medicare 101
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Medicare 101 . Part 1: Introduction to Medicare Part B. Provider Outreach & Education – January 8, 2014. Disclaimer. - PowerPoint PPT PresentationTRANSCRIPT
MEDICARE 101 Part 1: Introduction to Medicare Part B
Provider Outreach & Education – January 8, 2014
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DISCLAIMER
This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although, every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited.
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Agenda
Medicare Basics
Types of Medicare
Part B Providers
Part B Helpful Hints
Medicare Appeals
Cahaba GBA Website Self-Service Tools
Online Polling
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MEDICARE BASICS
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Inception of Medicare1965 – Medicare signed into law by President Lyndon B. Johnson
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Key Medicare Administrators
Congress Department of Health and Human Services (HHS) Social Security Administration (SSA) Centers for Medicare and Medicaid Services (CMS) Office of the Inspector General (OIG)
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Medicare Contractors
Medicare Administrative Contractor (MAC) Beneficiary Contact Center (BCC) Coordinator of Benefits Contractor (COBC) Medicare Secondary Pay Recovery Contractor (MSPRC) Comprehensive Error Rate Testing (CERT) Recovery Auditor (RA) Zone Program Integrity Contractor (ZPIC)
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Medicare Eligibility Requirements
Qualifiers
Age 65 or Older
Disabled
End Stage Renal Disease
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65Beneficiary Eligibility based on:
65 years or older Individual/Spouse/Parent Work a minimum of 10 years Contributions to FICA US Citizen or Permanent Legal Resident
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DisabilityBeneficiary Eligibility based on:
Under the age of 65 Beneficiary is entitled to Social Security disability benefits for 24 months Beneficiary received a disability pension from the railroad retirement board and meet certain conditions Beneficiary receives Social Security disability benefits because of Lou Gehrig’s disease (amyotrophic lateral sclerosis) Beneficiary worked long enough in a government job where Medicare taxes were paid and is entitled to Social Security disability benefits for 24 months
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End Stage Renal Disease (ESRD)
Beneficiary Eligibility based on:
Any Age Diagnosed with ESRD:
Receiving Dialysis Kidney Transplant Recipient
http://cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html?redirect=/center/esrd.asp
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Identifying the Medicare Beneficiary
Red, White, and Blue Card Name Health Insurance Claim Number (HICN) Sex Type of Entitlement Effective Date
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Medicare Beneficiary Identification Tips
Ask patients for insurance cards instead of Medicare Card Recommend making copies of all insurance cards presented Update patient information annually, preferably after open enrollment ends Check the effective dates on the coverage types, they are not always the same Enter the patients name exactly on the claim as it appears on the patients Medicare card
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TYPES OF MEDICARE
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Part A
Covers: Inpatient Care in Hospitals
Inpatient Care in a Skilled Nursing Facility
Hospice
Home Health Services
Inpatient Care in a Religious Nonmedical Healthcare Institution
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Part B
Covers: Physicians Services
Outpatient Care
Durable Medical Equipment
Other Medical Services
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Part C
Offers: Part A & B Coverage Combination
May offer extra coverage
Most included Medicare Prescription drug coverage
Claims are processed by private insurance companies
http://www.cms.gov/transmittals/downloads/R97MCM.pdf
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Part D
Available: To anyone who is eligible for Medicare Part A or B
Provided through: Prescription Drug Plans Other Medicare Health Plans Retiree Employers and Union Plans
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PART B PROVIDERS
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Eligible Part B Providers
PHYSICIANS NON- PHYSICIAN PRACTITIONERS*
SUPPLIERS*
Doctors of Medicine (MD) or Osteopathy (DO)
Physician Assistant (PA) Ambulance
Dental Surgery Nurse Practitioner (NP) Ambulatory Surgical Center (ASC)
Chiropractor (DC) Clinical Nurse Specialist (CNS)
Independent Diagnostic Testing Facility (IDTF)
Podiatry Clinical Psychologist (CP) Independent Lab
Optometry Registered Dietician Mammography Center
*This is not an all-inclusive list
Provider Enrollment
Paper Applications:
CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits CMS 855O--Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html
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Provider Enrollment
Online Provider Enrollment
Provider Enrollment, Chain, and Ownership System
(PECOS) allows: New/Revalidation/Update Enrollment Applications Submit Related Documentation Electronic Signatures
https://pecos.cms.hhs.gov
Provider Enrollment
Electronic Funds Transfer (EFT) Authorization Agreement CMS 588 Form Signature required by authorized official
Providers initially enrolling in the Medicare program Providers enrolled in Medicare but not receiving EFT payments and making changes in your enrollment Revalidation -providers and suppliers that were enrolled prior to March 25, 2011
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS588.pdf
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Provider Participation
Participating
Agrees to accept assignment of Medicare benefits
Will accept Medicare’s allowable in full Payment is made to the provider Collects deductible, co-insurance and
excluded services from patient Allowance five percent higher of
Physician Fee Schedule Included in Medpard directory Automatic Medigap crossover
Non-Participating
Does not agree to accept assignment of Medicare benefits
Payment is made to the Medicare beneficiary
Allowable based on five percent less of Physician Fee Schedule
Cannot charge patient more than the 115% limiting charge
Medigap is not auto crossover Can accept assignment on case by case
but allowed non-participating allowable
Medicare Physician Fee Schedule
Used by physicians and non-physician practitioners
Pays 80% of the allowed amount for most services
Other fee schedules include:
Ambulance
Clinical Lab
Ambulatory Surgical Center
Drugs and Biologicals http://www.cahabagba.com/part-b/claims-2/fee-schedules/2014-fee-schedules/
Medicare Physician Fee Schedule
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html/
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Medicare Physician Fee Schedule
http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx
CMS SearchablePhysician Fee Schedule
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PART B HELPFUL HINTS
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2014 Medicare Part B Rates
2014 Part B Deductible: $147.00
2014 Therapy Cap: $1920.00Therapy Cap includes: physical therapy and speech-language pathology combined and for occupational therapy
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Contacting Cahaba GBA
Interactive Voice Response SystemClaim StatusEligibility informationOrder Remittance AdviceUnlimited Check Amounts
Provider AuthenticationContractor/Carrier assigned Provider Transaction Access Number (PTAN)National Provider Identifier (NPI)Last five digits of your Tax Identification Number
http://www.cahabagba.com/contact-us/
1-877-567-7271
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Provider Call Tips Have your provider information, be ready to provide the physician’s PTAN/NPI/Last 5 Digits of Tax ID Beneficiary Information as listed on the Medicare Card, Health Information Number and Exact Name If calling concerning a claim denial, be ready to provide the reason for the denial as listed on the Remittance Advice If calling concerning a claims denial, be ready to provide the dollar amount of the claims billed If calling concerning a particular payment, be ready to provide the Remittance Advice Number Request your call reference number Example: GINQ-0000000
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Railroad Medicare
Railroad Medicare Claims & Inquiries contact:Palmetto GBA IVR 877-288-7600 PCC 888-355-9165
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DMEPOS
Jurisdiction C Durable Medical Equipment, Prosthetics, Orthotics, and SuppliesClaims & Inquiries contact:CGS IVR 866-238-9650 CSR 866-270-4909
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Home Health & Hospice
Jurisdiction C Home Health & HospiceClaims & Inquiries contact:Palmetto GBA IVR 866-238-9650 CSR 866-270-4909
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MEDICARE APPEALS
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Medicare Appeal Levels
RedeterminationReviewed byCahaba GBA
120 DaysTo File
No AIC
1 Reconsideration
180 DaysTo File
No AIC
2 AdministrativeLawJudge (ALJ)
60 Days To File
$140AIC
3 Medicare Appeals Council
60 DaysTo File
No AIC
4 Federal JudicialReview
560 DaysTo File
$1430AIC
*AIC – Amount in Controversy
Redetermination Submission
Paper – CMS20027 Form Fax – Redetermination Smart Form
http://www.cahabagba.com/documents/2012/02/part-b-redetermination_request_b.pdf
http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf
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CAHABA GBA WEBSITE
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Claims Issue Log
http://www.cahabagba.com/part-b/claims-2/claims-issue-log/
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Claims Submission Errors
http://www.cahabagba.com/part-b/claims-2/claims-submission-issues-and-tips-to-prevent-denials/
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Provider Education
http://www.cahabagba.com/part-b/education/
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Calendar of Events
https://apps.cahabagba.com/apps/course_registration/al/calendar.jsp
Date Seminar Type
01-08-2014 Medicare 101 Series: Part 1-"Introduction to Medicare Part B" Webinar
01-15-2014 Medicare 101 Series: Part 2-"The Part B Appeals Process"
01-22-2014 Medicare 101 Series: Part 3-"ICD-10"<BR< a> Webinar
01-29-2014 Medicare 101 Series: Part 4-"The Procedural Coding System"
01-30-2014 The Comprehensive Error Rate Testing (CERT) Program 02-06-2014 Medical Review: "The Probe Review Process"
Coming Soon!Webinar
02-13-2014 "The Basics of Modifiers"Coming Soon! Webinar
02-26-2014 Completing the CMS 1500 Form: "Recent Change" Coming Soon!Webinar
03-05-2014 Navigating the Cahaba GBA Website: "The Favorites" Coming Soon!Webinar
03-12-2014 Navigating the CMS Website: "The Bookmarks" Coming Soon!Webinar
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FORESEE Survey
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ONLINE POLLING
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Live ~ Post Presentation Polling
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RESOURCES
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ResourcesCahaba GBA Websitehttps://www.cahabagba.com/
Centers for Medicare and Medicaid Services http://www.cms.gov/
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Provider Contact Center 1 (877) 567-7271
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