Post on 05-May-2018
Disclaimer
National Government Services, Inc. has produced this material as an
informational reference for providers furnishing services in our contract
jurisdiction. National Government Services employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of
Medicare information is error-free and will bear no responsibility or
liability for the results or consequences of the use of this material.
Although every reasonable effort has been made to assure the accuracy
of the information within these pages at the time of publication, the
Medicare Program is constantly changing, and it is the responsibility of
each provider to remain abreast of the Medicare Program requirements.
Any regulations, policies and/or guidelines cited in this publication are
subject to change without further notice. Current Medicare regulations
can be found on the CMS website at https://www.cms.gov.
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No Recording
▪ Attendees/providers are never permitted to
record (tape record or any other method) our
educational events
▪ This applies to our webinars, teleconferences, live events
and any other type of National Government Services
educational events
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Acronyms
▪ Please access the Acronyms page on the
NGSMedicare.com website to view any acronym
used within this presentation.
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Objectives
▪ This session will help connect the dots between
the traditional four parts of Medicare (Parts A, B,
C and D) and associated billing considerations
for providers and suppliers
▪ After this session, attendees will be more
familiar with all parts of the Medicare program
and will be able to distinguish differences
between traditional Medicare and Medicare
Advantage plan
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Agenda
▪ What Are the Four Parts of Medicare
▪ Part A – Hospital Insurance
▪ Part B – Medical Insurance
▪ Part C – Medicare Advantage Plans
▪ Part D – Drug Coverage
▪ Mandatory Medicare Claim Submission
▪ Medicare Tools for People with Medicare
▪ Wrap Up and Questions
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▪ Medicare was passed by Congress and signed by President Lyndon B. Johnson in 1965
▪ Medicare is a health insurance program for
▪ People 65 years of age and older
▪ Some people with disabilities
▪ People with end-stage renal disease (ESRD)
▪ Enrollment handled by Social Security Administration
▪ Administered by the Centers for Medicare & Medicaid Services (CMS) within the Department of Health & Human Services (DHHS)
Background
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▪ CMS is part of the U.S. Department of Health &
Human Services (HHS)
▪ Oversees Medicare, Medicaid, and SCHIP
▪ Establishes policies for paying health care providers
▪ Assesses quality of health care facilities and services
▪ Assures that Medicare is run properly by contractors
▪ Central office and regional offices
Centers for Medicare & Medicaid Services (CMS)
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What are the Four Parts of Medicare?
▪ Medicare Part A – hospital insurance
▪ Medicare Part B – medical insurance
▪ Outpatient services
▪ Physician services
▪ Durable medical equipment, prosthetics, orthotics and
suppliers (DMEPOS)
▪ Medicare Part C – Medicare Advantage plans
▪ Medicare Part D – prescription drug coverage
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▪ Private insurance companies
▪ Under contract with federal government
▪ Medicare Administrative Contractors
▪ Process both Part A and Part B claims
▪ DME
▪ Home Health and Hospice
▪ Federally Qualified Health Centers
▪ Contractors bound by service area
Medicare Contractors
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▪ Responsible for
▪ Medicare enrollment
▪ Premium billing and payment
▪ General Medicare questions (not claim-related)
▪ Replacement Medicare cards and questions regarding
enrollment
▪ Telephone Number: 1-800-772-1213
▪ Website: http://www.ssa.gov
Social Security Administration (SSA)
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Current Medicare Card
▪ Used for Medicare Parts A and B
Front
▪ More information on the back of the card
Back
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The New Medicare Number Project
▪ By April 2019, all Health Insurance Claim Numbers (HICN) will be replaced with a generic Medicare Beneficiary Identifier (MBI)
▪ Why is CMS doing this?
• To better protect private and federal health care benefits and the financial information tied to these health plans for an individual
▪ What is the difference?
• Currently a Medicare patient’s identification number is based on a SSN
• Each MBI is unique, randomly generated, and the characters are “non-intelligent,” which means they don’t have any hidden or special meaning
• The MBI is confidential and shall be protected as PII
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The New Medicare Number Project
▪ What do I do as a Medicare provider?
▪ Be aware and prepare
• Persons newly enrolled in Medicare as of 4/1/2018 will receive an MBI
• Existing Medicare patients will be transitioned to MBIs throughout 2018 and 2019 (January 2020 transition ends)
• Ensure your claims systems/vendors systems are updated to accept the entry and relay of the MBI to the MAC
• Encourage your Medicare patients to verify their address with SSA is correct
▪ Where do I find more information on this project?
▪ https://www.cms.gov/Medicare/New-Medicare-Card/index.html
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The New Medicare Card
▪ Example of the new Medicare Card
▪ https://www.cms.gov/Medicare/New-Medicare-Card/index.html
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Medicare Part A Helps to Pay
▪ Inpatient hospital stays
▪ SNF care
▪ Home health care
▪ Hospice care
▪ Blood
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Medicare Part B Helps to Pay for Medical Services
▪ Doctors’ services
▪ Outpatient medical/surgical services and supplies
▪ Diagnostic tests
▪ Outpatient therapy
▪ Mental health services
▪ Preventive services
▪ Clinical laboratory services
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Medicare Part B Helps to Pay for Medical Services
▪ DMEPOS
▪ Facility outpatient services (Part B of A) Including outpatient prospective payment system (OPPS) and FQHC
▪ Ambulance service
▪ Home health care
▪ Blood
▪ Medical nutrition therapy
▪ Other medical services
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Billing Requirement
▪ The Social Security Act (Section 1848(g)(4)) requires▪ Claims must be submitted for all Medicare patients for services rendered on or
after 9/1/1990
▪ Applies to all physicians and suppliers who provide covered services to Medicare beneficiaries
• Requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment
▪ Medicare beneficiaries may not be charged for preparing or filing a Medicare claim
▪ Compliance with mandatory claim filing requirements is monitored by CMS, and violations of the requirement may be subject to a civil monetary penalty of up to $2,000 for each violation, a ten percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare Program exclusion
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Claim Timely Filing Requirement
▪ Medicare regulations at 42 CFR 424.4425 define the timely filing period for Medicare fee-for-service claims ▪ In general, claims must be filed to the appropriate Medicare
claims processing contractor no later than 12 months, or one calendar year, after the date the services were furnished
▪ Determination that a claim was not filed timely is not subject to appeal
▪ Provider is responsible when a claim is not timely
• Must not charge beneficiary for such services except deductible and/or coinsurance
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Where Are Services Billed?
▪ Services are billed to Medicare Administrative Contractors (MAC)
▪ AB MAC
▪ Medicare Part A – hospital insurance
▪ Medicare Part B – medical insurance
▪ DME MAC
▪ Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
▪ Patient’s Medicare Advantage Plan
▪ Medicare Part C – Medicare Advantage plans
▪ Patient’s Prescription Drug Plan provider
▪ Medicare Part D – prescription drug coverage
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Locating Contractors (MACs and more)
▪ https://www.cms.gov/Research-
Statistics-Data-and-
Systems/Monitoring-
Programs/Medicare-FFS-
Compliance-Programs/Review-
Contractor-Directory-Interactive-
Map/#il
▪ Select the state and the
information populates below the
map
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Medicare Summary Notice
▪ Medicare Summary Notice (MSN) – mailed to people with Medicare once every 90 days – Part A and Part B for assigned claims
▪ MSN contains claims details such as date of service, procedure codes, payment information and resource information
▪ 1-800-MEDICARE or https://www.mymedicare.gov
▪ Electronic Medicare Summary Notice (eMSN)
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Paperless Solutions
▪ Provider Enrollment Chain & Ownership System (PECOS) is an Electronic Medicare enrollment system https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
▪ Submit: Enrollment; change of information; reactivation; revalidation; voluntary withdrawal/termination; reassign benefits
▪ View/print current enrollment information
▪ Track status of enrollment application
▪ Note: Once you update PECOS, allow 60 days for processing
▪ Additional information is available on our website; click on the Enrollment tab
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Paperless Solutions
▪ Electronic Remittance Advice (ERA)
▪ On our website > Enrollment > EDI Enrollment
▪ An EDI transaction allowing payment information to be received electronically
▪ With software, an ERA file created by Medicare can be automatically posted to your accounts receivable system thus allowing more efficient and accurate payment posting process
▪ Much quicker process than standard paper remittance (SPR) advice
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▪ Medicare Advantage (MA) plans are health plan options that are approved by Medicare and are run by private companies
▪ They are part of the Medicare Program and are sometimes called “Part C”
▪ Medicare Advantage Plan Directory
▪ https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/MA-Plan-Directory.html
Medicare Part C: Medicare Advantage Plans
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▪ When a beneficiary selects a plan within an
MAO, all health care claims will have to be
submitted to that Medicare Advantage plan
Did You Know…
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How Do MA Plans Work?
▪ Beneficiaries get Medicare-covered services through the plan ▪ All Part A and Part B covered services
▪ Some plans may provide additional benefits
• Examples: Hearing aids, eyeglasses
▪ Most plans include prescription drug coverage ▪ Part D
▪ May have to go to network hospitals or doctors
▪ MA may be different than traditional fee-for-service Medicare ▪ Benefits and cost-sharing
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Frequently Asked Question
▪ Is an MA plan required to cover all of the
services that traditional Medicare covers or are
they allowed to exclude services?
▪ Answer: MA plans are required to cover all the services
that traditional Medicare covers; they are not allowed to
exclude such services
• MA plan may have different ways of covering the services
• MA plan may cover more services than traditional Medicare
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Medicare Advantage Claim Processing
▪ Reminder: Traditional (fee-for-service) Medicare
is NOT secondary to MA
▪ When an MA plan is in effect, bill all services for that
beneficiary to the MA plan
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Medicare Part D – Drug Coverage
▪ Available to all People with Medicare, voluntary; Medicaid automatic
▪ People must join a plan to get Medicare drug coverage
▪ Extra help paying drug plan costs is available to some people
▪ Medicare drug plans are offered by insurance companies and other private companies approved by Medicare
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A Comprehensive Eligibility Verification Addresses These Questions
▪ Is patient entitled to Medicare coverage?
▪ Is patient’s identifying information reported accurately?
▪ Does patient have Part A, Part B?
▪ Enrolled in an MA plan?
▪ Is patient enrolled in hospice?
▪ Does patient have insurance primary to Medicare (MSP
situation)?
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▪ Maintains national beneficiary records
▪ Entitlement, date of birth, and date of death
▪ Recent benefit periods (including any deductibles due)
▪ MA enrollment
▪ Home health episode
▪ Preventive services
▪ Hospice enrollment
▪ MSP information
What is CWF?
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Termination of Provider CWF Access
▪ CR 8248 – HIQA, HIQH, HUQA, ELGA, ELGH
will be terminated
▪ CMS released SE1249 on 2/12/2014:
▪ “While termination was originally scheduled for April 2014,
CMS is delaying the date. CMS will provide at least 90
days advanced notice of the new termination date.”
▪ Providers advised to use HETS system as
replacement for CWF access
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What is HETS?
▪ HIPAA Eligibility Transaction System
▪ Provides same eligibility data as HIQA, with some exceptions
▪ http://www.cms.gov
• Research, Statistics, Data and Systems > HIPAA Eligibility Transaction System (HETS) Help (270/271)
▪ CMS website has section on HETS, including:
• Vendor and registration information
• HETS user guide
• FAQs
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▪ Patient presents insurance information and/or cards
▪ Provider determines proper order of insurance
▪ Must know COB/MSP concepts
▪ Provider verifies Medicare eligibility
▪ Patient
▪ CWF/FISS
▪ IVR
▪ NGSConnex (NGS providers only)
Proper Claim Submission Starts at Patient Registration
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▪ Conduct MSP screening process
▪ Registrar discusses questions with beneficiary
▪ Keep copy of answers either hardcopy or electronically
▪ Provider must compare information gathered
with Medicare system information prior to
submitting claims
MSP Screening Process
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▪ Compare MSP information in Medicare’s records to collected MSP information
▪ Determine proper primary payer
▪ MSP Provision conditions/criteria met?
▪ Resolve conflicts
▪ May need to have Medicare’s records updated by Benefits Coordination & Recovery Center (BCRC)
▪ Submit claims accordingly
Determining the Proper Primary Payer
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▪ Report employment changes, any other insurance coverage information
▪ Report liability, automobile/no-fault, and workers compensation case
▪ Add new MSP file to CWF
▪ General MSP questions/concerns
▪ Telephone inquiries to BCRC: 1-855-798-2627
• CMS MLN SE1416 “Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)”
Benefits Coordination & Recovery Center (BCRC)
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▪ State Health Insurance Assistance Program
▪ https://www.shiptacenter.org/ or contact your
▪ Home page > Need Local Help with Medicare? Contact
your state SHIP > use drop-down box to select your state
Medicare Tools for People with Medicare
Medicare Tools for People with Medicare
▪ “Medicare & You” Handbook
▪ https://www.Medicare.gov > Forms, Help, &
Resources > select the handbook from the drop-
down box
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Resources
▪ CMS Manuals
▪ http://www.cms.gov/Manuals/IOM/list.asp
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
Chapter 13
• CMS IOM Publication 100-04, Medicare Claims Processing Manual,
Chapter 9
• Medicare Advantage Resource
– CMS IOM Publication 100-16, Medicare Managed Care Manual
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Resources
▪ FQHC Center
▪ https://www.cms.gov/Center/Provider-Type/Federally-
Qualified-Health-Centers-FQHC-Center.html
• FQHC GAFs effective 01/01/2018-12/31/2018
• FQHC PPS Specific Payment Codes (Qualifying Visit codes)
• FQHC PPS FAQs
• FQHC Preventive Services Guide
• FQHC Fact Sheet
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Resources
▪ National Uniform Billing Committee
• http://www.nubc.org/
• NUBC Official UB-04 Data Specifications Manual
• Annual fee
• Providers also receive updates throughout the year
▪ U.S. Preventive Services Task Force (USPSTF)
• http://www.uspreventiveservicestaskforce.org
– Provides Grade A and B preventive services
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Preventive Services Resources
▪ Preventive Services – provider resources ▪ https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Pro
viderResources.html
▪ Medicare Part B Immunization Billing: Seasonal Influenza Virus, Pneumococcal, and Hepatitis B▪ https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/Downloads/qr_immun_bill.pdf
▪ Preventive Services Interactive Chart ▪ https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/me
dicare-preventive-services/MPS-QuickReferenceChart-1.html
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▪ Medicare Advantage Plan Directory
▪ https://www.cms.gov/MCRAdvPartDEnrolData/PDMCPDO/list.asp
▪ Quick Reference New Medicare Provider
▪ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Quick_Reference_New_Provider.pdf
▪ Medicare Enrollment and Claim Submission Guidelines
▪ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN906764.pdf
CMS Resources
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▪ Two Ways to Contact Us:
▪ Telephone Inquiries
▪ Written Inquiries
▪ Contact Information
▪ http://www.NGSMedicare.com > Contact Us
Provider Inquiries to NGS
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▪ http://www.NGSMedicare.com
▪ Medicare Monthly Review
• Published monthly
• Updates and changes to Medicare
• New and revised LCDs
• Upcoming educational sessions
▪ Electronic mailing list (E-mail Update)
• New Medicare information (billing and coverage)
• Provider education and training announcements
Information for NGS Providers
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