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Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
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Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 1: Introduction
Glossary of Terms
Beneficiary: An individual who is eligible for Medicare.
Benefit Period: The way that Medicare measures the use of hospital and SNF inpatient days.
Claim: A bill for services rendered by a provider that is submitted in a specified format to Medicare or another payer. Claims can be submitted hard copy (limited situations) or electronically.
Coinsurance: Percentage of the Medicare-approved amount that the beneficiary has to pay after the deductible for Part A and/or Part B is met.
Deductible: The amount the beneficiary (or his/her supplemental insurance) must pay for health care, before Medicare begins to pay, either each benefit period for Part A, or each year for Part B. These amounts can change each year.
DRG: A method of payment for inpatient hospital stays and related services (e.g., x-rays, medications, therapy).
Dually Eligible Beneficiary: A beneficiary who has both Medicare and Medicaid.
DME: Equipment that is purchased or rented from a supplier (e.g., a walker, a cane, crutches).
EDI: A format to electronically submit claims from a provider to Medicare.
CMS: The federal agency responsible for administering the Medicare program. Until 2001, CMS was known as HCFA.
HIC Number: A beneficiary’s Medicare number, which is used for identification and billing purposes. The HIC number is alphanumeric and is usually nine numbers with a one- or two- letter suffix or prefix.
Inpatient Care: Care provided to a beneficiary who has been formally admitted as an inpatient to a hospital.
Legacy Provider Number/PTAN: A 6–9 digit number that is specific to each provider and used for billing purposes.
Medicare: A federal health insurance program for people age 65 or older, some people with disabilities who are under age 65 and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Medicaid: A joint federal and state program that helps with medical costs for certain people with low incomes and limited resources. Medicaid programs vary from state to state.
MSN: A statement sent to a beneficiary from a Medicare contractor explaining how a claim was processed (e.g., deductible or coinsurance due, if services were denied and why).
Medigap: A group of ten federally-mandated health insurance policies offered by private insurers to individuals entitled to Medicare. Specifically designed to supplement Medicare, it fills in the “gaps” in Medicare coverage. Also see Supplemental Insurance.
NPI: A ten-digit number that is specific to each provider and used for billing purposes.
Outpatient Care: A hospital outpatient is a person who has not been admitted to the hospital as an inpatient, but receives services from the hospital.
Preventive Services: Services such as colorectal cancer screenings, mammograms and flu shots. Medicare has specific coverage guidelines for covered preventive services.
Primary Payer: The payer, such as an insurance company, that has primary responsibility for processing a claim. Medicare is always the primary payer to Medicaid when a patient is enrolled in both Medicare and Medicaid.
Secondary Payer: A payer who processes a claim after the primary payer has processed that claim. Medicare can be a secondary payer in certain circumstances, for example, if the beneficiary is still working.
Supplemental Insurance: A health insurance policy offered by private insurers to individuals entitled to Medicare that may pay for all or part of Medicare deductibles and/or coinsurance and may include coverage in addition to traditional Medicare coverage of services.
Reviewed 6/4/2024