Can we bill Attorney for Medical cost ?

Subrogation

Subrogation is another liability recovery activity in which medical costs that are the result of actions or omissions of a third party are recovered from the third party (and/or his insurer). In some instances, Tufts Health Plan has the right to recover the value of services provided to Members for which a third party is responsible.

Tufts Health Plan has outsourced subrogation recovery services to the Rawlings Company in La Grange, KY, and as a result you may receive correspondence from Rawlings related to duplicate claim payments (e.g., Tufts Health Plan and a motor vehicle carrier). 

Inquiries related to such claims should be directed to the Rawlings Company representative at the number indicated on the correspondence. All other subrogation questions should be directed to the Provider Relations Department at 1-800-279-9022.

Note: Do not bill the member or the member’s attorney directlyeven if you are requested to do so by either of them. If you choose to bill the member or attorney directly, you do so at your own risk.

Motor Vehicle Accidents (No-Fault or PIP Coverage)

Tufts Health Plan coordinates with no-fault auto insurance coverage Personal Injury Protection (PIP) and/or Medical Payment (Medpay) on claims for services rendered as a result of a motor vehicle accident (MVA). 

Members should not be billed or required to pay up front for services as a result of a MVA, other than applicable cost-sharing amounts. For motor vehicle accident claims, providers should bill the motor vehicle carrier directly. The no-fault auto insurance coverage is primary for the full PIP coverage and/or any available MedPay coverage.

After receiving the insurer’s statement or check, if further payment is requested for a Tufts Medicare Preferred HMO member, providers must bill Tufts Health Plan within the 60-day filing deadline date from the date the statement or check was issued.

Note: Under your Tufts Medicare Preferred HMO contract, once the member’s PIP and MedPay benefits are exhausted, you cannot balance bill the member or file a lien against the member’s third party settlement or judgment. 

For more information, refer to the Motor Vehicle Accident Payment Policy on our website. For questions regarding third-party liability, contact the Rawlings Company at 502.587.1279.

What are the forms need to submit with worker compensation claims

3.0 Complete Bills;

(a) To be complete a submission must consist of the following:

(1) The correct uniform billing form/format for the type of health care provider.

(2) The correct uniform billing codes for the applicable portion of the OMFS under which the services are being billed.

(3) The uniform billing form/format must be filled out according to the requirements specified for each format in Appendix A and/or the Companion Guide. Nothing in this paragraph precludes the claims administrator from populating missing information fields if the claims administrator has previously received the missing information.

(4) A complete bill includes required reports and supporting documentation specified in subdivision (b).

(b) All required reports and supporting documentation sufficient to support the level of service or code that has been billed must be submitted as follows:

(1) A Doctor?s First Report of Occupational Injury (DLSR 5021), must be submitted when the bill includes Evaluation and Management services and a Doctor?s First Report of Occupational Injury is required under Title 8, California Code of Regulations § 9785.

(2) A PR-2 report or its narrative equivalent must be submitted when the bill is for Evaluation and Management services and a PR-2 report is required under Title 8, California Code of Regulations § 9785.

(3) A PR-3, PR-4 or their narrative equivalent must be submitted when the bill is for Evaluation and Management services and the injured worker?s condition has been declared permanent and stationary with permanent disability or a need for future medical care. (Use of Modifier – 17.)

(4) A narrative report must be submitted when the bill is for Evaluation and Management services for a consultation.

(5) A report must be submitted when the provider uses the following Modifiers – 22, – 23 and – 25.

(6) A descriptive report of the procedure, drug, DME or other item must be submitted when the provider uses any code that is payable “By Report”.

(7) A descriptive report must be submitted when the Official Medical Fee Schedule indicates that a report is required.

(8) An operative report is required when the bill is for either professional or facility Surgery Services fees.

(9) An invoice or other proof of documented paid costs must be provided when required by the OMFS for reimbursement.

(10) Appropriate additional information reasonably requested by the claims administrator or its agent to support a billed code when the request was made prior to submission of the billing. (This does not prohibit the claims administrator from requesting additional appropriate information during further bill processing.)

(11) For paper bills, any written authorization for services that may have been received by the physician.

(c) For paper bills, if the required reports and supporting documentation are not submitted in the same mailing envelope as the bill, then a header or attachement cover sheet as defined in Section One – 7.3 for electronic attachments must be submitted.

How to resolve when denial received on two provider submitting on DOS ?

My inpatient claim is overlapping a home health episode with the same date(s) of service. How can I resolve this?

A: Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.
• Verify dates of service on your claim
• If dates of service are incorrect, correct your claim and resubmit.
• If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim.
• Edit exclusions:
• The inpatient claim admission date is the same as the home health agency transfer/discharge date
• The inpatient claim discharge date is the same as the home health agency admission date
• The inpatient claim dates are between the occurrence span code 74 ‘From’ date and the day following the occurrence span code ‘Through’ date


Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Q: What steps can be taken to identify claims that overlap with another provider?

A: If you receive an overlap reason code, you can do one of the following:

• Verify your claims submitted through direct data entry (DDE) pdf file

• Option -1 (inquiry menu), then option -12 (claims summary), and key in the beneficiary’s health insurance claim (HIC) number, your provider number, and press enter

• Review the list of claims submitted to identify those with identical dates of service, and validate they were submitted accurately

• Verify eligibility for home health episodes and hospice election from the ELGA and/or ELGH screens

• Verify the beneficiary/eligibility tab submenu on the secure provider online tool (SPOT)

• Home health episode start and end date, and the servicing provider’s NPI

• Hospice election effective and termination date, revocation code and the servicing provider’s NPI

• Click here to learn more about the SPOT

• NPI registry lookup external link enables you to search for the provider’s information

• Verify additional eligibility information from the submenu on the interactive voice response (IVR)

• Hospice effective and termination dates (if applicable), and the servicing provider’s ID

• Home health effective and termination dates (if applicable), and the servicing provider’s ID

• Skilled nursing facility (SNF) effective and termination dates (if applicable), and the servicing provider’s ID

Provider Enrollment - Complete list of question and answer - From Medicaid

What is PEAP?
PEAP is the Internet-based Provider Enrollment/Revalidation Application Portal (PEAP) that will be accessed by pay-to providers newly enrolling or revalidating with West Virginia Medicaid beginning in the Summer of 2013.

What does Fiscal Agent mean?
Fiscal Agent means a contractor that processes claims on behalf of the Medicaid agency. Molina Medicaid Solutions is the current fiscal agent for WV Medicaid.

Which providers are considered New Enrollment?
Providers that:
• Are enrolling with WV Medicaid for the first time as a new group, individual sole practitioner, facility, or agency.
• Have a change of ownership as determined by WV Medicaid’s Legal Department.
Stock transfers are not considered a Change of Ownership, however, you are required
to notify WV Medicaid’s fiscal agent, Molina Medicaid Solutions, of any stock transfer changes.

Which providers are considered Revalidating?

Existing WV Medicaid providers are required by CMS Federal guidelines to revalidate at least every five(5) years.


I have thirteen clinics in West Virginia; will I have to revalidate all of them?
Yes, if all 13 are enrolled with WV Medicaid separately, all locations will require a separate enrollment revalidation.
If the Pay-To entity changes, will I need to complete a new enrollment? Yes. You are required to notify WV Medicaid, Molina’s Provider Enrollment Department 30 days in advance of a change. This type of change can delay claim payments, so the sooner you notify Provider Enrollment, the less impact there will be to timely reimbursement.

What if a provider was previously enrolled in WV Medicaid, but has terminated and wants to re-apply for enrollment?
The provider will be required to complete the application process to re-enroll in WV Medicaid.


What does individual or direct practitioner mean?
Individual practitioner means a physician or other person licensed or certified under State law to practice in his or her profession. An individual direct practitioner is a sole proprietor who receives payment directly.


What does group of practitioners mean?
Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

What provider type and specialty would a skilled nursing home use? The provider will use the Nursing Home provider type and Nursing Home specialty.
To locate the provider types, please refer to the Provider Enrollment Matrix.

What is an FEIN? A Federal Employer Identification Number (FEIN) is a nine digit code used by businesses to classify and identify them as a tax payer, for banking services and for other official and legal purposes. Businesses with no employees and sole proprietorship may use the Social Security number for tax reporting. Companies with employees must have a FEIN. This number is unique to a business just like Social Security Number is unique to an individual.


Is there a limit to the number of specialties I can have under a certain provider type?
No, you can have multiple specialties under one (1) provider type. However, the number of specialties available to you within WV Medicaid is based on your provider type. You can refer to the Provider Enrollment Matrix at www.wvmmis.com and go to the Provider Enrollment webpage.


What if there is a Change of Ownership. Will I need to do a new enrollment? Yes, a change of ownership requires completion of a new enrollment application.
Does the payment address have to be a physical location or can it be a PO Box? A Pay-To and Service Location allows for mailing addresses and may be P.O. Boxes. The physical, or site of service location address can not be a P.O. Box address.


Do I have to verify that all employees have not been sanctioned or if an employee has record of the information? 

Providers are responsible for developing an internal process to ensure that all staff are in compliance with regulatory requirements. You are required by Federal law to verify with the Office of Inspector General (OIG), and SAM (formerly Exluded Parties List (EPLS)) to identify if a provider has any sanctions, or exclusions.


What are the differences in the provider risk levels “limited,”“moderate” & “high”?
According to the Federal regulations on provider screening and enrollment, the “limited” risk category includes physicians or non-physician practitioners, medical groups, ambulatory surgery centers, federally qualified health centers, hospitals, end stage renal facilities, mammography screening centers, radiation therapy centers, rural health clinics, and skilled nursing facilities. For providers or suppliers posing a “limited” risk, State Medicaid agencies must verify that the provider or supplier meets all of the applicable federal and state regulations, conduct license verifications (including verifications across state lines), and conduct database checks on a pre and post enrollment basis to ensure providers and suppliers continue to meet criteria.

“Moderate” risk providers include independent diagnostic testing facilities, community mental health centers, comprehensive outpatient rehab facilities, hospice organizations, and independent clinical laboratories. Providers and suppliers classified as “moderate” risk will be subject to all of the screening performed at the “limited” risk level as well as unscheduled or unannounced on-site visits.

The “High” risk category will impose the same level of screening as the “moderate” risk level but also will require the provider/supplier to submit to a fingerprint-based state and federal background check. This includes all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier. In the final rule, CMS identified newly enrolling home health agencies and durable medical equipment companies as “high” risk.


You can access the WV Medicaid Provider Enrollment Matrix on the Provider Enrollment webpage at www.wvmmis.com to determine the risk level by Provider Type.



What about the risk level for provider types not enrolled by Medicare?
For provider types not enrolled by Medicare, WV Medicaid has elected, at this time, to categorize these provider types as “limited” risk.


Will my risk level change?
The final rule allows Medicaid to adjust the screening level of a provider or supplier from “limited” or “moderate” to “moderate” or “high” based on adverse findings/actions by Federal, State, or local agencies.


When I sign, which provider name should I use, the Pay-To NPI name or the physician name?
The Provider Name should match the Pay To/W9 name used in enrollment and the Signatory name should be the name of the person authorized by your organization to sign this type of application.

What fields are required to be answered in the PEAP system?
All required fields will display a red asterisk.


How can I edit information in the PEAP system once entered?
After you submit your application, no edits can be made on the PEAP system. To submit the change in writing with the provider NPI, TAXID, and name, and send to the Provider Enrollment Department. However, prior to submission of your application in PEAP some information entered can be edited by clicking on the edit button in a particular section of the screen. However, there is some information that cannot be edited, and you will have to delete the record by clicking on the delete button. An example would be the ownership screen. For more information, please refer to the PEAP User Guide.

What if I don’t have all the information I need at the time of entry?

The PEAP system allows you to ‘SKIP’ the specific page, and continue the application process. You can ‘SAVE and CLOSE, the application, and resume at a time when the information is obtained. You will be required to have the FEIN Number, email address used when starting the application and the Case Number to resume enrollment.

What is the difference between Business License and State License in the PEAP system?
The business license is the license registered with the West Virginia Secretary of State, or the appropriate out of State agency. The State License is the professional license of the facility provider type or practitioner specialty.

Do I have to provide banking information for revalidation when the PEAP system already has the correct banking information populated?
Yes, it is necessary for you to provide the EFT form, and all banking information required in order to verify and update our records as part of the revalidation process.

The EFT documentation only allows for one document upload, but several pieces are required.

 How do I upload all of the documents?
It will be necessary to scan all pages as one document to upload to the PEAP portal.
Why am I receiving an error when identifying my Tax Identification number as an SSN?
For revalidation the PEAP system requires you choose FEIN, even when entering your SSN.

When can we expect to receive our notification of revalidation with our Case Number to access the PEAP system?
Providers will first receive a Revalidation Notification letter 2 to 3 weeks prior to receiving their Case Number letter that will initiate their phase of revalidation. Providers will be allowed 60 days to complete their revalidation. The revalidation will be conducted in phases by provider type and specialty beginning 6/3/2013 with approximately 60 days between each phase. The planned phases of revalidation by provider type and specialties will be published on Molina’s website at www.wvmmis.com on the Provider Enrollment web page. Upon implementation only the first few phases of revalidation will be publicized, but will periodically be updated. The planned revalidation phases are subject to change. Please check the website periodically to make sure you have the most up to date information available.

Does the reference to Referring mean physicians we refer members to?
No, ordering/referring is an individual provider that can order test and provide services but doesn’t directly receive payment from WV Medicaid.


The providers at my location bill as a group. However, one of the providers contracts with another organization. Who enrolls the contracted providers?
You will enroll your group and add all associated rendering, prescribing, ordering and referring physicians. The entity where the provider contracts will do the same thing.

Will FQHC be in the group phase?
While not all phases of revalidation have been finalized, it is planned that the FQHC’s will be revalidated separately from the Group providers.


We have a hospital, a nursing home, a swing bed and an ER. Will I have to revalidate all of these?
WV Medicaid does not enroll Swing Beds, but for the Nursing Home and Hospital, they have separate Medicaid records and will have to revalidate both independently.


We are a group but received a case letter for 3 individual rendering practitioners today. The
Based upon researching the provider ID’s, we were able to determine that the individuals had been directs at some point and were still listed as such on their provider record. If the providers no longer want to be directs please send a letter to Provider Enrollment requesting termination. Do not revalidate them as individual wait until your group phase and revalidate the group and include the 3 directs as being associated with the group. (Referring\ordering\prescribing\rendering)


Can I revalidate on June 3?
No, you must wait to receive your case number. You will receive your case number by letter when it is time for your revalidation phase. We anticipate publishing the phases of revalidation by the end of June 2013 on the Molina website. Initially only the first few phases will be published. The revalidation phases are subject to change, so it is important to verify the schedule periodically on the Provider Enrollment web page at www.wvmmis.com.


I have 300 providers; do I have to revalidate all 300?
It depends upon how they bill. If they are directs, meaning they bill under their individual provider numbers then yes you will have to complete the revalidation process for all 300. If they bill as a group then you only have to revalidate for the group and list the 300 providers as rendering\ordering\referring\prescribing.

You said the Provider Agreement Form must be printed, signed and mailed hardcopy to Molina. Do I have to get all 300 providers to sign the agreement?
The owner or an authorized official of the business entity, directly or ultimately responsible for operating the business is the authorized signatory of this form. A delegated administrator may sign this form if it has been expressly indicated in written correspondence on company letterhead signed by the authorized official on file or attached. Individual renderings will have to sign a WV Medicaid Statement of Rendering Practitioner Authorization. This is required for all rendering providers affiliated to Group, or Corporation for purposes of claims payment authorization to the group and documenting the rendering signature on file.

What if the appropriate person in our office doesn’t actually receive the case letter?
If you have checked the Molina website and confirmed your provider type phase is underway, but you have not received your case letter, please contact Provider Enrollment Department will verify your identity and provide you with your case number.

I am a non-physician practitioner who works out of my home. I meet members at their home or in the DHHR office to conduct evaluation. I have no set office hours. How should I document my hours on the revalidation application?
Enter the hours your are available to conduct the evaluation. If you are available at any time, you would indicate 12:00 AM to 12:00 PM to indicate 24 hours.


How long after I complete my revalidation application should I wait before I submit claims? This is a seamless process for the providers and will not impact claims submission or payment as long as you submit your revalidation application within 60 days.


In the PEAP system, How many digits should I enter for telephone numbers?
Enter only your 3 digit area code and 7 digit telephone number. It is NOT necessary to add a leading “1.”

Is there an option in the languages on PEAP for American Sign Language?
There is an option for Sign Language.

How long will the revalidation through the PEAP system take?
If you have all collected information necessary to complete the revalidation process, the estimated times of completion for a group practice size of 2 to 10 rendering, or ordering/referring/prescribing only providers will take approximately 2 ½ to 4 hours to complete. Add an additional 5 to 10 minutes for additional rendering providers
.
Is there a copy of the webinar presentation available for us to print?
There will be a video of this exact presentation on the Molina website.

Are we required to obtain a login to revalidate?
No, you will receive your Case Number letter when your revalidation phase begins. The information in that letter, including your case number will give you access to revalidate on the PEAP system.

What if the provider is associated with multiple groups or tax ids?
Groups will revalidate and all associated providers will be listed as one of the following: ordering, referring, rendering or prescribing.

Should we be concerned if we do not get a revalidation letter by a certain time? For instance, if we don't receive a revalidation letter by July 1st, should we be concerned?
No, because this is a phased approach that extends for more than a year. However, you should be concerned if it is your phase and you haven’t received your letter. In this case please contact Provider Enrollment toll free 1-888-483-0793, and locally at (304) 348-3360.


Can we add a rendering physician with our group who is not currently enrolled with Medicaid/Molina during this process?
Yes, during the revalidation process, you can add new rendering practitioner, as well as your ordering/referring/prescribing-only (ORP) providers.


We have providers who are part of our group and individual practice or are part of another group. Will this jeopardize/compromise their payments or enrollment process?
No. You will revalidate your group and revalidate or add the rendering, or ordering/referring/rescribing-only (ORP) practitioners as an affiliated provider of your group. The other groups will be responsible for revalidating, or adding their affiliated practitioiners when they revalidate their group.


We have general surgery, pathology, hospitalists, plastic surgery, bariatric surgery, oral & maxillofacial surgery, hematology/oncology. Will we need to revalidation multiple times?
If your group is enrolled as a multi-specialty group practice, with multiple specialties of rendering or ordering/referring/rescribing-only (ORP) practitioners, you will revalidate the group and all practitioners of the group in one application in the PEAP system. If you have separate group practices with separate pay-to records, then each of the groups will have to revalidate separately.


If board members are completely voluntary do we have to list them and their information?
Yes.

Provider agreement form, is there a special address this needs to be sent to?
Yes, the address to send in signed provider agreements is:
Molina Medicaid Solutions
Attn: Provider Enrollment Department
P.O. Box 625
Charleston, WV 25322-0625


Does every provider have to complete revalidation?
Yes, CMS requires that all providers be revalidated.


My provider just enrolled recently will he need to do this again?
Yes, any provider enrolled prior to 6/3/2013 will go through the revalidation based on the Provider Type and phases of Revalidation. The new enrollment process ensure all CMS requirements and WV Medicaid requirements are met for providers enrolled prior to 6/3/2013.

Are there any Application Fees?
For revalidation with WV Medicaid no application fees will be required.


Revalidating groups does this jeopardize a provider’s individual provider ID?
No nothing is changing; the purpose of revalidation is to collect accurate data.


If a provider has multiple specialties can we add them all?
Yes, it will ask if you want to add additional specialties. You must refer to the Enrollment Matrix on the Provider Enrollment webpage at www.wvmmis.com to identify the criteria for the additional specialties and determine enrollment eligibility.


Will revalidation have any effect on billing and payments?
No, there will be no interruption in processing claims or payments unless you do not submit your completed application timely. Revalidation follow-up letters will generate to providers who have not submitted their application by 30, and 45 days from the Case Number notification letter. The follow-up letters will advise you of the potential payment hold that will be placed on your account if you do not submit your application by 60 days from date of notification. If you have not received your Case Number letter and you have verified your provider type is in the timeframe of revalidation contact Provider Enrollment toll free at 1-888-483-0793, or locally at (304) 348-3360.


We can’t start revalidation until we get a notification letter, correct?
Yes, you have to wait until you receive a letter to revalidate. You can start collecting all the documents from your group and individual providers to streamline your process. If the Phases of Revalidation schedule at www.wvmmis.com


Do I have to submit my EFT information if I am already receiving payments electronically?
Yes, the Provider Enrollment Department must verify all Electronic Funding information during the revalidation process.


I already have a trading partner agreement; do I have to submit this information again?
Yes, the information must be collected by the Provider Enrollment Department during revalidation.


I forgot to download my Cover Sheet.
Although it is much more efficient if you download the Cover Sheet and will allow the Provider Enrollment Department to process your revalidation in a timelier manner, you may however, create your own coversheet. You MUST include the Case Number, NPI and Name on your Coversheet.


I cannot resume my application.
The most common reason for this is because the user is not using the correct email address.

I cannot find my Case Number.
You may call the Provider Enrollment Department to obtain your Case Number. Please have your NPI or FEIN number ready when calling.


I do not recognize the Taxonomy Code on my Case Letter.
This is a Molina internal code and would not be familiar.


Do I start billing with this taxonomy code?
No, this is code Molina uses for internal purposes only.


How do I find my CLIA level?
You will need to determine this on the CLIA website.


I saved and closed my enrollment application, but the information I entered is not there.

This could be one of two possibilities:
1. Only one user should be in the Enrollment Application at a time, if more than one user is updating information, the user that closes last will have the saved information.
2. The user may be in edit mode if you are in the Service Location specialty section, if so cancel edit as the instructions show in the Service Location section.

Can we appeal while using GA modifier -Medicare

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

What is retrospective billing ?

Q: What is the difference between the effective date and retrospective billing date?

A: The effective date is the later of the following two dates:

• The filing date of an enrollment application that was subsequently approved, or

• The date the provider first began furnishing services at a new practice location.

The provider may bill retrospectively for services when:

• The supplier has met all program requirements, including state licensure requirements, and

• The services were provided at the enrolled practice location for up to

1. 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or

2. 90 days prior to their effective date if a presidentially-declared disaster precluded enrollment in advance of providing services to Medicare beneficiaries.

Example:

Suppose that a non-Medicare enrolled physician began furnishing services to beneficiaries at her office March 1. She submitted the CMS-855I initial enrollment application May 1, and the application was approved June 1. The physician’s effective date of enrollment would be May 1, which is the later of: (1) the date of filing, and (2) the date she began furnishing services. The retrospective billing date is April 1 (or 30 days prior to the effective date of enrollment).

Q: How do I obtain beneficiary eligibility information and/or claim status?

A: To access the status of a claim or a beneficiary's Medicare eligibility information (including the date of birth, date of death, entitlement dates, benefit dates, deductible, or coinsurance) use these options below.

Prior to providing services, obtain a copy of the beneficiary’s Medicare card and verify the beneficiary’s insurance information with either the beneficiary or his/her legal representative.

Part B providers

• Contact the Part B IVR at 877-847-4992.

Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.