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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
Medicare Administrative Contractors
Table of Contents
- Medicare Administrative Contractors
- Who Is National Government Services?
- The Focus of the Provider Outreach & Education Department
Medicare Administrative Contractors
Payments to providers for hospital and medical services rendered to Medicare beneficiaries are handled by private insurance companies under contract with the federal government. Medicare Contracting Reform (or section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003) mandated the Secretary for Health & Human Services replace the previous contracting authority to administer the Medicare Part A and Part B FFS programs, contained under Sections 1816 and 1842 of the Social Security Act, with the new Medicare Administrative Contactor authority. MACs, as these companies are now known, process claims for services covered under the Medicare Part A (Hospital) and Medicare Part B (Medical) programs.
MACs, under the Part A program, process claims submitted by facilities including (but not limited to) hospitals, skilled nursing facilities, home health associations, hospices, outpatient rehabilitation facilities and Community Mental Health Centers. Inpatient treatment in these facilities is covered under the Part A program and outpatient treatment in these facilities is covered under the Medicare Part B program. However, both types of treatment are billed to Part A program when the service is rendered in a facility setting.
Providers may often hear terminology that outpatient treatment at certain facility types is known as covered under “Part B of A.” This phrase is used when a Part B service is rendered in a facility setting, such as a hospital emergency room visit. Since this Part B service is rendered in a facility, it is billed to the Part A program.
MACs, under the Part B program, process claims submitted by physicians, freestanding laboratories and X-ray facilities, vendors and suppliers.
Who Is National Government Services?
National Government Services, Inc., a subsidiary of Elevance Health, has a long history of supporting federal health agencies, including the CMS. Throughout the country, NGS has served as a Medicare contractor since the inception of the Medicare Program nearly 60 years ago. NGS associates are located throughout the country and are committed to Our Mission of: Improving Lives and Communities. Simplifying Healthcare. Expecting More.
NGS works closely with CMS to process 20 percent of the nation’s Medicare claims, more than any other contractor in the country. NGS proudly serves nearly 500,000 providers and over 20 million beneficiaries in 20 states and five U.S. territories.
The Focus of the Provider Outreach & Education Department
The NGS POE Team consists of subject matter experts with expansive knowledge of Medicare rules and regulations. POE is dedicated to educating NGS providers on Medicare billing issues using the following methods:
- Teleconferences
- Live events i.e., conferences, conventions and seminars
- Webinars
- New provider education classes
- Medicare University
- Speaking engagements at provider and other professional associations
- Articles in the Medicare Monthly Review, NGS’ monthly provider bulletin
- YouTube.com/NGSMedicare and LinkedIn.com/NGSMedicare
POE also assists other NGS departments, such as PCC, with provider-related issues. Information regarding our educational efforts can be found on our website. Materials on the website include:
Revised 5/31/2024