Medicare

Know about Medicare

• Medicare EOB
• Payment Floor
• Waiver of Liability
• Crossover
• Freelook (Medigap)
• Development letter

Medicare EOB:

Medicare used to mail Remittance Advice (RA) to providers and the patient receives a Beneficiary RA. RA has been replaced by Medicare Remittance Advice also called the Medicare Summary Notice. Electronic Claim sending offices receive Electronic Remittance Advice (ERA), The ERA post payments automatically

Payment Floor:

The timeframe established for carrier payment Of Medicare Part B claims. As of October 1,1993, electronically submitted claims will be paid 14 days after the date of receipt, while paper claims will be paid 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services

ABN(Advance Beneficiary Notice) (Waiver of Liability):

A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Crossover:

A situation whereby gaps in coverage for the medical expenses for a Medicare Beneficiary are forwarded by the Medicare contractor to the Patient’s medigap insurer for payment. Medigap crossovers occur only if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating Medicare provider. Crossover takes place only in case of Medicare, Medicaid and Medigap Plans.

Free look (Medigap):

A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.

Development Letter:

A notice from Medicare that a claim submitted by a provider organization cannot be processed without additional information/documentation. The letter identifies the additional information needed and the date by which the information must be received by Medicare .

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Medicare coverage - Physician Expense for Surgery, Childbirth, and Treatment for Infertility

Surgery and Childbirth


Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care. Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e., where the life of the mother would be endangered if the fetus were brought to term), the need for skilled medical management and/or medical services is equally important as in those cases carried to full term. After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mother’s eligibility.

Most surgeons and obstetricians bill patients an all-inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child. All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and post-operative/postnatal services, are considered incurred on the date of surgery or delivery, as appropriate. This policy applies whether the physician bills on a package charge basis, or itemizes the bill separately for these items.

Occasionally, a physician’s bill may include charges for additional services not directly related to the surgical procedure or the delivery. Such charges are considered incurred on the date the additional services are furnished.

The above policy applies only where the charges are imposed by one physician or by a clinic on behalf of a group of physicians. Where more than one physician imposes charges for surgical or obstetrical services, all preoperative/prenatal and post-operative/postnatal services performed by the physician who performed the surgery or delivery are considered incurred on the date of the surgery or delivery. Expenses for services rendered by other physicians are considered incurred on the date they were performed.



Treatment for Infertility
Reasonable and necessary services associated with treatment for infertility are covered under Medicare. Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally is expected to be fertile to seek medical consultation and treatment.

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Medicare

About Medicare

How is Medicare funded?

Learn about how Medicare is funded through 2 trust accounts held by the U.S. Treasury: the Hospital Insurance Trust Fund (which pays for Medicare Part A, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and combating fraud and abuse), and the Supplementary Medical Insurance Trust Fund (which pays for Medicare Part B outpatient health care and Medicare Part D prescription drug coverage).

The Affordable Care Act & Medicare

Learn about how the health care law (Affordable Care Act or ACA) affects people with Medicare. If you have Medicare, you don't need to change to a Marketplace plan, you get more preventive services without paying the Medicare Part B coinsurance or deductible, you can save money on brand name drugs (Medicare Part D), your doctor may get more resources to support care coordination, and you can be assured that Medicare funding will be available to help you save on premiums and coinsurance.

Contact Medicare

Learn how to contact the Center for Medicare & Medicaid Services (CMS), the Federal agency that runs the Medicare Program, by phone, TTY, or mail.

Plain writing

Read about our progress in the Plain Writing Act compliance. Learn about what CMS is doing to help you understand documents needed to: apply for federal goverment benefits or services, file taxes, get information about federal government benefits or services, and understand federal requirements.

Information in other languages

Learn about our plan to get information to people in other languages, including Arabic, Armenian, Chinese, Farsi, French, German, Greek, Haitian Creole, Japanese, Italian, Korean, Polish, Portuguese, Russian, Spanish, Tagalog, Vietnamese, and American Sign Language.

"Nondiscrimination Notice" & "Notice of Availability of Auxiliary Aids & Services"

Learn how CMS makes its programs, benefits, services, facilities, information, and technology accessible in accordance with Sections 504 and 508 of the Rehabilitation Act of 1973

Source :https://www.medicare.gov/about-us/about-medicare.html

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Procedures for providers submitting appeals for multiple beneficiaries as a single package using a roster or coversheet

Appeal and Time limit filing

Good cause for extension of the time limit for filing appeals

The time limit for filing a request for redetermination may be extended in certain situations. Generally, providers, physicians, or other suppliers are expected to file appeal requests on a timely basis. A request from the provider, physician, or other supplier to extend the period for filing the request for redetermination would not be routinely granted.

Note: A finding by the contractor that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration.

Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following:

• Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties;

• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (the Centers for Medicare & Medicaid (CMS), the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline);

Note: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.

• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request;

• When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster);

• Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely;

• Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person;

• A death or serious illness in his or her immediate family; or

• A request was sent to a government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.

Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. Also, good cause does not exist where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

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