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Claim Submission

Topic Brief Description
Jurisdiction List

Year specific lists created to assist suppliers in determining which Medicare contractor to bill for certain HCPCS codes.

Administrative Simplification Compliance Act (ASCA) View the purpose of ASCA, supplier's responsibility, circumstances under which a supplier may submit paper claims, claim processing information.
Assignment Agreement

An assignment agreement is between a supplier of services and a Medicare beneficiary.

Claim Status Inquiry (CSI)

Important Note: The below information is not the Noridian Medicare Portal.

CSI allows suppliers to check eligibility and claim status (paid, denied or pending claims). Suppliers can check the status of claims within three days of a successful transmission.

Clean Claims - Payment / Interest A "clean" claim is one that does not require investigation or development outside the DME MAC operation on a prepayment basis.
CMS-1500 Claim Form Instructions

Required elements of the claim form are provided.

CMS-1500 Claim Form Tutorial Move the cursor for more information on how to complete the claim form.
Common Working File (CWF) View information regarding CWF hours of availability, Dark Days and how the national record is used for Noridian Interactive Voice Response (IVR) and Endeavor portal inquiries.
Crossover Claims Supplemental insurers or payers and Medicaid agencies contract with CMS' Coordination of Benefits Contractor (COBC) to receive Medicare crossover claims.
Definition and Filing

Medicare regulations define a claim for payment as a request for payment from a provider, supplier or beneficiary, and the provider, supplier or beneficiary requesting payment must furnish appropriate Medicare contractor with sufficient information to determine amount of payment.

Electronic Submission of Medical Documentation (esMD) The intent of esMD is to reduce supplier costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation.
Health Insurance Claim Number (HICN) Prefixes and Suffixes

View the definitions of beneficiary Medicare number prefixes and suffixes.

Incomplete or Invalid Claims Processing Terminology

View definitions of incomplete or invalid claims processing terminology.

Mandatory Claim Submission View guidelines and resources regarding provider's responsibilities when accepting Medicare beneficiaries.
Medically Unlikely Edits (MUEs) An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

Not Otherwise Classified Codes

When billing for nuts, bolts, screws, or other small parts, these items are included in the allowance for the accessory with which they are being used.

PECOS Edits The edits ensure the ordering/referring provider is enrolled in Provider Enrollment, Chain & Ownership System.

Place of Service

Coverage for any DMEPOS item is limited to certain places of service.

PWK (Paperwork)

PWK is a segment within the 837 Professional and Institutional electronic transactions. The PWK segment provides the ‘linkage' between electronic claims and additional documentation which is needed for claims adjudication.

Sales Tax

Medicare does not reimburse separately for sales tax.

Signature Requirements

Signatures by both the beneficiary and supplier are required for claim submission.

Social Security Number Removal Initiative (SSNRI) Congress requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new randomly generated Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number on new Medicare cards.
Timely Filing

The Patient Protection and Affordable Care Act (PPACA), Section 6404, reduced the maximum period for timely submission of Medicare claims to not more than 12 months beginning with dates of service on or after January 1, 2010.

 

Last Updated Jan 23, 2017