Medicare Secondary Payer

M 

MAC Medicare Administrative Contractor 

Medical Necessity A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic. 

Medi-Cal Medi-Cal is California’s Medicaid program. Provides health services for categorically eligible and low-income persons. www.medi-cal.ca.gov. 

Medicare A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). www.medicare.gov Medigap Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. 

Medigap is meant to fill this gap in reimbursement, so that the Medicare beneficiary is not at risk for the difference. 

Modifier In CPT coding, a two-digit add-on or five-digit number, representing the modifier, placed after the usual procedure code number. The two-digit modifier may be separated by a hyphen. 

MSP Medicare Secondary Payer

N

 N/C Non-Covered Charge -- Procedure is not covered by health plan.

 NPI National Identification Number – Standard unique 10-digit identifier assigned to health care providers by CMS. It replaces all previous identifiers. 

P 

Palmetto GBA Effective September 2, 2008 Palmetto is the Medicare contractor for Jurisdiction 1 Part A/B. www.palmettogba.com/J1B 

Participating Provider A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan.

 PCP Primary Care Physician -- The doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them. 

POS Point of Service -- An insurance plan that allows a patient to choose doctors and hospitals without having to first get a referral from his/her primary care doctor. 

PPO Preferred Provider Organization -- A plan that contracts with independent providers at a discount for services. The physicians in a PPO are paid on a fee-for-service schedule that is discounted, usually about 10% to 20% below normal fees. A patient can use a physician outside of the PPO providers, but he or she will have to bear a bigger portion of the fee. 

Procedure Code CPT or HCPC code used to describe the service rendered. 

PTAN Provider Transaction Access Number -- Also known as your legacy Medicare number. 

R 

RA Remittance Advice -- Supplied by the payer to outline payment for submitted claims. Also contains explanations for claim denials. Also referred to as EOB. 

Referral Permission from your primary care doctor for you to see a specialist or get certain services. Responsible Party The person(s) responsible for paying a patient’s office or hospital bill, usually referred to as the guarantor 

S 

Secondary Insurance Extra insurance that may pay some charges not paid by the primary insurance company. 

Skilled Nursing Facility Typically an institution for convalescence or a nursing home. The skilled nursing facility provides a high level of specialized care for long-term or acute illness. It is an alternative to extended hospital stays or difficult home care. 

SOF Signature on File Supplemental Insurance An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell 

Supplemental Insurance for Medicare. 

Subscriber For group policies, subscriber is the term used to describe the employee. For individual policies, subscriber is the term to describe the policyholder. 

T

 TAR Treatment Authorization Request -- An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered. 

Tele Comm Support Internet software or hardware support with the staff of Tele Comm Computer Systems, Inc. 

Term Date The date the insurance contract expired or the date a subscriber or dependent ceases to be eligible for coverage. 

TIN Tax Identification Number -- Also known as Employer Identification Number (EIN) 

TOS Type of Service -- A description of the category of the service preformed. 

TTY Teletypewriter for the hearing impaired 

Florida Blue submitting secondary claim address

Filing the Medicare Cross-Over Claim

File the claim to your Medicare carrier for primary payment. Claim information will not be crossed over to the member’s supplement plan (the secondary payer) until after Medicare has processed the claim and released it from the Medicare payment hold. Medicare secondary claims will normally be electronically forwarded by GHI (the CMS vendor) directly to the member’s supplement Blue Plan for processing of the secondary benefits. Check the Medicare Remittance Notice to identify whether the claim was crossed over directly to the member’s Medicare supplement Blue Plan. If it did, you do not need to take further action. The paper remittance notice will state “Claim information forwarded to: (Name of secondary payer). “ The 835 (electronic remittance) record can also carry the secondary forwarding information.

You will receive payment or processing information from the member’s supplement plan after they receive the Medicare payment. Please allow 45 days from the Medicare payment date for the secondary claim (Medicare Supplement coverage) to process.

If the claim did not crossover electronically to the secondary payer (Medicare supplement plan), then file the claim to BCBSF with the Medicare Remittance Notice attached. Send the claim to:

Florida Blue P.O. Box 1798 Jacksonville, Florida 32231-0014

Do not send secondary claims directly to the member’s Blue Plan secondary payer.

Note: If more than one claim appears on the Medicare Remittance Notice, please indicate the specific claim you are filing.

Inquiries around Medicare Crossover Claims

Direct inquiries on secondary claims to Florida Blue unless the member’s Blue Plan have requested specific information from you on a particular claim. Inquiries received on secondary claims by BCBSF will be coordinated with the member’s Blue Plan for resolution.

Example: A provider received the primary Medicare payment. The Medicare Remittance Notice stated, “Claims information was forwarded to: (Name of secondary payer).” It has been 45 days since Medicare’s payment and no communication has been received from the member’s supplement plan. This should be sent to Florida Blue as an inquiry so the member’s Blue Plan can be contacted and a resolution made on the status of the secondary claim. Florida Blue will communicate the resolution back to the provider. 13

Medicare secondary payer

Medicare was always primary ?. How do you determine primary or secondary?

In most cases, Medicare is primary. Some of the most common situations where Medicare can pay secondary are:

-The individual or his/her spouse is currently employed/working and covered under an employer group health plan as a result of current employment.The company has 20 or more employees or participates in a multiple

 -employer or multi-employer group health plan where at least one employer has 20 or more employees.

  

-Individual in question is entitled to Medicare as a result of a disability, the company has 100 or more employees, or participates in a multi-employer/multiple-employer group health plan where one employer has 100 or more employees.

Payment posting and EOB

What is Payment Posting?

Payment posting is simply posting payments from the insurance company into the system. The insurance company sends a check along with an EOB. On the EOB the insurance company will tell you the allowed amount and the amount they paid. You would then bill the patient any copays, coinsurance or deductibles.

What is an EOB?

EOB means Explanation of Benefits. Insurance companies send information to both the patient and provider on exactly what they paid and allowed. Allowed amount means the maximum amount the insurance company would consider for payment. Any difference above the allowed amount is written off if the provider participates with the insurance company.

Example. The charged amount for the doctors’ visit was $100. The insurance company allowed $70($30 gets written off write away if the doctor participates) out of the $70(they allowed) they pay $50 and states patient has a$20 copay. The $50 they paid plus the $20 copay equals the allowed amount of $70.