What is Other Claims (other than clean) and Data Element matrix

Claims that do not meet the definition of “clean” claims are “other” claims. “Other” claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. “Other” claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development. Examples are claims on which the provider’s FI/carrier:

• Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

• Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

• Develops Medicare Secondary Payer (MSP) information;

• Requests information necessary for a coverage determination;

• Performs sequential processing when an earlier claim is in development; and

• Performs outside development as a result of a CWF edit.

How Medicare Determining and Paying Interest

The contractor must pay interest on clean, non-PIP (FIs) claims for which it does not make payment within the payment ceiling specified in § 80.2.1.1, provided payment is due on such claim. The interest rate and formula for calculation are shown above. The interest rate is determined by the rate applicable on the carrier or FI’s payment date.

The contractor applies interest to the net payment amount after all applicable deductions are determined (e.g., deductible, copayment, and/or MSP). Interest is rounded to the nearest penny.

A. Reporting Interest Payment on Remittance Record

See 100-22 for remittance advice completion instructions

B. Payment Made to Beneficiary

If interest is paid on a claim for which payment is made directly to the beneficiary, the contractor adds the following messages on the beneficiary notice:

“Your payment includes interest since we were unable to process your claim timely.”

C. Claims Paid Upon Appeal

Interest payments are not payable on clean claims initially processed to denial and on which payment is made subsequent to the initial decision as a result of an appeal request. This applies to appeals where more than the applicable number of days elapsed before an initial denial, but the claim was later paid upon appeal. Where an appeal of a previously paid claim results in increased payment FIs follow the following section.

Medicare provider Enrollment time frame - How to make it quicker

How you can expedite your enrollment application process

As the Medicare administrative contractor (MAC) for jurisdiction N (JN), First Coast Service Options Inc. (First Coast) is not only responsible for processing Medicare claims but also for processing enrollment applications for providers and suppliers located in Florida, Puerto Rico, and the U.S. Virgin Islands.

The Centers for Medicare & Medicaid Services (CMS) has established the following timeliness standards for contractors responsible for processing enrollment applications within their assigned jurisdictions:

• PECOS Web applications (initial enrollment with no site visit) -- 80% must be processed within 45 days

• Paper-based applications (initial enrollment with no site visit) -- 80% must be processed within 60 days

• Paper-based applications (initial enrollment with site visit) -- 80% must be processed within 80 days

• Paper-based applications (changes to enrollment record or reassignment) -- 80% must be processed within 60 days

First Coast Provider Enrollment Average YTD Processing Times

(Through August 31)

 

PECOS Web Applications

Part A                Part B

 

No development 23 days 31 days

With development 83 days 60 days

Paper Applications

 

No development 36 days 26 days

With development 91 days 57 days

Factors affecting total processing times

Although First Coast processes each enrollment application as quickly as possible, the following key factors may affect the total processing time needed:

• Provider type:

• Part A -- institutional providers

• Part B -- physicians, non-physician practitioners, clinics, and group practices

Shortest processing times: Enrollment applications for Part B providers and suppliers

Medicare deductible, coins - can we collect from patient when patient have secondary insurance

The Medicare Program

The Original Medicare Program, also known as Fee-For-Service (FFS) Medicare, consists of:

• Part A, hospital insurance; and

• Part B, medical insurance.

Under FFS Medicare, eligible individuals may enroll in Part A, Part B, or both Part A and Part B. Most individuals choose to enroll in both Part A and Part B.

FFS Medicare was expanded in 1973 to include:

• Individuals who are under age 65 with certain disabilities; and

• Individuals with End-Stage Renal Disease.

Two parts were added to the Medicare Program in 1997 and 2006, respectively:

• Part C, Medicare Advantage (MA) (first known as Medicare+Choice); and

• Part D, the Prescription Drug Benefit.

MA is another health plan choice available to beneficiaries. It is a program run by Medicare-approved private insurance companies. Most MA organizations arrange for or directly provide health care items or services to the beneficiary who:

• Is entitled to Part A and enrolled in Part B;

• Permanently resides in the service area of the MA Plan; and

• Elects to enroll in a MA Plan.

The Prescription Drug Benefit provides prescription drug coverage to all beneficiaries enrolled in Part A and/or Part B who elect to enroll in a Medicare Prescription Drug Plan (PDP) or a MA Prescription Drug Plan. Insurance companies or other companies approved by Medicare provide prescription drug coverage to such individuals who live in the Plan’s service area. Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for PDP costs.

The Medicaid Program

The Medicaid Program is a cooperative venture funded by Federal and State governments that pays for medical assistance for certain individuals and families with low incomes and limited resources. Within broad national guidelines established by Federal statutes, regulations, and policies, each State:

Medicare - Payment Ceiling Standards - Payment days

Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987. “Clean” claims must be paid or denied within the applicable number of days from their receipt date as follows:

Time Period for Claims Received  Applicable Number of Calendar Days

01-01-93 through 09-30-93   24 for EMC and

                             27 for paper claims

10-01-93 and later   30

All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.

Interest must be paid on claims that are not paid within the ceiling period.

The count starts on the day after the receipt date and it ends on the date payment is made. For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.