Electronic Data Interchange

Medicare Part B 101 Manual Electronic Data Interchange Table of Contents Electronic Data Interchange Transactions Benefits of Submitting Electronically Becoming an Electronic Submitter PC-ACE EDI: Beyond Claims and Extra Features [...]

National Provider Identifier

Medicare Part B 101 Manual National Provider Identifier Table of Contents National Provider Identifier Background Application Process Sharing Your NPI NPI Contractor Mailing Address NPI Registry [Return to Top] National [...]

About Provider Outreach and Education

Medicare Part B 101 Manual About Provider Outreach and Education Table of Contents About Provider Outreach and Education Educational Activities Provider Outreach and Education Advisory Group [Return to Top] About Provider Outreach [...]

Appendix 3: Place of Service Codes

Medicare Part B 101 Manual Appendix 3: Place of Service Codes Table of Contents Place of Service Codes Health Insurance Portability and Accountability Act Special Considerations Homeless Shelter (Code 04) Indian Health Service [...]

Reminder – Beginning 11/18/2024, Beneficiary Eligibility Information Not Offered on the IVR

Reminder – Beginning 11/18/2024, Beneficiary Eligibility Information Not Offered on the IVR To help protect Medicare beneficiaries against fraud, CMS is instructing all MACs to remove beneficiary eligibility information from our IVR [...]

Inpatient Hospital Issued Notices

Inpatient Hospital Issued Notices Applies to: All hospitals Medicare beneficiaries and hospitals have certain rights and protections related to financial liability and appeals under the Medicare Program. These financial liability and appeal [...]

Modifiers

Modifiers Table of Contents General Modifier Information CPT Modifiers (Used in Medicare Part B) HCPCS Modifiers ABN Modifiers GA, GX, GY and GZ Ambulance Origin and Destination Modifiers [Return to Top] General Modifier [...]

Modifier Usage

Modifier Usage Table of Contents E/M Services Within a Global Surgical Period – Modifiers 24, 25 and 57 24 – Unrelated E/M Service by the Same Physician During a Postoperative Period 25 – Significant, Separately Identifiable E/M [...]

Proper Use of Modifiers 59 and 91

Proper Use of Modifiers 59 and 91 Table of Contents Modifier 59 Appropriate Usage Inappropriate Usage Modifier 91 Appropriate Usage Inappropriate Usage Additional Information Related Content [Return to Top] [...]

Repeat Procedures - Modifiers 76 and 77

Repeat Procedures - Modifiers 76 and 77 Exact duplicate data fields submitted for claims include: Same beneficiary Same provider Same dates of service Same types of services Same place of service Same procedure codes Same billed [...]

Deceased Beneficiary Claims

Medicare Part B 101 Deceased Beneficiary Claims Table of Contents Deceased Beneficiary Claims Unpaid Bills Paid Bills Assigned Claims [Return to Top] Deceased Beneficiary Claims Medicare law outlining the payment of the medical [...]

Payment Floor Standards

Medicare Part B 101 Manual Payment Floor Standards The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail or otherwise finalize the initial determination on a clean claim. The “payment [...]

Limiting Charge

Medicare Part B 101 Manual Limiting Charge Table of Contents Federal Limiting Charge Federal Limiting Charge for Medicare Secondary Payer [Return to Top] Federal Limiting Charge As part of the Omnibus Budget Reconciliation Act of [...]

Medigap

Medicare Part B 101 Manual Medigap Table of Contents Medigap Medigap Crossover Billing Procedures Item 13 Completion Requirement Automatic Crossover Medigap Versus Commercial Crossovers Medicaid Crossovers [Return to Top] [...]

Modifiers

Medicare Part B 101 Manual Modifiers What Is a Modifier? Modifiers are two-digit codes used to report additional information used during claims processing. Modifiers may be alpha-alpha, alphanumeric or numeric-numeric. Modifiers are used [...]

Nonphysician Practitioners

Medicare Part B 101 Manual Nonphysician Practitioners Table of Contents Nonphysician Practitioners Direct Billing/Payment for NPP Services Furnished to Inpatients and Outpatients Related Content [Return to Top] Nonphysician [...]

Standard Remittance ANSI Codes and Remittance Advice

Medicare Part B 101 Manual Standard Remittance ANSI Codes and Remittance Advice Table of Contents What Is a Remittance Advice? What are the Uses for a Remittance Advice? What are the Different Types of Remittance Advice? What You [...]

Appendix 1: Forms

Medicare Part B 101 Manual Appendix 1: Forms Appeals Coverage Customer Care Documentation EDI Enrollment Other Advance Payments CMS Forms Investigational Device Exemption Requests Medicare Privacy Statement Form Vaccine [...]

Appendix 2: Glossary

Medicare Part B 101 Manual Appendix 2: Glossary of Terms The Glossary of Terms listed below are in alphabetical order. Term Definition ABN Advance Beneficiary Notice: A formal notice of noncoverage that a [...]

Evaluation and Management Services

Medicare Part B 101 Manual Evaluation and Management Services Table of Contents Evaluation and Management Services General Principles of Medical Record Documentation New Patient and Established Patient What Should Be Provided if [...]

Hospice

Medicare Part B 101 Manual Hospice Table of Contents General Requirements Coinsurance Coinsurance on Outpatient Drugs and Biologicals Respite Care Coinsurance Physicians’ Services Attending Physician Services Care Plan Oversight [...]

Participation Program

Medicare Part B 101 Manual Participation Program Table of Contents Eligibility Participation Enrollment Period/Participating Status Changes Participation Program Participating Provider Nonparticipating Provider When [...]

Ordering and Referring Claims Information

Medicare Part B 101 Manual Ordering and Referring Claims Information Table of Contents Ordering and Referring Claims Information How to Identify the Ordering or Referring Provider on a Claim Ordering and Referring Eligible Provider [...]

Refunds and Overpayments

Medicare Part B 101 Manual Refunds and Overpayments Table of Contents Medicare Contractor Initiated Demand Letters Providers Not on Automatic Recoupments Jurisdiction K (CT, MA, ME, NH, NY, RI , VT) Jurisdiction 6 (IL, MN, WI) [...]

Return/Reject

Medicare Part B 101 Manual Return/Reject While it's easy to group processed claims as either approved or denied, there are differences in the way claims are returned unpaid by Medicare. Only claims that are filed with complete and correct [...]

Health Professional Shortage Area

Medicare Part B 101 Manual Health Professional Shortage Area What is a HPSA? What is the HPSA Incentive Bonus? Who is Eligible for the Incentive Bonus? How is the Bonus Billed? What Else You Should Know To Learn More [Return to [...]

Assignment of Benefits

Medicare Part B 101 Manual Assignment of Benefits Table of Contents Assignment of Benefits Mandatory Assignment Collecting from Medicare Patients on Assigned Claims Related Content [Return to Top] Assignment of Benefits An [...]

Advance Beneficiary Notice of Noncoverage for Not Reasonable and Necessary Denials

Medicare Part B 101 Manual Advance Beneficiary Notice of Noncoverage for Not Reasonable and Necessary Denials Table of Contents Limited Coverage Medical Necessity Expectations ICD-10-CM Coding Reasons for Noncoverage Beneficiary [...]

Set Up a Beneficiary's Medicare Secondary Payer Record

Table of Contents Background: Set Up a Beneficiary’s Medicare Secondary Payer Record Step 1: Provider Receives New MSP Information for a Beneficiary Step 2: Check for a Matching Medicare Secondary Payer Record for the Beneficiary in the [...]

Modifier 90 Reference to Outside Laboratory

Modifier 90: Reference to Outside Laboratory Modifier 90 is to be used when the billing laboratory refers a specimen to another laboratory for testing. In these cases, the billing laboratory is titled the “referring laboratory” while the [...]

Initiate Patient Status Lookup

Initiate Patient Status Lookup Click the Eligibility Lookup button from the NGSConnex homepage. In the Select a Provider panel, click the Select button next to the applicable provider account. In the Select a Beneficiary panel, [...]

Hospice Payment Rates

MSP Post-Pay Overpayments

Forms You’ll Need Jurisdiction K CT-MA-ME-NH-NY-RI-VT Medicare Part B MSP Overpayment Request Form Jurisdiction 6 IL-MN-WI Medicare Part B MSP Overpayment Request Form JK or J6 Medicare Secondary Payer Part B Voluntary [...]

Cognitive Assessment and Care Plan Information

Cognitive Assessment and Care Plan Information Select Cognitive Assessment & Care Plan Information from the left-side navigation. The Cognitive Assessment & Care Plan information panel provides information for the following HCPCS [...]

Part B Deductible

Part B Deductible Select Part B Deductible from the left-side navigation. The information displayed in this section will provide the current year’s Part B deductible amount and if available up to four years of additional historical deductible [...]

Beneficiary Eligibility Information Panel

Beneficiary Eligibility Information Panel Table of Contents Beneficiary Eligibility Information Panel Printable View Initiate a New Search [Return to Top] Beneficiary Eligibility Information Panel The Beneficiary Eligibility [...]

Flu Vaccine

Flu Vaccine Select Flu Vaccine from the left-side navigation. You will find the patient's flu vaccination history in this section. The Medicare beneficiary must have active Part B coverage and must not have a date of death on file at the [...]

Hepatitis Screening

Hepatitis Screening Select Hepatitis Screening from the left-side navigation. The Hepatitis Screening panel provides information for the following HCPCS codes. 86704 ‒ Hepatitis B core antibody (HBcAb); total 86706 ‒ Hepatitis B surface [...]

Hospice Payment Rates

Hospice Payment Rates National Government Services publishes hospice rate sheets you can use to validate hospice payments based on your service location. Although FISS is the official payment made by the Medicare Program, you can use the rates [...]