Medicare A National Program
Understanding Coverage, Plans and Eligibility
Medicare is a federal health insurance program for the following categories of people:
A patient whose Medicare card claim number ends in “A” has the same Social Security and claim numbers. A patient whose Medicare card claim number ends in “B” or “D” has different Social Security and claim numbers.
BILLING NOTE: A quick check between Social Security and card claim numbers may identify a submission error and forestall a claims rejection. Learn more about claims COVERAGE | Medical Insurance - covered services & preventive care
As the title suggests, the plans are self-explanatory, except for Medicare Part C. This one gets a little tricky. Let me explain. Medicare Part C ( also known for Medicare Advantage Plan MA) provides expansion of healthcare options in addition to those that are available under Part A and B.
These plans are better know the public as:
BENEFICIARIES PREVIOUSLY ENROLLED IN A MEDICARE HMO/MANAGED
When a beneficiary who was previously enrolled in a Medicare HMO/managed care program transitions to traditional FFS, he or she is subject to all benefits, rules, requirements and coverage criteria as a beneficiary who has always been enrolled in FFS. When a beneficiary transitions to FFS, it is as though he or she has become eligible for Medicare for the first time. Therefore, if a beneficiary received any items or services from their HMO or Managed Care plan, they may only continue to receive such items and services if they would be entitled to them under Medicare FFS coverage criteria and documentation requirements. For example, if a beneficiary received a manual wheelchair under their HMO/managed care plan, he or she would need to meet Medicare coverage criteria and documentation requirements for manual wheelchairs. He or she would have to obtain a Certificate of Medical Necessity (CMN), and would begin an entirely new rental period, just as a beneficiary enrolled in FFS would to obtain a manual wheelchair for the first time. There is an exception to this rule if a beneficiary was previously enrolled in FFS and received a capped rental item, then enrolled in an HMO, stayed with the HMO for 60 or fewer days, then returned to FFS. For instructions on how to deal with this situation, refer to §5102.1(E)(3). For purposes of this instruction, CMS has interpreted an end to medical necessity to include enrollment in an HMO for 60 or more days. |
MAC | Useful Links
Noridian FEE SCHEDULE Noridian JE Part B Provider Portal Medicare Fee Schedule Look up Tool Look up Tool help PDF HIC Prefixes & Suffixes Medicare Coverage - Enrollees GPCI Payment Review PDF NPFS Relative Value Files The claim number is the Social Security number of the wage earner with an alpha suffix.
Resource-Based Relative Value Scale
TERMS TO KNOW
Geographical Practice Cost Indices Relative Value Unit (formula below) Geographic Adjustment Factor Malpractice Chart for services are published in the Federal Register
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