Medicare coverage and benefits
What information is detailed in NCDs and LCDs
-A description of service - a list of indications - the appropriate CPT or hcpcs code - the appropriate ICD-9-CM code - a bibliography containing recent clinical articles to support the Medicare policy
Medigap plans
Private insurance that beneficiaries May purchase to fill in some of the gaps, or unpaid accounts, in Medicare coverage. These gaps including annual deductibles, coinsurance, and payment for some non-covered services
Medicare recovery auditor program
Program that aims to ensure that claims paid by the MAC are correct.
Medicare Integrity program
Program that identifies and addresses fraud, waste, and abuse. The MIP has three key programs for documentation and billing. Medical review program, recovery auditor program, and Zone Program Integrity contractors
Medicare part A (Hospital Insurance [HI])
Program that pays for hospitalization care in a Skilled Nursing facility, home health care, and hospice care. No premium paid unless over age 65 and not eligible for social security.
Blank E
Reason Medicare may not pay
Roster billing
A simplified process that allows a provider to submit a single Paper claim for vaccines
Medicare Part D
Voluntary prescription drug plans that is open to people who are eligible for Medicare.
The Medicare Advantage Plus prescription drug program under Medicare Part D
Combines a prescription drug plan with a Medicare Advantage plan that includes medical coverage for doctor visits and Hospital expenses
The header
Completed by the Notifier before the form is given to the patient, this area shows the provider's name address and telephone number.
What are some incentives to Physicians that the MSC offers to encourage participation in Medicare
- Medicare physician fee schedule amounts are 5% higher than for non participating providers - participating providers do not have to forward claims for beneficiaries who also have a supplemental insurance coverage and to assign their supplemental insurance payments to a non-participating provider - participating providers are listed in the NEC use online directory of Medicare participating providers and receive referrals in some circumstances - Medicare has created health professional shortage areas for Primary Care and mental health professionals. Providers located in such areas are eligible for 10% bonus payments from Medicare
What are the modifiers of ABN
-GZ (no ABN) -GA (Mandatory ABN on file) -GY (ABN not required) -GX (Voluntary ABN)
What are the six beneficiary categories which would qualify you for Medicare
1. Individuals aged 65 or older 2. Disabled adults 3. Individuals disabled before age 18 4. Spouses of entitled individuals 5. Retired federal employees enrolled in the Civil Service Retirement System (CSRS) 6. Individuals with end-stage renal disease (ESRD)
What percentage of beneficiaries are in the original Medicare Plan
75%
Common suffixes for the Medicare health insurance claim number
A - primary wage earner B - Aged wife, first claimant B1 - husband, first claimed C1 - C9 child or grandchild, disabled/student D - aged widow, first claimant T - uninsured; health insurance benefits only
Medicare
A federal medical insurance program established in 1965 under Title 18 of the Social Security Act, and managed by the centers for Medicare and Medicaid services (CMS) under the Department of Health and Human Services (HHS)
What are the five sections of the ABN
A-C - header D-F - body G - Options box H - additional information I-J - signature box
After what day of the receipt of the claim in a paper claims be paid
After the 29th day
Medicare Learning Network matters site
An important online resource which is a collection of articles that explains all Medicare topics. It Is searchable by topic or by year.
Medicare Part B (supplementary medical insurance)
An optional program that pays for Physician Services, outpatient hospital Services, durable medical equipment, and other services and supplies
Zone Program Integrity contractors
Anti-fraud agency that conducts both prepayment and post-payment audits based on the rules for medical necessity that the LCDs set
Medicare participating provider enrollment requirements
CMS requires all providers who wish to participate or to renew contracts to apply either online using a system called internet-based PECOS (Provider Enrollment, Chain and Ownership System), or the paper form CMS 855.
Medicare health insurance claim number
Consists of nine digits followed by a numeric or alphanumeric suffix
Medicare administrative contractor
Contractor who handles claims and related functions. ( replaced the part a fiscal intermediaries and the part B contractors under the Medicare modernization Act)
CCI
Correct coding initiative
The prescription drug plan under Medicare Part D
Covers only drug that can be used with an original Medicare Plan and/or a Medicare Supplement Plan
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Descriptors. May include items, service, lab test, test, procedure, care, equipment
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Estimated cost
Advanced beneficiary notice of non-coverage (ABN)
Form used to inform patients that a service is not likely to be reimbursed. The Form is designed to identify the service or item that Medicare as unlikely to pay for, State the reason Medicare is unlikely to pay, and estimate how much the service or item will cost the beneficiary of Medicare does not pay.
Health professional shortage area (HPSA)
Geographic area offering participation bonuses to Physicians
Fiscal intermediary
Government contractor, such as Blue Cross Blue Shield, that processes claims
G0010
Hepatitis B vaccine
Limiting charge
Highest fee non participating physicians may charge for a particular service. Does not apply to immunization supplies or Ambulance Service.
G0008
Influenza virus vaccine Administration
Medicare modernization act (MMA)
Law with a number of Medicare changes including a prescription drug benefit
Medicare Part C
Managed Care Health Plans under the Medicare Advantage program, in which Private health insurance companies contract with CMS to offer Medicare beneficiaries Medicare Advantage plans that compete with the original Medicare Plan.
What are the three major types of Plans offered by the Medicare Advantage
Medicare Coordinated Care plans, Medicare private fee-for-service, and Medicare savings accounts
Local coverage determination
Notices sent to Physicians with information about the coding and medical necessity of a service
Blank G options
Option 1 allows the beneficiary to receive the items or services at issue and requires a Notifier to submit a claim to Medicare. Option 2 allows the beneficiary to receive the non-covered items and services and pay for them out of pocket. No claim will be filed. Option 3 means the beneficiary does not want the question.
Medicare Advantage organization
Organization responsible for providing all medicare-covered services, except Hospice Care, in return for a predetermined capitated payments
Medical review program
Paris procedures for ensuring patients are given appropriate care in a cost-effective manner
G0009
Pneumococcal vaccine Administration
National coverage determinations
Policy stating whether and under what circumstances a service is covered
Incident to services
Services of Allied health professionals provided under the Physicians direct supervision that may be billed under Medicare
If a paper claim and a HIPAA 837 P claim are sent on the same day what will happen
The HIPAA 837 P claim will be paid first
Under the Medicare program an armed forces speeding physician may not Bill more than 115% of what
The approved charge on the nonPAR fee schedule
Why would the modifier GA be appended to procedure codes for non-covered medical service
The item is expected to be denied but there is a signed ABN
Medigap insurance plans can be purchased purchased as a supplement for individuals enrolled in what
The original Medicare Plan
What does it mean when a beneficiaries card shows a prefix
The patient is eligible for railroad retirement benefits and claims must be submitted to the railroad Medicare Part D claim office
MPFS - Medicare physician fee schedule
Where the charger mounts are listed for Medicare, developed from the resource-based relative value scale system
