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 

The Differences Between Crossover and Medigap

Crossover 

Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

The first claim submitted to Railroad Medicare will not cross over. This is because your eligibility information must be added to Railroad Medicare's system. As long as your name and HIC number appear on a company's monthly crossover listing, Railroad Medicare will continue to forward claims information to the supplemental insurer.

Some supplemental insurers do not offer crossover. You should contact your insurance company to see if your policy is eligible for the crossover program.

Medicaid offers a crossover program with Medicare. The crossover list consists of eligible Medicaid recipients. However, if you are on crossover with a supplemental insurer, we will only forward information to the supplemental insurer, not to Medicaid. In order for you to be on crossover with Medicaid, you cannot be on crossover with any supplemental insurer. If you have both Medicare and Medicaid, your health care providers must accept assignment on all Medicare claims.

Services not covered by Medigap

What Medigap policies don’t cover
Medigap policies don’t cover long-term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, and private-duty nursing.

Types of coverage that are NOT Medigap policies
• Medicare Advantage Plans (Part C), like an HMO, PPO, or Private Fee-for-Service Plans
• Medicare Prescription Drug Plans (Part D)
 • Medicaid
 • Employer or union plans, including Federal Employees Health Benefits Program (FEHBP)
 • TRICARE
• Veterans’ benefi ts
• Long-term care insurance policies
• Indian Health Service, Tribal, and Urban Indian Health plans
• Generally, you must have Medicare Part A and Part B to buy a Medigap policy.

• You pay a premium for your Medigap policy to the private insurance company, in addition to the monthly Part B premium that you pay to Medicare.

• A Medigap policy only covers one person. If you and your spouse both want Medigap coverage, most likely, you each will have to buy separate Medigap policies.

Understand Medigap and what does it cover and not covered

What is a Medigap policy?

A Medigap (also called “Medicare Supplement Insurance”) policy is private health insurance that is designed to supplement Original Medicare. Th is means it helps pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). Medigap policies may also cover certain things that Medicare doesn’t cover. If you are in Original Medicare and you have a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share. (Note: Medicare doesn’t pay any of the costs for you to get a Medigap policy.) Also, a Medigap policy is different than a Medicare Advantage Plan (like an HMO or PPO) because it’s not a way to get Medicare benefits.

Every Medigap policy must follow Federal and state laws designed to protect you, and it must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies can only sell you a “standardized” Medigap policy identified by letters A through L. Each standardized Medigap policy must off er the same basic benefi ts, no matter which insurance company sells it. Cost is usually the only difference between Medigap policies sold by different insurance companies.

In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. See pages 44–46. In some states, you may be able to buy another type of Medigap policy called Medicare SELECT (a Medigap policy that requires you to use specific hospitals and in some cases specific doctors to get full benefits)

Some examples of costs you could pay if you have Original Medicare and don’t have a Medigap 

policy

Medicare Part B Coinsurance or Copayment for other than preventive services

 YOU PAY all coinsurance, generally 20% of the Medicare-approved amount for most covered services aft er you meet the $165 yearly Part B deductible. You also pay any copayment.