The History of Medicare

Section 2: Medicare Basics The History of Medicare During the 30 years following the passage of the SSA in 1935, many attempts were made to include health insurance as part of the Social Security system. It was not until the bill H.R. 6675 [...]

What Is the Medicare Program and How Is It Funded?

Section 2: Medicare Basics What Is the Medicare Program and How Is it Funded? Medicare is a federally funded health insurance program for: People age 65 or older Certain individuals under age 65 who qualify due to disability People with [...]

Medicare Eligibility and Premiums

Section 2: Medicare Basics Medicare Eligibility and Premiums The following groups of people are eligible for Medicare: Individuals aged 65 or older (or their spouse) who have worked at least 40 quarters, or ten years, in Medicare-covered [...]

The Social Security Administration and Medicare Enrollment

Section 2: Medicare Basics The Social Security Administration and Medicare Enrollment The SSA office has the responsibility for handling Medicare enrollment and managing premium billing and payment. Premiums may be deducted from a [...]

The Medicare Card

Section 2: Medicare Basics The Medicare Card Once a person is enrolled in Medicare, they are issued a card that indicates they are covered by Medicare. The Medicare card is red, white and blue in color. It is issued (and can be reissued) [...]

Inpatient Hospital Care

Section 2: Medicare Basics Inpatient Hospital Care Table of Contents Inpatient Hospital Care Inpatient Benefit Days and Cost-Sharing Full Days—Renewable Coinsurance Days—Renewable Lifetime Reserve Days—Nonrenewing Inpatient [...]

Skilled Nursing Facility Inpatient Care

Section 2: Medicare Basics Skilled Nursing Facility Inpatient Care Table of Contents Skilled Nursing Facility Inpatient Care Requirements for Coverage Technical Requirements Medical Requirements Inpatient SNF/Swing Bed Benefit [...]

Home Health Care Benefit

Section 2: Medicare Basics Home Health Care Benefit Table of contents Home Health Care Benefit Responsibilities of Hospitals Discharging Medicare Beneficiaries Home Health Prospective Payment System Responsibilities of Providers [...]

The Hospice Benefit

Section 2: Medicare Basics The Hospice Benefit Table of Contents The Hospice Benefit Requirements for Coverage Hospice Benefit Days and Costs Hospice Services Noncovered Hospice Services [Return to Top] The Hospice Benefit [...]

Medicare Part B Medical Insurance

Section 2: Medicare Basics Medicare Part B—Medical Insurance Table of Contents Medicare Part B—Medical Insurance Part B Costs Medicare Deductible, Coinsurance and Premium Rates Covered Part B Services Covered Physicians’ Services [...]

Fundamentals of Medicare - Medicare Program Exclusions

Section 2: Medicare Basics Medicare Program Exclusions No payment can be made under Medicare Part A or Medicare Part B for certain items and services. The list below includes the general Medicare program exclusions. For details regarding [...]

Medicare Advantage Organizations

Section 2: Medicare Basics Medicare Advantage Organizations Table of Contents What are Medicare Health Plans? Medicare Managed Care Plans [Return to Top] What are Medicare Health Plans? Medicare health plans provide different ways [...]

Medicare Secondary Payer

Section 2: Medicare Basics Medicare Secondary Payer Table of Contents Medicare Secondary Payer MSP Provisions MSP Billing - General Benefits Coordination & Recovery Center Contacting the BCRC [Return to Top] Medicare [...]

Coordination of Benefits Trading Partners

Section 2: Medicare Basics Coordination of Benefits Trading Partners COBC exclusively crosses over all claims to trading partners. “Trading partner” is defined as an issuer of an insurance policy that supplements Medicare or a state agency [...]

Fraud and Abuse

Section 3: Fraud and Abuse Fraud and Abuse Table of Contents Fraud and Abuse Examples of Fraud Examples of Abuse [Return to Top] Fraud and Abuse Fraud occurs when there is an intentional deception or misrepresentation that an [...]

Benefit Integrity

Section 3: Fraud and Abuse Benefit Integrity Providers have an obligation, under law, to conform to the requirements of Medicare. A key to avoiding fraud and abuse is the integrity of the provider as an entity and of each individual that is [...]

Fundamentals of Medicare: Program Safeguard Contractor/Zone Program Integrity Contractor

Section 3: Fraud and Abuse Program Safeguard Contractor/Zone Program Integrity Contractor The primary goal of the PSC/ZPIC is to: identify cases of suspected fraud; develop them thoroughly and in a timely manner; and take immediate [...]

Office of Inspector General

Section 3: Fraud and Abuse Office of Inspector General Table of Contents Office of Inspector General Compliance Programs Benefits of a Compliance Program Elements of A Compliance Program OIG Compliance Guidance Self-Discovery [...]

Fraud and Abuse/Compliance Resources

Section 3: Fraud and Abuse Fraud and Abuse/Compliance Resources CMS Resources CMS IOM Publication 100-08, Program Integrity Manual OIG website OIG Fraud Prevention and Detection NGS Fraud and Abuse Resources Reviewed 6/4/2024

Appeals Process

Section 3: Fraud and Abuse Appeals Process Table of Contents Appeals Process The Five Levels of Appeal Appeals Request Process First Level—Redetermination Second Level—Reconsideration Third Level—Administrative Law Judge [...]

Comprehensive Error Rate Testing Process

Section 3: Fraud and Abuse Comprehensive Error Rate Testing Process Table of Contents Comprehensive Error Rate Testing Process What is CERT? Who Performs CERT? How Does It Work? CERT Information Available from CMS [Return to Top] [...]

Registration of the Medicare Patient

Section 4: Getting Ready to Bill Medicare Registration of the Medicare Patient When a Medicare beneficiary receives hospital or other medical services, he/she is generally registered at the facility. It is possible that the patient may [...]

MLN Connects® Newsletter: November 7, 2024

MLN Connects® Newsletter: November 7, 2024 Final Rules Physician Fee Schedule CY 2025 Final Rule Hospital Outpatient Prospective Payment System & Ambulatory Surgical Center Payment System CY 2025 Final Rule ESRD Prospective Payment [...]

Top Tobacco Counseling Claim Errors

Top Tobacco Counseling Claim Errors Reason Code(s) Description Avoiding/Correcting This Error OA-18 A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a [...]

Skin Substitutes

Skin Substitutes CMS provides pricing for some wound care products; however, there are many that do not have established pricing. When a skin substitute/wound care product does not have established pricing, the pricing for the item will be [...]

NGSConnex

Section 4: Getting Ready to Bill Medicare NGSConnex NGSConnex is a self-service web application developed by National Government Services that offers providers and suppliers to access to information at their fingertips via the Internet. [...]

Common Working File

Section 4: Getting Ready to Bill Medicare Common Working File The CWF was developed in 1989 as a means to maintain all of the records for each Medicare beneficiary. These records are a detailed account of each Medicare beneficiary’s status [...]

Fiscal Intermediary Standard System

Section 4: Getting Ready to Bill Medicare Fiscal Intermediary Standard System National Government Services utilizes FISS to process claims and maintain Medicare beneficiary information. Providers have access to this information through a [...]

Advance Beneficiary Notice of Noncoverage

Section 4: Getting Ready to Bill Medicare Advance Beneficiary Notice of Noncoverage An ABN is a written notice a provider gives to a Medicare beneficiary before items or services are furnished, when the provider believes that Medicare [...]

Prepare and Submit a Medicare Tertiary Claim

Table of Contents Prepare and Submit a Medicare Tertiary Claim Step 1: Determine When a Claim(s) Must be Submitted to Medicare Step 2: Check for MSP Insurer Information in Medicare’s Records Step 3: Prepare and Submit Medicare Tertiary [...]

Fast Track Access

Fast Track Access You will be prompted for the fast-track access when you use a feature that requires provider authentication (NPI, PTAN, TIN). Features: Claim Status, Checks, Offsets, Pricing, Appeals You can obtain a code after you [...]

Fast Track Access

Fast Track Access You will be prompted for the fast-track access when you use a feature that requires provider authentication (NPI, PTAN, TIN).  Features: Claim Status, Checks, Remittance Statements, Patient Status, Appeal Status You [...]

General Information <8>

General Information <8> When General Information is selected, the IVR will present the caller with a submenu. Voice Touch-Tone Entry IVR Supplies Phone Numbers 1 Commonly requested telephone numbers [...]

Use National Government Services Self-Service Tools to Maximize your Workload

Use National Government Services Self-Service Tools to Maximize your Workload Our PCC telephone lines are busiest at the beginning and end of each month, and this creates long wait times for providers trying to resolve claim payments, denials, [...]

Common Denials Guide for Diabetes Self-Management Training and Medical Nutrition Therapy

Common Denials Guide for Diabetes Self-Management Training and Medical Nutrition Therapy National Government Services, MAC for Jurisdiction K and Jurisdiction 6, continues to provide you with resources to help reduce the burden of claim [...]

Non-Appealable Situations with Medicare Advantage Plans - Make Sure Your Staff is Aware

Non-Appealable Situations with Medicare Advantage Plans - Make Sure Your Staff is Aware When a Medicare Beneficiary enrolls in a MA Plan, that MA plan takes the place of Traditional Medicare benefits. National Government Services is [...]

Determine if Medicare is Primary or Secondary for a Beneficiary's Services

Table of Contents Determine if Medicare is Primary or Secondary for a Beneficiary's Services Step 1: Collect MSP Information from the Beneficiary During an MSP Screening Process Step 2: Check for Open MSP Records for a Beneficiary in [...]

Fundamentals of Medicare

Track the Status of Your Application

How to Search You may track the status of your provider enrollment application (PECOS or paper) submissions via the: Check Provider Enrollment Application Status tool by: Case number/web tracker id or NPI and TIN combination [...]

Provider Enrollment Application Process Timeline

All MACs, including National Governments Services, have a goal to finalize an Internet-based PECOS application within 15 days and a CMS-855 paper application within 30 days, if all required information is available. About the Application [...]