For Medicare Providers

Medicare Part A and Medicare Part B Included for Some People Automatically

When you are enrolling in your Medicare coverage you often have to decide what coverage parts you want to apply to you and what parts you don’t.  This isn’t the same with some people who carry Medicare because Medicare Part A and Medicare Part B may be automatically included.  There are a few scenarios in which this is always the truth and they are outlined below. Continue reading

The Blue Button on and What it Means to You

Insurance companies are constantly trying to improve the level of service they provide to customers even if it means a lot of work on new products and services. In 2012 Medicare is trying to improve service on their website with the “Blue Button” that should help with navigation. Your information and previous records will be much easier to access with this tool. You can logon from anywhere at any time and be able to access your medical history, health care providers and medications. Continue reading

Medicare Part D Coverage and the Coverage Gap in 2012

When prescription medication becomes vital to your everyday health you do not need the added concern of being able to afford your prescriptions. Medicare has long made this nightmare possible with the Coverage D coverage gap or “donut hole” but this is being shrunk as we speak. The coverage gap is regularly fading as it nears complete removal by 2020. Continue reading

Can Changes be made to a Medicare Advantage Plan after December 7th?

Medicare, or any health insurance company for that matter, is pretty
rigid about the dates that a plan can start or stop. As a policy
holder your responsibility is to abide by these rules and make sure
that your coverage is valid. As a Medicare Advantage Plan holder you
would be smart to know the options available if you missed the open
enrollment plan or wanted to change your options. Continue reading

Medicare Doesn’t Cover Custodial Care

It can sometimes be a very intimidating and frustrating process to try to care for your loved one when they are ill or elderly. It makes it much easier when Medicare covers the type of situation that your loved one is in and this is why it is hard if your loved one needs “custodial care”. This term is covered below in the exact wording as it is defined by Medicare. Continue reading

Is the Pneumococcal Shot Covered by Medicare?

Certain illnesses and sicknesses have the potential of being much worse when they happen to someone that is already sick or elderly.  The human body isn’t quite as apt to battling off the issues when these things happen and for this reason it is good to be prepared.  The way that you prepare your body for such a situation is to get vaccinated and help your body build up its defenses with things like the pneumococcal shot. Continue reading

Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) with Medicare

It is very important for women of a certain age to be tested on a regular basis for some possible medical conditions or afflictions.  Medicare will cover the cost of many of these procedures for the women that are at risk and this is a good thing for your bank account.  The following information will help you to determine if you qualify for the testing and what is covered. Continue reading

Medical Nutrition Therapy Services and Medicare

After some major medical procedures there is the need to consult with a nutritionist about the way that your body will be able to handle the effects of your procedures.  In addition, just handling a condition that you are afflicted with can become much easier if you know what types of food you can eat to help to treat the situation.  Medicare will cover some of the cost for you getting help in these situations, the details are as follows. Continue reading

Mammograms and Medicare

Due to the frequent nature of breast cancer occurring in women over 30 it is a good idea to get mammograms on a regular basis.  The ugly disease or condition of breast cancer will not go away if you ignore it so you need to screen regularly to see if you can prevent it.  Medicare does allow for screenings for breast cancer in the form of mammograms, but only according to the 12 month rule. Continue reading

Medicare Will Offer Better Chronic Care in 2011

Chronic care is a very important part of Medicare because of its relation to the patients that actually use Medicare and rely on its opportunities to stay healthy.  As part of the initiative to improve health care in the last year Medicare has made some changes to how they treat chronic care, which can only be good for patients.  Here are two things that will change to improve the service that is offered to patients that rely on Medicare. Continue reading

Reviewing the Status of Medicare Enrollment Part D

Reviewing yearly changes made on your website or with your business is important to find out what, if anything, has changed. Review each part of each plan when Medicare enrollment is going on and make the best decision for you in reference to Medicare Part D. Continue reading

How to file your claim with secondary insurance after Medicare has processed.

While Medicare does provide many answers to people who need insurance coverage and must have the coverage to survive, it does not always have all of the answers.  What you must do is know enough about how the process works in order to keep yourself and your medical insurance going.  Here is how to file a claim with your secondary insurance if Medicare doesn’t pay the full claim the first time around. Continue reading

Medicare Bariatric Surgery: Medicare Creates Coverage for Obesity Surgery

In February 2006, Medicare announced that it would cover bariatric surgery, which is surgery used to treat obesity.  Three different types of surgeries are covered:  The Roux-enY bypass, which creates a small pouch in the stomach to connect to the bowel in order to bypass most of the stomach; open and laparoscopic biliopancreatic diversions to bypass most of the small intestine and pancreas, and laparoscopic adjustable gastric banding, which pinches off part of the stomach.

Obesity rates in America are extremely high, according to experts.  Statistics show that approximately 65% of American adults are now overweight.  This has now become a national epidemic, as obesity increases the risk of heart disease, diabetes, cancer and other complications.  Americans are turning more and more to bariatric surgery. 

It used to be that Medicare only covered bariatric surgery if it was needed to correct an illness caused by or exacerbated by obesity.  There was no national coverage policy, so each state had its own.  Now, there is a uniform policy, which covers all Medicare recipients for the surgery.  The Centers for Medicaid and Medicare Services no longer require patients to try other weight-loss treatments first, as most have already made several attempts to lose weight.  To qualify, their body mass index must be over 35 and they must suffer from other weight-related issues such as diabetes or heart disease.  In addition, the surgery must be performed at a medical center approved by the American Society for Bariatric Surgery, or at a certified Level 1 Bariatric Surgery Center by the American College of Surgeons.

Advocates of the new provision claim that covering the surgery will reduce Medicare costs, as patients recover from their obesity-related health problems.  The agency estimates that the new procedure will cost less than expenses associated with heart disease, such as coronary bypass and defibrillators.  It is expected that the patients’ health will improve after surgery, and they may even be able to go off disability.  ASBS President Neil Hutcher, MD says that Medicare coverage for bariatric surgery will begin to remove the stigma of obesity and gastric-bypass surgery, and will cause private health insurance providers to follow suit.

Medicare HCPCS Codes Explained

An estimated 42.5 million Americans received health care through Medicare in 2005.  Medicare is the U.S. Government’s health insurance program offered to citizens and permanent residents who are at least 65 years old.  Most individuals are automatically enrolled in the free Medicare Part A program on their 65th birthday, and have the option to enroll in Part B, which requires a monthly premium.  People younger than 65 who meet certain specific requirements are also eligible for Medicare coverage.

Medicare spending is estimated to grow by 7% per year, so how will the system keep up?  The money issues are the responsibility of the government.  As far as patient care and recordkeeping goes, Medicare has a form for every situation, and will likely create more.  The system also has a Medicare code for every conceivable medical condition and drug.

A brief overview of how a Medicare code works and some examples are given below.

A Simple Example

The Medicare code is comprised of alphanumeric characters, which means it can contain both letters and numbers.  Every treatment a patient receives under Medicare has an associated Medicare code.  When a provider requests reimbursement from Medicare for patient services, it must provide the unique Medicare code for each medical service or product provided.

The Medicare system generally reimburses a specific amount for each medical procedure.  That amount is associated with a Medicare code.  When a medical provider’s reimbursement request reaches the system, each Medicare code on the request is matched to the reimbursable amount for that code.  Medicare then totals all the individual reimbursable amounts related to each Medicare code, and computes a total reimbursement for the provider.

Of course, this is a greatly oversimplified example and does not take real-world conditions into account.  Not all medical items have set reimbursable amounts, and not all are automatically covered either.  The point is that without the Medicare code list, the system would grind to a halt.

Healthcare Common Procedure Coding System

The Healthcare Common Procedure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs. The codes are divided into three levels, or groups, as described below.

Level I is a Medicare code list containing descriptors used by the American Medical Association’s current procedural terminology. Each Medicare code is a 5 number representing both physician and non-physician services.

Level II is comprised of a list of each Medicare code and descriptor used by the American Dental Association’s current dental terminology. Each Level II Medicare code is a 5 character alphanumeric code comprising the D series.

The Level III Medicare code list includes codes and descriptors developed by Medicare carriers for use at the local level.  These are 5 character alphanumeric codes representing both physician and non-physician services not already represented by a Level I or II Medicare code.


These are simply three levels each type of Medicare code.  The degree of complexity of the Medicare code system is enough to give one a migraine headache.  And there’s a Medicare code for a migraine: J3030 (prescription Imitrex ™ with a dosage of up to 6 mg administered via subcutaneous administration).  The doctor and pharmacy visits to get the Imitrex ™ would generate even more Medicare codes.  Maybe we’re better off not knowing.

Medicare Provider Number Application Tips

The Medicare Program is a health insurance program of the U.S. Government.  U.S. citizens and permanent residents are eligible for Medicare coverage if they (or their spouses) worked 10 years or more in employment covered by Medicare and are at least 65 years old.

Additionally, persons less than 65 years old can be covered by Medicare benefits if they are disabled or have end-stage renal disease requiring either kidney dialysis or a transplant.

Before Medicare patients can be accepted by a health care provider, however, it is necessary for the provider to submit a Medicare application.

Below are some tips for a health care provider to get faster approval of its Medicare application.

Medicare coverage and information is subject to change without notice. Always check with your local Medicare professional for the most recent information.

1.  Obtain A National Provider Identifier (NPI) Before Applying

Health providers must supply a valid NPI on the Medicare application.

2.  Health Providers and Suppliers Should Submit The Most Recent Version

The Centers for Medicare & Medicaid Services (CMS) revised the CMS-
855 Medicare enrollment applications starting May 1, 2006.  Health care providers must complete that version of the form at the time of this writing.  The Medicare application version is located in the lower left-hand corner of the form.

3.  Health Providers and Suppliers Should Submit The Proper Form Type

The Medicare application form differs for each type of health care provider.  For example, a doctor’s office, ambulance provider, and mental health care institution would each submit a different version of the form.  Each provider’s form lists the types of providers that can utilize it.

4.  Include All Supporting Documentation

All requested records must accompany the completed Medicare application.  These records may include professional and business licenses, identification numbers, and other professional documents.

5.  Make Sure Your Application Is Complete

Submitting an incomplete Medicare application requires the agency to either contact you for the missing information, or return the form for completion.  Save time by supplying all information the first time.

6.  Health Providers and Suppliers Should Submit To The Proper Place

Different contractors process the Medicare application from different parts of the country.  Submitting the completed form to the wrong address will delay the enrollment.

7.  Include All Application Fees If Required

Certain institutions must include a Medicare application fee.  The provider must include all information to pay this fee via electronic transfer.

8.  The Responsible Official Must Sign And Date The Form

The Medicare application process for providers can sometimes be difficult, so failure to sign and date the form is a common mistake.

9.  Handle Medicare Application Information Requests Promptly

The contractor handling a provider’s form may have questions.  Prompt responses can keep the application process going.

Most health care providers can get their Medicare application approved faster if they follow a careful and methodical approach to completing the enrollment form.

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