medicare tips

Claim Status:

Wait for the 14 day electronic and 29 day paper payment floor before calling-use the IVR system.

Remittance Advice:

Group Code meanings to assist providers in reading remittance advices
Payment Calculation
Medicare payment at 80% of the allowable, minus deductibles for a participating provider. Example: Charge $120Allowed $100Medicare Paid (80%) $80Deductible/coinsurance amounts $20 (20%)

PR Patient Responsibility:

This signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary's behalf. The PR codes are used with the reason codes.· Patient deductible or coinsurance· Patient assumed financial responsibility for a service not considered reasonable· Cost of therapy or psychiatric services after the coverage limit has been reached· Charge denied because of the patient's failure to supply primary payer or other information· Patient is responsible for payment of excess non-assigned physician chargesCharges that have not been paid by Medicare and/or are not included in a PR group, such as a late filing penalty (Reason Code B4), excess charges on an assigned claim (Reason Code 42), services that are not reasonable and necessary for care (Reason Code 50 or 57), etc., are the liability of the provider. Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

CO Contractual Obligation:

This includes any amounts for which the provider is financially liable, such as participation agreement violations, assignment amount violations, excess charges by a managed care plan provider, late filing penalties, or medical necessity denials/reductions. The patient may not be billed for these amounts.

OA Other Adjustment:

This would only be used if neither PR nor CO applied. At least one PR, CO or OA group will appear on each remittance statement. Neither the patient nor the provider can be held responsible for any amount classified as an OA adjustment.

Medicare and its plans

Medicare advantage plan are run by private companies and approved by CMS. Usually employer provide these plan for more coverage than Medicare. In this scenrio all your claims covered by Medicare advantage plan. Medicare and Medigap will not pay your claims.
The only problem in the Medicare advantage plan is patient has to see the PCP before see other doctors. In other words referral will be integeral part here

List of Plans:

Medicare Health Maintenance Organization (HMOs)Preferred Provider

Organizations (PPO) Private Fee-for-Service Plans

Action on Denial for non-covered services

Denied as non-covered services and Action


Medicare Denial - PR-96: Non-covered charge(s).

Medicare Denial - N115: This decision is based on an LMRP or LCD. An LMRP/LCD
provides a guide to assist in determining whether a particular item or service is covered.

Medicare Denial - PR-204: This service/equipment/drug is not covered under the patient’s current benefit plan.

Medicare Denial - N103: Social Security records indicate this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while he is in state or local
custody under a penal authority unless, under state or local law, the individual is personally liable for the cost of his health care while incarcerated and the state or local government pursues such debt in the same way and with the same vigor as any other debt.

Action on Medicare Denial:

The MRA messages above are examples of some that may appear when providers bill/report services that are non-covered under the Medicare program.

Medicare exclusions include, but are not limited to: personal comfort items; self-administered drugs and biologicals (i.e., pills and other medications not administered by injection); cosmetic surgery (unless to repair an accidental injury or improvement of a malformed body member); eye exams (for purpose of prescribing, fitting or changing eyeglasses or contact lenses in absence of disease or injury to eye); and routine immunizations. So we can't bill for these services.

Denial for Lack of information and Action

Action on the Medicare Denial for Lack of information

CO-16 Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice.

When ever you received this denial , check the additional code for which will descripe what the info was required. It could be some of the belows.

- DENIED-RENDERING PHYSICIAN #INVALID/MISSING. SUBMIT A NEW CLAIM
- REFERRING NAME AND UPIN REQUIRED. RESUBMIT AS A NEW CLAIM
- DENIED-CLIA NUMBER INVALID OR MISSING

Action on medicare Denial for provider not eligible

Action on medicare Denial for provider not eligible

Medicare reason code of denial

CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service.

CO-38: Services not provided or authorized by designated (network/primary care) providers.

Action on Denial

Services were denied because the date of service on the claim is prior to the effective date or after the termination date of the provider number submitted on the claim.

1: The provider should verify the correct date of service appears on the remittance advice. If the date of service on the remittance advice is not correct, the procedures for having errors corrected should be followed.

2: If the correct date of service appears on the remittance advice, there may be an issue with the effective date and/or termination date of the provider’s Medicare billing number.

Sometime it is necessary to contact Provider Enrollment.

Action on enrolled Hospice Denial from Medicare

Medicare enrolled Hospice Denial and action

CO B9: Services are not covered because the patient is enrolled in a hospice.


Description in easy words: THESE SERVICES ARE DENIED BECAUSE THE PATIENT IS IN A HOSPICE

Action on Hospice Denial from Medicare

There are specific guidelines pertaining to Medicare hospice benefits. Certain Medicare coverage does not apply to a beneficiary that is enrolled in a hospice program.

To determine if a patient is enrolled in a hospice program, contact the IVR, from which the following data pertaining to the beneficiary can be obtained:

1: Hospice effective date
2: Hospice termination date (if applicable)
3: Servicing contractor number

Certain modifiers apply when the services/providers are not related to hospice:

GW Modifier: Services not related to the hospice patient’s terminal condition

GV Modifer: Attending physician not employed or paid under agreement by the patient’s hospice provider

Action on Medicare Denial for Patient cannot be identified

Denial Reason of Medicare

CO 31 - Claim denied as patient cannot be identified as our insured
Description - (PATIENT'S HIC# NONENTITLED. SUBMIT A NEW CLAIM WITH VALID HIC#.)

Action on Medicare Denial for patient not identified

1: make sure that you have a copy of the patient’s most recently issued Medicare card in order to compare that number with the one you are submitting


2: Verify how the beneficiary’s name is listed on their Medicare card and place it that way on the claim (e.g., no nicknames)

3: Verify the beneficiary’s date of birth (DOB)

4: Ensure the numbers are not being transposed (possibly via software)

5: Verify for which part(s) of Medicare the patient is eligible

6: Check eligibility for beneficiaries using the IVR, Call (877) 847-4992; in the menu of eligibility.

7: Resubmit claim with correct Medicare number and patient name