Skip over navigation

Claim Submission

Claim Submission

Topic Brief Description
Annual Benefits See premium, deductible and coinsurance amounts.
Claims Processing Timeliness Interest Rate Interest must be paid on clean claims if payment is not made within 30 days (ceiling period) after the date of receipt. The ceiling period is the same for both EMC and paper claims.
CMS-1500 Claim Form Crosswalk to EMC Loops and Segments A list of the most comonly used CMS-1500 Claim Items and their electronic counterparts.

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.
Crossover Claims

The Benefit Coordination & Recovery Center (BCRC) processes all claims crossovers. View the details:

  • CMS Coordination of Benefits (COB) webpage
  • Supplemental Insurance vs. Secondary Insurance
  • Trading Partner/Supplemental Insurer Criteria Selections

Electronic Claim Submission

Connect with Electronic Data Interchange (EDI) regarding electronic claim submissions.
HICN Suffixes View the definition of the suffix in beneficiary Medicare numbers.
Mandatory Claim Submission When Congress passed the Omnibus Budget Reconciliation Act of 1989, it included the requirement that providers and suppliers submit Medicare claims for all covered services on behalf of Medicare beneficiaries, beginning September 1, 1990.
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.  All HCPCS/CPT codes do not have an MUE.
Medigap It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the applicability of deductibles, coinsurance amounts, or other limitations imposed by Medicare.
Modifier and HCPCS Changes View the new and deleted National Level II modifiers and HCPCS.
National Correct Coding Initiative (NCCI) Edits Access code pairs that should not be reported together for a number of reasons.
Place of Service The Medicare program uses a two-digit (11 for office) numeric place of service coding structure. The place of service identifies the location where the item was used or the service was performed. A place of service is required for all services and must be entered in Item 24B of the CMS-1500 claim form or in the electronic equivalent.
Professional Provider Telecommunications Network (PPTN) PPTN allows providers to access beneficiary eligibility, claim status, summary of claim volume and payments, pricing information and diagnosis and procedure code lookups.
PWK (Paperwork) PWK (Paperwork) 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.
Railroad Medicare This link takes you to an external website.

When a beneficiary's Medicare card shows an alpha-prefix instead of a suffix (A000000000), patient is eligible for Railroad Retirement benefits Medicare Part B claims or related questions
for Railroad beneficiaries must be submitted to:

Palmetto Government Benefits Administration
PO Box 10066
Augusta, GA 30999

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 timely filing requirements for claim submission are provided.

 

Last Updated Nov 18, 2016