MEDICARE TIPS

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 $120
Allowed $100
Medicare Paid (80%) $80
Deductible/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 charges

Medicare EOB - Detailed Review 1

Detail Fields:

Serv Date: This field provides the service from and to dates as well as the patient's responsibility.

POS: The place of service field contains a two digit number that references where the services were rendered.

NOS: The number of service field shows how many services were billed per procedure code.

Proc: The procedure code is located in this column as well as the patients Health Insurance Claim number (HIC) or the Medicare number.

MODS: If any modifiers were billed, they will be located in this field.

Medicare EOB - Detailed Review

Claim Total Fields:

Medicare EOB - Detailed Review

An ANSI Group Code is always shown with each ANSI reason code to indicate when you may or may not, bill a beneficiary for the non-paid balance of the services or equipment you furnished. Group codes are not used with Medicare Reference (REF) or Medicare Outpatient Adjudication (MOA) remark code entries.

PR - Patient Responsibility

A PR group code signifies the amount that may be billed to the beneficiary or to another payer on the beneficiary’s behalf. For example, PR would be used with the reason code for patient deductible or coinsurance, if the patient assumed financial responsibility for a service not considered reasonable and necessary, for the cost of therapy or psychiatric services after the coverage limit had been reached, for a charge denied as result of the patient’s failure to supply primary payer or other information, or where a patient is responsible for payment of excess non-assigned physician charges. Charges 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), excess charges attributable to rebundled services (reason code B15), charges denied as result of the failure to submit necessary information by a provider who accepts assignment, or services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements 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.

b. CO - Contractual Obligations

Checklist: 6 things to do when you Get Medicare

1.Fill out an "Initial Enrollment Questionnaire" (IEQ) so your bills are paid correctly and on time.

About 3 months before your Medicare coverage starts, you’ll get an Initial Enrollment Questionnaire (IEQ) in the mail. It asks about other health insurance you have that might pay before Medicare does, like group health plan coverage from your or a family member’s employer, liability insurance, or workers' compensation. You can also complete the IEQ online at MyMedicare.gov.

2.Fill out an Authorization Form if you want your family or friends to be able to call Medicare on your behalf.

Medicare can't give personal health information about you to anyone unless you give permission in writing first. Fill out and submit an e-Authorization Form now in case you can’t do it later.

3.Make a "Welcome to Medicare" Preventive Visit appointment during the first 12 months you have Medicare.