status of Your Application

How to Search You may track the status of your provider enrollment application (PECOS or paper) submissions via the: Check Provider Enrollment Application Status tool by: Case number/web tracker id or NPI and TIN combination [...]

Provider Enrollment Application Process Timeline

All MACs, including National Governments Services, have a goal to finalize an Internet-based PECOS application within 15 days and a CMS-855 paper application within 30 days, if all required information is available. About the Application [...]

PECOS Application Status Tool

The status of your application is indicated by the step that is highlighted. If an application fee is required, an additional step will be added and the system will generate five steps. Your application was successfully [...]

Identify the Proper Order of Payers for a Beneficiary's Services

Table of Contents Background Step 1: Check for Open Medicare Secondary Payer Records for the Beneficiary in the Common Working File Step 2: Collect MSP Information from the Beneficiary  Step 3: Compare the MSP Information you [...]

Checking Eligibility and Knowing Your Point of Contact

Checking Eligibility and Knowing your Point of Contact Table of Contents Checking Eligibility and Knowing your Point of Contact How to Verify Patient Eligibility Related Content Listed below are the different patient eligibility and [...]

Go Paperless Today - Protect Your Bottom Line

Go Paperless Today ‒ Protect Your Bottom Line Every day is a great day to choose electronic solutions rather than paper. Make today the day you go electronic. If you are sending paper to National Government Services, change that now. You can [...]

Medicare Home Health Collaboration with Other Provider Types

Medicare Home Health Collaboration with Other Provider Types Table of Contents The Medicare Home Health Benefit Therapy Providers and the Home Health Benefit Durable Medical Equipment Suppliers and the Home Health Benefit Hospice and the [...]

One Week Until Beneficiary Eligibility Information Leaves the IVR

One Week Until Beneficiary Eligibility Information Leaves the IVR  As we’ve communicated, beginning 11/18/2024, beneficiary eligibility information will not be offered on the IVR. This includes all beneficiary eligibility information that [...]

CERT Program Information

CERT Program Information What Is the CERT Program? The CMS implemented the CERT program to measure improper payments in the Medicare FFS program. CERT selects a stratified random sample of claims submitted to Part A/B MACs and DME MACs [...]

CERT Tools

CERT Tools   Centers for Medicare & Medicaid Services CERT Page  CERT C3HUB provider website CERT Reports Revised 11/13/2024

CERT Tools

CERT Tools Centers for Medicare & Medicaid Services CERT Page  CERT C3HUB provider website CERT Reports  Revised 11/13/2024

Announcement About Medicare Participation for Calendar Year 2025

Announcement About Medicare Participation for Calendar Year 2025 The Centers for Medicare & Medicaid Services has posted the Announcement About Medicare Participation for Calendar Year 2025. Posted 12/2/2024

Checking Medicare Eligibility

Checking Medicare Eligibility To determine the last date a patient received tobacco cessation counseling, providers can check patient eligibility through these online tools and services: Table of Contents NGSConnex HIPAA Eligibility [...]

Provider Enrollment: Reminder for Open Enrollment and Participation Agreement

Provider Enrollment: Reminder for Open Enrollment and Participation Agreement The 2025 Annual Participation Open Enrollment Period is approaching for another year. While this is an important time (from mid-November to December 31) for [...]

Register Now for the 2024 Preventive Services Virtual Conference!

Register Now for the 2024 Preventive Services Virtual Conference! Dive deep into critical preventive services topics! All Part B Providers! Register now for the National Government Services Medicare Part B 2024 Preventive Services Virtual [...]

Explore Our Exciting Sessions at the 2024 Preventive Services Virtual Conference!

Explore Our Exciting Sessions at the 2024 Preventive Services Virtual Conference! View All Our Sessions and Register Now! As we gear up for the National Government Services Medicare Part B 2024 Preventive Services Virtual Conference, we [...]

Next Week - 2024 Preventive Services Virtual Conference!

Next Week – 2024 Preventive Services Virtual Conference! We hope you’re as excited as we are about the upcoming National Government Services Medicare Part B 2024 Preventive Services Virtual Conference, taking place on December 9th to 11th! [...]

Submitting Electronic Medical Records

Submitting Electronic Medical Records National Government Services can accept medical records submitted on a CD or thumb drive however, submitting via our free, secure, web-based portal NGSConnex is preferred and far more advantageous for [...]

Medicare Part A Rebuttal Form

Medicare Part B Rebuttal Form

Provider Enrollment Appeals Cover Sheet

Provider Enrollment Appeals Cover Sheet

Common Working File Incorrectly Rejecting for Edit 538H

National Government Services is informing Part A and Part B providers of an error in CWF in the Eligibility Database, incorrectly identifying some beneficiaries as incarcerated and rejecting new claims for Edit 538H. This may also generate [...]

Submitting Electronic Medical Records via CD or Thumb Drive

Submitting Electronic Medical Records via CD or Thumb Drive National Government Services can accept medical records submitted on a CD or thumb drive however, submitting via our free, secure, web-based portal NGSConnex is preferred and far more [...]

Eligibility

Eligibility information is no longer available via the IVR. To obtain Eligibility information login to NGSConnex and select Eligibility Lookup. If you haven’t already registered for NGSConnex, you can obtain detailed step-by-step instructions [...]

Documentation Submission Responsibilities

Documentation Submission Responsibilities When medical records are requested, the billing provider is responsible to obtain sufficient documentation to support the medical necessity of the service(s) billed. If the documentation is [...]

Part B Claims Impacted by CWF CLIA File Issue

The CWF Host has recognized an issue in the CLIA file and has successfully reloaded the corrected CLIA file.

Correct or Adjust a Claim Due to an MSP-Related Issue

Table of Contents Background Step 1: Identify the Fiscal Intermediary Shared System Direct Data Entry Status Location of the Claim and the Reason for the Claim Correction or Change Status Location TB9997 (Returned to Provider Claims) [...]

Hospital Acquired Conditions and Present on Admission Resource for Physicians

Hospital Acquired Conditions and Present on Admission Resource for Physicians Did you know that documentation about your patient’s inpatient stay is vital for accurate submission of an inpatient hospital claim to Medicare? This resource [...]

Revalidation Application Checklist

Revalidation Application Checklist Use the Revalidation Application Checklist to assist when revalidating your enrollment information. The general checklist will allow you to understand requirements while the PECOS and CMS-855 paper [...]

November 2024

In This Issue National Government Services Articles for Part A and Part B Providers Local Coverage Determination Open Meeting Reminder – Beginning 11/18/2024, Beneficiary Eligibility Information Not Offered on the IVR NGSConnex: Overview, [...]

Prevent Revalidation Processing Delays

When National Government Services receives a revalidation application, we often determine additional information is needed to process the application. In those cases, a request for additional information is sent which is commonly referred to as [...]

How to Search on the Medicare Revalidation List Tool for Due Date

Table of Contents How to Search on the Medicare Revalidation List Tool for Due Date Find a Provider By NPI By Name Associated Datasets [Return to Top] How to Search on the Medicare Revalidation List Tool for Due Date [...]

Revalidate My Enrollment

Step 1: Determine You Are in the Right Place Medicare provider enrollment revalidation is part of the Patient Protection and Affordable Care Act, Section 6401(a), which established a requirement for all enrolled providers/suppliers to [...]

Revalidate My Enrollment

Step 1: Determine You Are in the Right Place Medicare provider enrollment revalidation is part of the Patient Protection and Affordable Care Act, Section 6401(a), which established a requirement for all enrolled providers/suppliers to [...]

Deactivation of Billing Privileges/Suspension of Payment

Reasons for Deactivation of Medicare Billing Privileges/Suspension of Payment (not all inclusive) Inactivity Failure to complete revalidation within required time frame Unreported provider address and/or bank information Inactivity [...]

Deactivation of Billing Privileges/Suspension of Payment

Reasons for Deactivation of Medicare Billing Privileges/Suspension of Payment (not all inclusive) Inactivity Failure to complete revalidation within required time frame Unreported provider address and/or bank information [Return to [...]