Eligibility and Entitlement for Persons with Medicare

Medicare coverage may be impacted by the following:

End-Stage Renal Disease (ESRD)

When a patient elects to receive dialysis, the ESRD facility is responsible for services related to his/her dialysis.  Providers may confirm if a service is related to the patient's stay by speaking with the ESRD facility. For services not related, providers may append modifier AY.

Point of Contact for Updates
  • Providers must contact ESRD facility to confirm if a service is related to a beneficiary's stay
  • If national file is incorrect, providers must contact ESRD facility and/or patient to request updates to patient's ESRD record
  • If file is correct, providers must work with ESRD facility to seek payment for their services
  • Noridian is unable to make any changes to ESRD facility claims on national file or pay for ESRD eligible services
Resource

 

Home Health Agency (HHA)

When a beneficiary elects home health through a home health agency, the Medicare services received are subject to home health consolidated billing and include nursing and therapy services, routine and non-routine medical supplies, home health and medical social services are not paid separately by Medicare, but are paid to the home health agency.

Point of Contact for Updates
  • All HHA information on national file is maintained by HHA
  • If file is incorrect, providers must contact HHA and/or patient to request updates to HHA record
  • If file is correct, providers must work with HHA to seek payment for their services
  • Noridian is unable to make any changes to HHA records on national file or pay for HHA eligible services
Resources

 

Hospice

When a beneficiary elects a hospice, he/she waives all rights to Medicare payments for services related to the treatment of his/her terminal condition(s) or related condition equivalent to hospice care. Bill the attending physician services, who is not employed by hospice, with modifier GV. Bill services unrelated to terminal illness with modifier GW.

Point of Contact for Updates
  • All hospice information on national file must be updated by hospice
  • If file is incorrect, providers must contact hospice and/or patient to request updates to hospice record
  • If file is correct, providers must work with hospice to seek payment for their services
  • Noridian is unable to make any changes to hospice records on national file or pay for hospice eligible services
Resources

 

Hospital

When a beneficiary is considered inpatient in a hospital, Part B is responsible for the professional services.  Providers submitting their professional services must bill using the appropriate POS matching the patient's status. For Pathology services, providers may submit the technical component to Part B only when the referring provider has received payment outside of the hospital for the same date of service (DOS).

Point of Contact for Updates
  • Hospital claims on national file are updated by hospital
  • Providers must contact hospital and/or patient to request an update to hospital claim or seek payment for services rendered
  • Provider Contact Center is unable to make changes to hospital claims
Resources

 

Incarceration / Unlawfully Present

When a patient is a prisoner in custody and/or incarcerated, services are not covered by Medicare. Applicable federal, state or local authority may cover such claims. This includes situations such as home detention, supervised release, medical furlough, required residence in a mental health facility, or halfway house.

Point of Contact for Updates
  • Social Security is responsible for maintaining a patient's incarceration record
  • Providers must contact appropriate authority responsible for patient's custody to request an update to patient's national file or seek payment for services rendered from local authority
Resources

 

Medicare Advantage Plan, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO)

When a beneficiary elects an alternative to the traditional Fee for Service Medicare program, providers bill the alternative Medicare Advantage, HMO, or PPO plans.

Point of Contact for Updates
  • If file is incorrect, providers must contact the plan and/or patient to request updates to plan record
  • If file is correct, providers must work with the plan to seek payment for their services
  • Noridian is unable to make any changes to plan records on national file or pay for plan eligible services under most circumstances
    • Exceptions for hospice, clinical trials, and inpatient status may be applicable
Resources

 

Medicare Secondary Payer (MSP)

Patients may have insurance paying before Medicare and Medicare becomes secondary to a primary insurance.

Point of Contact for Updates
  • Beneficiary or provider must contact Benefit Coordination and Recover Center (BCRC) to make MSP file updates
Resources

 

Qualified Medicare Beneficiary (QMB)

Dual Eligible Medicare Medicaid Coverage

"Dual-eligible beneficiaries" are individuals enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A and/or Part B who also receive Medicaid benefits or assistance with Medicare premiums, or cost sharing through various programs. One program is the Qualified Medicare Beneficiary (QMB) Program which assists low-income beneficiaries with his/her Medicare premiums and cost sharing.

Certain requirements and restrictions apply when a beneficiary is dual eligible.

  • Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries
  • Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance, or copayments
  • Medicare and Medicaid payments made for services rendered to a QMB are considered as payment in full
  • Providers cannot charge QMB individuals even if patient's QMB benefit is provided by a different State
  • Providers are encouraged to understand the processes required to request payment for Medicare cost-sharing amounts if owed by the State.
  • Providers may need to complete a State Provider Registration Process and be entered into State payment system to bill the State
  • All original Medicare and MA providers and suppliers–not only those accepting Medicaid–must abide by billing prohibitions
Point of Contact for Updates
  • Providers must contact their beneficiary's state Medicaid agency for QMB status/questions or to discuss appropriately billing beneficiary for a deductible amount
Resources

 

Skilled Nursing Facility (SNF)

When a beneficiary is considered inpatient in a SNF, services such as non-professional services, physical therapy, and ambulance transportation between two SNFs are subject to Skilled Nursing consolidated billing. If the service allows, provider may bill for the professional component to Part B.

Point of Contact for Updates
  • SNF claims on national file are updated by the SNF
  • Providers must contact SNF and/or patient to request an update to SNF claim or seek payment for services rendered
  • Provider Contact Center is unable to make changes to SNF claims or pay for SNF eligible services
Resources

 

Social Security Administration (SSA)

The SSA maintains a beneficiary's Medicare eligibility regarding the spelling of his/her name, date of birth, date of death, requests for new Medicare cards, effective/termination dates and/or related updates to Medicare information.

Point of Contact for Updates
  • Providers must request patient contact SSA to update these files
Resource
  • SSA Phone Number: 1-800-772-1213 (TTY 1-800-325-0778)

 

Supplemental Insurance Coverage

When a beneficiary has an insurance secondary to Medicare, those insurance agencies work with Medicare contractors to define the types of finalized claims (adjusted, initial, unprocessable) sent to them for processing. Each insurance company must provide accurate, timely files. When applicable, a provider's Medicare Remittance Advice (RA) will reflect the name of the supplemental insurance Medicare sent the claim-specific RA.

Point of Contact for Updates
  • Supplemental insurance coverage files must be updated by supplemental insurance or Benefits Coordination & Recovery Center (BCRC)
  • If file is incorrect, providers must contact supplemental insurance, patient, and/or BCRC to request updates
  • If an error occurred in the crossing over of a Medicare claim to supplemental insurance occurs, provider must contact supplemental insurance to submit Medicare RA
  • Noridian is unable to make any changes to supplemental records on national file or attempt a second crossover attempt to them
Resource
  • BCRC Phone Number: 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for hearing and speech impaired)

 

Last Updated Oct 19, 2018