claims/appeals/fraud topics to highlight handouts/case ...case study – barbie que (gap downgrade)...

Day 5 Chapter 6 – Claims/Appeals/Fraud

Topics to Highlight

□ Medicare Summary Notice □ Coordination of benefits

□ Mass Ban on Balance Billing Law vs. other states

□ Stress importance of time limit for appeals

□ Stress importance of using MAP

Handouts/Case Studies □ MSN A & B examples and How to Read a MSN Guide

□ Advanced Beneficiary Notice of Noncoverage (ABN)

□ MAP’s information / Brochures (Not included)

□ Appeals Process Flow Chart

□ Case Study – Felix DeKatt (Podiatry coverage for diabetic)

□ Case Study – Cal Asthenik (Wheelchair coverage-not doctor ordered)

□ Case Study – Fran Tikk (Pt. B late enrollee appeal – MAP)

□ Claims Processing/Appeals/Fraud/Abuse Quiz

□ Case Study – Jack R. Abbot (Insurance denial of payment)

□ Case Study – Perry Scope (Discontinue PT services)

□ Case Study – Barbie Que (Gap downgrade)

□ Case Study – Al Falfa (LIS eligible)

□ Case Study – Jen Teal (PA eligible)

□ Medicare Coverage of Durable Medical Equipment and Other Devices

□ Medicare’s Wheelchair and Scooter Benefit

□ Homework: Read Chapter Seven – Public Benefits

What is New on Your Redesigned “Medicare Summary Notice”?

Part AYou’ll notice your “Medicare Summary Notice” (MSN) has a new look. The new MSN will help to make Medicare information clearer, more accessible, and easier to understand. Based on comments from people like you, we have redesigned the MSN to help you keep track of your Medicare-covered services.

Your New MSN: Part A | Page 2

Your New MSN for Part A – OverviewYour Medicare Part A MSN shows all of the services billed to Medicare for inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care services.

Each Page with Specific Information: Page 1: Your dashboard, which is a summary of your notice,

Page 2: Helpful tips on how to review your notice,

Page 3: Your claims information,

Last page: Find out how to handle denied claims.

Bigger Print for Easy ReadingPage titles and subsection titles are now much larger. Using a larger print throughout makes the notice easier to read.

Helpful Tips for Reading the NoticeThe redesigned MSN explains what you need to know with user-friendly language.

Medicare Summary Noticefor Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services

Your Deductible Status

Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay.

Part A Deductible: You have now met your $1,184.00 deductible for inpatient hospital services for the benefit period that began May 27, 2013.

Be Informed!

Welcome to your new Medicare Summary Notice! It has clear language, larger print, and a personal summary of your claims and deductibles. This improved notice better explains how to get help with your questions, report fraud, or file an appeal. It also includes important information from Medicare!

THIS IS NOT A BILLJENNIFER WASHINGTON TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789

Notice for Jennifer Washington

Medicare Number XXX-XX-1234A

Date of This Notice September 15, 2013

Claims Processed Between

June 15 – September 15, 2013

¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227)

Your Claims & Costs This Period

Did Medicare Approve All Claims? YESSee page 2 for how to double-check this notice.

Total You May Be Billed $2,062.50

Facilities with Claims This Period

June 18 – June 21, 2013 Otero Hospital

Page 1 of 4

Page 1

THIS IS NOT A BILL | Page 2 of 4Jennifer Washington

Making the Most of Your Medicare

How to Check This Notice

Do you recognize the name of each facility? Check the dates.

Did you get the claims listed? Do they match those listed on your receipts and bills?

If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.

How to Report Fraud

If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).

Some examples of fraud include offers for free medical services or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.

You can make a difference! Last year, Medicare saved tax-payers $4.2 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare.

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535.

TTY 1-877-486-2048 (for hearing impaired)

Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555.

Your Benefit Periods

Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row.

Inpatient Hospital: You have 56 out of 90 covered benefit days remaining for the benefit period that began May 27, 2013.

Skilled Nursing Facility: You have 63 out of 100 covered benefit days remaining for the benefit period that began May 27, 2013.

See your “Medicare & You” handbook for more information on benefit periods.

Your Messages from Medicare

Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment.

To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms.

Want to see your claims right away? Access your Original Medicare claims at www.MyMedicare.gov, usually within 24 hours after Medicare processes the claim. You can use the “Blue Button” feature to help keep track of your personal health records.

Page 2

Jennifer Washington THIS IS NOT A BILL | Page 3 of 4

Part A Inpatient Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.

Definitions of ColumnsBenefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)

Claim Approved?: This column tells you if Medicare covered the inpatient stay.

Non-Covered Charges: This is the amount Medicare didn’t pay.

Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.

Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges.

For more information about Medicare Part A coverage, see your “Medicare & You” handbook.

Your Inpatient Claims for Part A (Hospital Insurance)

June 18 – June 21, 2013Otero Hospital, (555) 555-1234 PO Box 1142, Manati, PR 00674Referred by Jesus Sarmiento Forasti

Benefit Days Used

Claim Approved?

Non- Covered Charges

Amount Medicare

Paid

Maximum You May Be Billed

See Notes Below

Benefit Period starting May 27, 2013 4 days Yes $0.00 $4,886.98 $0.00

Total for Claim #20905400034102 $0.00 $4,886.98 $0.00 A,B

Notes for Claims Above

A

B

Days are being subtracted from your total inpatient hospital benefits for this benefit period. The “Your Benefit Periods” section on page 2 has more details.$2,062.50 was applied to your skilled nursing facility coinsurance.

Page 3

File an Appeal in Writing

Follow these steps:

1 Circle the service(s) or claim(s) you disagree with on this notice.

2 Explain in writing why you disagree with the decision. Include your explanation on this notice or, if you need more space, attach a separate page to this notice.

3 Fill in all of the following:

Your or your representative’s full name (print)

Your or your representative’s signature

Your telephone number

Your complete Medicare number

4 Include any other information you have about your appeal. You can ask your facility for any information that will help you.

5 Write your Medicare number on all documents that you send.

6 Make copies of this notice and all supporting documents for your records.

7 Mail this notice and all supporting documents to the following address:

Medicare Claims Office c/o Contractor Name Street Address City, ST 12345-6789

Get More Details

If a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the facility to contact our claims office to correct the error. You can ask the facility for an itemized statement for any service or claim.

Call 1-800-MEDICARE (1-800-633-4227) for more information about a coverage or payment decision on this notice, including laws or policies used to make the decision.

If You Need Help Filing Your Appeal

Contact us: Call 1-800-MEDICARE or your State Health Insurance Program (see page 2) for help before you file your written appeal, including help appointing a representative.

Call your facility: Ask your facility for any information that may help you.

Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.

Find Out More About Appeals

For more information about appeals, read your “Medicare & You” handbook or visit us online at www.medicare.gov/appeals.

If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount on this Notice, You Can Appeal

Appeals must be filed in writing. Use the form to the right. Our claims office must receive your appeal within 120 days from the date you get this notice.

We must receive your appeal by:

January 21, 2014


How to Handle Denied Claims or File an Appeal

Last Page


Page 1 – Your Dashboard

Medicare Summary Noticefor Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services


Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay.

Part A Deductible: You have now met your $1,184.00 deductible for inpatient hospital services for the benefit period that began May 27, 2013.

Be Informed!





Date of This Notice September 15, 2013


June 15 – September 15, 2013



Did Medicare Approve All Claims? YESSee page 2 for how to double-check this notice.

Total You May Be Billed $2,062.50

Facilities with Claims This Period

June 18 – June 21, 2013 Otero Hospital

Page 1 of 41 DHHS Logo

The redesigned MSN has the official Department of Health & Human Services (DHHS) logo.

2 Your InformationCheck your name and the last 4 numbers of your Medicare number, as well as the date your MSN was printed and the dates of the claims listed.

3 Your Deductible InfoYou pay a Part A deductible for services before Medicare pays. You can check your deductible information right on page 1 of your notice!

4 Title of your MSNThe title at the top of the page is larger and bold.

5 Total You May Be BilledA new feature on page 1, this summary shows your approved and denied claims, as well as the total you may be billed.

6 Facilities You Went ToCheck the list of dates for services you received during this claim period.

7 Help in Your LanguageFor help in a language other than English or Spanish, call 1-800-MEDICARE and say “Agent.” Tell them the language you need for free translation services.


Page 2 – Making the Most of Your Medicare




Do you recognize the name of each facility? Check the dates.

Did you get the claims listed? Do they match those listed on your receipts and bills?


How to Report Fraud

If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).




1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535.



Your Benefit Periods

Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row.

Inpatient Hospital: You have 56 out of 90 covered benefit days remaining for the benefit period that began May 27, 2013.

Skilled Nursing Facility: You have 63 out of 100 covered benefit days remaining for the benefit period that began May 27, 2013.

See your “Medicare & You” handbook for more information on benefit periods.






1 Section TitleThis helps you navigate and find where you are in the notice. The section titles are on the top of each page.

2 How to CheckMedicare offers helpful tips on what to check when you review your notice.

3 How to ReportHelp Medicare save money by reporting fraud!

4 How to Get HelpThis section gives you phone numbers for where to get your Medicare questions answered.

5 Your Benefit PeriodThis section explains benefit periods.

6 General MessagesThese messages get updated regularly, so make sure to check them!

Your Claims for Part A (Hospital Insurance)Your New MSN: Part A | Page 5


Part A Inpatient Hospital Insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility following a hospital stay, home health care, and hospice care.

Definitions of ColumnsBenefit Days Used: The number of covered benefit days you used during each hospital and/or skilled nursing facility stay. (See page 2 for more information and a summary of your benefit periods.)

Claim Approved?: This column tells you if Medicare covered the inpatient stay.

Non-Covered Charges: This is the amount Medicare didn’t pay.

Amount Medicare Paid: This is the amount Medicare paid your inpatient facility.

Maximum You May Be Billed: The amount you may be billed for Part A services can include a deductible, coinsurance based on your benefit days used, and other charges.

For more information about Medicare Part A coverage, see your “Medicare & You” handbook.

Your Inpatient Claims for Part A (Hospital Insurance)

June 18 – June 21, 2013Otero Hospital, (555) 555-1234 PO Box 1142, Manati, PR 00674Referred by Jesus Sarmiento Forasti

Benefit Days Used

Claim Approved?

Non- Covered Charges

Amount Medicare

Paid


See Notes Below

Benefit Period starting May 27, 2013 4 days Yes $0.00 $4,886.98 $0.00

Total for Claim #20905400034102 $0.00 $4,886.98 $0.00 A,B


A

B

Days are being subtracted from your total inpatient hospital benefits for this benefit period. The “Your Benefit Periods” section on page 2 has more details.$2,062.50 was applied to your skilled nursing facility coinsurance.

1 Type of ClaimClaims can either be inpatient or outpatient.

2 DefinitionsDon’t know what some of the words on your MSN mean? Read the definitions to find out more.

3 Your VisitThis is the date you went to the hospital or facility. Keep your bills and compare them to your notice to be sure you got all the services listed.

4 Benefit PeriodThis shows when your current benefit period began.

5 Approved ColumnThis column lets you know if your claim was approved or denied.

6 Max You May Be BilledThis is the total amount the facility is able to bill you. It’s highlighted and in bold for easy reading.

7 NotesRefer to the bottom of the page for explanations of the items and supplies you got.


Last Page – How to Handle Denied Claims


Follow these steps:








4 Include any other information you have about your appeal. You can ask your facility for any information that will help you.





Get More Details

If a claim was denied, call or write the hospital or facility and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the facility to contact our claims office to correct the error. You can ask the facility for an itemized statement for any service or claim.




Call your facility: Ask your facility for any information that may help you.







January 21, 2014


How to Handle Denied Claims or File an Appeal 1 Get More DetailsFind out your options on what to do about denied claims.

2 If You Decide to AppealYou have 120 days to appeal your claims. The date listed in the box is when your appeal must be received by us.

3 If You Need HelpHelpful tips to guide you through filing an appeal.

4 Appeals FormYou must file an appeal in writing. Follow the step-by-step directions when filling out the form.

What is New on Your Redesigned “Medicare Summary Notice”?

Part BYou’ll notice your “Medicare Summary Notice” (MSN) has a new look. The new MSN will help to make Medicare information clearer, more accessible, and easier to understand. Based on comments from people like you, we have redesigned the MSN to help you keep track of your Medicare-covered services.

Your New MSN: Part B | Page 2

Your New MSN for Part B – OverviewYour Medicare Part B MSN shows all of the services billed by Medicare for doctors’ services, hospital outpatient care, home health care, preventive services, and other medical services.

Each Page with Specific Information: Page 1: Your dashboard, which is a summary of your notice,

Page 2: Helpful tips on how to review your notice,

Page 3: Your claims information,

Last page: Find out how to handle denied claims.

Bigger Print for Easy ReadingPage titles and subsection titles are now much larger. Using a larger print throughout makes the notice easier to read.

Helpful Tips for Reading the NoticeThe redesigned MSN explains what you need to know with user-friendly language.

Page 1 of 4Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services


Your deductible is what you must pay for most health services before Medicare begins to pay.

Part B Deductible: You have now met $85.00 of your $147.00 deductible for 2013.

Be Informed!




Did Medicare Approve All Services? NO

Number of Services Medicare Denied 1See claims starting on page 3. Look for NO in the “Service Approved?” column. See the last page for how to handle a denied claim.

Total You May Be Billed $90.15

Providers with Claims This Period

January 21, 2013 Craig I. Secosan, M.D.




Date of This Notice March 1, 2013


January 1 – March 1, 2013

Page 1




Do you recognize the name of each doctor or provider? Check the dates. Did you have an appointment that day?

Did you get the services listed? Do they match those listed on your receipts and bills?


How to Report Fraud

If you think a provider or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).




1-800-MEDICARE (1-800-633-4227) Ask for “doctors services.” Your customer-service code is 05535.








Medicare Preventive ServicesMedicare covers many free or low-cost exams and screenings to help you stay healthy. For more information about preventive services:

• Talk to your doctor.• Look at your “Medicare & You” handbook for a

complete list.• Visit www.MyMedicare.gov for a personalized list.

Page 2


Part B Medical Insurance helps pay for doctors’ services, diagnostic tests, ambulance services, and other health care services.

Definitions of ColumnsService Approved?: This column tells you if Medicare covered this service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged.

Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid your provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

Your Claims for Part B (Medical Insurance)

Service Provided & Billing CodeService

Approved?

Amount Provider Charged

Medicare- Approved

Amount

Amount Medicare

Paid


See Notes Below

Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits (92014)

Yes $143.00 $107.97 $86.38 $21.59

Destruction of skin growth (17000) NO 68.56 0.00 0.00 68.56 A

Total for Claim #02-10195-592-390 $211.56 $107.97 $86.38 $90.15 B

January 21, 2013Craig I. Secosan, M.D., (555) 555-1234 Looking Glass Eye Center PA, 1888 Medical Park Dr, Suite C, Brevard, NC 28712-4187


A This service was denied. The information provided does not support the need for this service or item.

B Your claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them.

Page 3



Get More Details

If a claim was denied, call or write the provider and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the provider to contact our claims office to correct the error. You can ask the provider for an itemized statement for any service or claim.




Call your provider: Ask your provider for any information that may help you.







July 13, 2013


Follow these steps:








4 Include any other information you have about your appeal. You can ask your provider for any information that will help you.





Last Page


Page 1 – Your Dashboard

Page 1 of 4Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services


Your deductible is what you must pay for most health services before Medicare begins to pay.

Part B Deductible: You have now met $85.00 of your $147.00 deductible for 2013.

Be Informed!




Did Medicare Approve All Services? NO

Number of Services Medicare Denied 1See claims starting on page 3. Look for NO in the “Service Approved?” column. See the last page for how to handle a denied claim.

Total You May Be Billed $90.15

Providers with Claims This Period

January 21, 2013 Craig I. Secosan, M.D.




Date of This Notice March 1, 2013


January 1 – March 1, 2013

1 DHHS LogoThe redesigned MSN has the official Department of Health & Human Services (DHHS) logo.

2 Your InformationCheck your name and the last 4 numbers of your Medicare number, as well as the date your MSN was printed and the dates of the claims listed.

3 Your Deductible InfoYou pay a yearly deductible for services before Medicare pays. You can check your deductible information right on page 1 of your notice!

4 Title of your MSNThe title at the top of the page is larger and bold.

5 Total You May Be BilledA new feature on page 1, this summary shows your approved and denied claims, as well as the total you may be billed.

6 Providers You SawCheck the list of dates and the doctors you saw during this claim period.

7 Help in Your LanguageFor help in a language other than English or Spanish, call 1-800-MEDICARE and say “Agent.” Tell them the language you need for free translation services.


Page 2 – Making the Most of Your Medicare




Do you recognize the name of each doctor or provider? Check the dates. Did you have an appointment that day?

Did you get the services listed? Do they match those listed on your receipts and bills?


How to Report Fraud

If you think a provider or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).




1-800-MEDICARE (1-800-633-4227) Ask for “doctors services.” Your customer-service code is 05535.








Medicare Preventive ServicesMedicare covers many free or low-cost exams and screenings to help you stay healthy. For more information about preventive services:

• Talk to your doctor.• Look at your “Medicare & You” handbook for a

complete list.• Visit www.MyMedicare.gov for a personalized list.

1 Section TitleThis helps you navigate and find where you are in the notice. The section titles are on the top of each page.

2 How to CheckMedicare offers helpful tips on what to check when you review your notice.

3 How to ReportHelp Medicare save money by reporting fraud!

4 How to Get HelpThis section gives you phone numbers for where to get your Medicare questions answered.

5 Preventive ServicesRemember, Medicare covers many preventive tests and screenings to keep you healthy.

6 General MessagesThese messages get updated regularly, so make sure to check them!

Your Claims for Part B (Medical Insurance)Your New MSN: Part B | Page 5


Part B Medical Insurance helps pay for doctors’ services, diagnostic tests, ambulance services, and other health care services.

Definitions of ColumnsService Approved?: This column tells you if Medicare covered this service.

Amount Provider Charged: This is your provider’s fee for this service.

Medicare-Approved Amount: This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged.

Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid: This is the amount Medicare paid your provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed: This is the total amount the provider is allowed to bill you, and can include a deductible, coinsurance, and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

Your Claims for Part B (Medical Insurance)

Service Provided & Billing CodeService

Approved?

Amount Provider Charged

Medicare- Approved

Amount

Amount Medicare

Paid


See Notes Below

Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits (92014)

Yes $143.00 $107.97 $86.38 $21.59

Destruction of skin growth (17000) NO 68.56 0.00 0.00 68.56 A

Total for Claim #02-10195-592-390 $211.56 $107.97 $86.38 $90.15 B

January 21, 2013Craig I. Secosan, M.D., (555) 555-1234 Looking Glass Eye Center PA, 1888 Medical Park Dr, Suite C, Brevard, NC 28712-4187


A This service was denied. The information provided does not support the need for this service or item.

B Your claim was sent to your Medicare Supplement Insurance (Medigap policy), Wellmark BlueCross BlueShield of N. Carolina. Send any questions regarding your benefits to them.

1 Type of ClaimClaims can either be assigned or unassigned.

2 DefinitionsDon’t know what some of the words on your MSN mean? Read the definitions to find out more.

3 Your VisitThis is the date you went to your doctor. Keep your bills and compare them to your notice to be sure you got all the services listed.

4 Service DescriptionsUser-friendly service descriptions will make it easier for you to know what you were treated for.

5 Approved ColumnThis column lets you know if your claim was approved or denied.

6 Max You May Be BilledThis is the total amount the provider is able to bill you. It’s highlighted and in bold for easy reading.

7 NotesRefer to the bottom of the page for explanations of the services you got.


Last Page – How to Handle Denied Claims



Get More Details

If a claim was denied, call or write the provider and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the provider to contact our claims office to correct the error. You can ask the provider for an itemized statement for any service or claim.




Call your provider: Ask your provider for any information that may help you.







July 13, 2013


Follow these steps:








4 Include any other information you have about your appeal. You can ask your provider for any information that will help you.





1 Get More DetailsFind out your options on what to do about denied claims.

2 If You Decide to AppealYou have 120 days to appeal your claims. The date listed in the box is when your appeal must be received by us.

3 If You Need HelpHelpful tips to guide you through filing an appeal.

4 Appeals FormYou must file an appeal in writing. Follow the step-by-step directions when filling out the form.

A. Notifier:

B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn’t pay for D. below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have

good reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

☐ OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

☐ OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

☐ OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on

this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566

★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★

CENTERS FOR MEDICARE & MEDICAID SERVICES

This official governmentbooklet explains the following:

★★ What durable medical equipment is

★★ Which durable medical equipment,prosthetic, and orthotic items are covered in Original Medicare

★★ Where to get help with your questions

Medicare Coverage of Durable MedicalEquipment andOther Devices

1

Do you need durable medical equipment orother types of medical equipment? Medicare can help.This booklet explains Medicare coverage for durable medicalequipment, prosthetic devices, orthotic items, prostheses andtherapeutic shoes in Original Medicare (sometimes calledfee-for-service) and what you might need to pay. Durablemedical equipment includes things like the following:

• Home oxygen equipment

• Hospital beds

• Walkers

• Wheelchairs

This booklet also explains coverage for prosthetic equipment(like cardiac pacemakers, enteral nutrition pumps, andprosthetic lenses), orthotic items (like leg, neck, and backbraces) and prostheses (like artificial legs, arms, and eyes). It’simportant for you to know what Medicare covers and what youmay need to pay. Talk to your doctor if you think you needsome type of durable medical equipment.

If you have questions about the cost of durable medicalequipment or coverage after reading this booklet, call1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.

Note: The information in this booklet was correct when it wasprinted. Changes may occur after printing. For the most up-to-dateinformation, visit www.medicare.gov on the web, or call1-800-MEDICARE (1-800-633-4227). A customer servicerepresentative can tell you if the information has been updated.TTY users should call 1-877-486-2048.

http://www.medicare.gov

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Table of Contents What is durable medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Does Medicare cover durable medical equipment? . . . . . . . . . . . . . . . . 3

When does Original Medicare cover durable medical equipment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

What if I need durable medical equipment and I am in a Medicare Advantage Plan? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3–4

If I have Original Medicare, how do I get the durable medical equipment I need? . . . . . . . . . . . . . . . . . . . . . . 4–5

Power wheelchairs and scooters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What is covered, and how much does it cost? . . . . . . . . . . . . . . . . . . 6–7

What is “assignment” in Original Medicare, and whyis it important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

How will I know if I can buy durable medical equipment or whether Medicare will only pay for me to rent it? . . . . . . . . . . . 8–9

New Rules for How Medicare Pays Suppliers for Oxygen Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10–11

Words to know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–13 (Definitions of red words in text)

“Medicare Coverage of Durable Medical Equipment and Other Devices” isn’t a legaldocument. Official Medicare Program legal guidance is contained in the relevantstatutes, regulations, and rulings.

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What is durable medical equipment? Durable medical equipment is reusable medical equipment suchas walkers, wheelchairs, or hospital beds.

Does Medicare cover durable medicalequipment? Anyone who has Medicare Part B can get durable medicalequipment as long as the equipment is medically necessary.

When does Original Medicare cover durablemedical equipment? If you have Part B, Original Medicare covers durable medicalequipment when your doctor or treating practitioner (such as anurse practitioner, physician assistant, or clinical nurse specialist)prescribes it for you to use in your home. A hospital or nursinghome that is providing you with Medicare-covered care can’tqualify as your “home” in this situation. However, a long-termcare facility can qualify as your home.

Note: If you are in a skilled nursing facility and the facilityprovides you with durable medical equipment, the facility isresponsible for this equipment.

What if I need durable medical equipment andI am in a Medicare Advantage Plan? Medicare Advantage Plans (like an HMO or PPO) must coverthe same items and services as Original Medicare. Your costs willdepend on which plan you choose, and may be lower thanOriginal Medicare. If you are in a Medicare Advantage Plan andyou need durable medical equipment, call your plan to find outif the equipment is covered and how much you will have to pay. Words in red

are definedon pages12–13.

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What if I need durable medical equipment and I am in aMedicare Advantage Plan? (continued) If you are getting home care or using medical equipment and youchoose to join a new Medicare Advantage Plan, you should call the newplan as soon as possible and ask for Utilization Management. They cantell if your equipment is covered and how much it will cost. If youreturn to Original Medicare, you should tell your supplier to billMedicare directly after the date your coverage in the MedicareAdvantage Plan ends.

Note: If your plan leaves the Medicare Program and you are usingmedical equipment such as oxygen or a wheelchair, call the telephonenumber on your Medicare Advantage Plan card. Ask for UtilizationManagement. They will tell you how you can get care under OriginalMedicare or under a new Medicare Advantage Plan.

If I have Original Medicare, how do I get thedurable medical equipment I need? If you need durable medical equipment in your home, your doctor ortreating practitioner (such as a nurse practitioner, physician assistant,or clinical nurse specialist) must prescribe the type of equipment youneed. For some equipment, Medicare also requires your doctor or oneof the doctor’s office staff to fill out a special form and send it toMedicare to get approval for the equipment. This is called aCertificate of Medical Necessity. Your supplier will work with yourdoctor to see that all required information is submitted to Medicare.If your prescription and/or condition changes, your doctor mustcomplete and submit a new, updated certificate.

The chart on page 6 shows which items require a Certificate ofMedical Necessity.

Words in redare definedon pages12–13.

If I have Original Medicare, how do I get the durable medicalequipment I need? (continued) Medicare only covers durable medical equipment if you get itfrom a supplier enrolled in the Medicare Program. This meansthat the supplier has been approved by Medicare and has aMedicare supplier number.

To find a supplier that is enrolled in the Medicare Program, visitwww.medicare.gov and select “Find Suppliers of MedicalEquipment in Your Area.” You can also call 1-800-MEDICARE(1-800-633-4227) to get this information. TTY users should call1-877-486-2048.

A supplier enrolled in the Medicare Program must meet strictstandards to qualify for a Medicare supplier number. If yoursupplier doesn’t have a supplier number, Medicare won’t payyour claim, even if your supplier is a large chain or departmentstore that sells more than just durable medical equipment.

Power wheelchairs and scooters For Medicare to cover a power wheelchair or scooter, your doctormust state that you need it because of your medical condition.Medicare won’t cover a power wheelchair or scooter that is onlyneeded and used outside of the home.

Most suppliers who work with Medicare are honest. There are afew who aren’t honest. Medicare is working with othergovernment agencies to protect you and the Medicare Programfrom dishonest suppliers of power wheelchairs and scooters.

For more information about Medicare’s coverage of powerwheelchairs or scooters, view the publication “ProtectingMedicare’s Power Wheelchair and Scooter Benefit.” Visitwww.medicare.gov and select “Find a Medicare Publication.” Youcan also call 1-800-MEDICARE (1-800-633-4227). TTY usersshould call 1-877-486-2048.

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http://www.medicare.govhttp://www.medicare.gov

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What is covered, and how much does it cost? The chart below and on page 7 shows some of the items Medicare covers and how muchyou have to pay for these items. This list doesn’t include all covered durable medicalequipment. For questions about whether Medicare covers a particular item, call1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If youhave a Medigap policy, it may help cover some of the costs listed below and on page 7.

Durable Medical Equipment

What Medicare Covers

• Air fluidized beds

• Blood glucose monitors

• Bone growth (or osteogenesis) stimulators*

• Canes (except white canes for the blind)

• Commode chairs

• Crutches

• Home oxygen equipment and supplies*

• Hospital beds

• Infusion pumps and some medicines used in them

• Lymphedema pumps/pneumatic compressiondevices*

• Nebulizers and some medicines used in them (if reasonable and necessary)

• Patient lifts*

• Scooters

• Suction pumps

• Traction equipment

• Transcutaneous electronic nerve stimulators (TENS)*

• Ventilators or respiratory assist devices

• Walkers

• Wheelchairs (manual and power)

What You Pay

Generally, you pay 20% of theMedicare-approved amount afteryou pay your Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. The Medicare-approvedamount is the lower of the actualcharge for the item or the feeMedicare sets for the item.However, the amount you paymay vary because Medicare paysfor different kinds of durablemedical equipment in differentways. You may be able to rent orbuy the equipment.

* You must get a Certificate of Medical Necessity before you can get this equipment. See page 4.

Prosthetic and Orthotic Items

What Medicare Covers

• Arm, leg, back, and neck braces • Artificial limbs and eyes • Breast prostheses (including a surgical brassiere) after

a mastectomy • Ostomy supplies for people who have had a

colostomy, ileostomy, or urinary ostomy. Medicarecovers the amount of supplies your doctor says youneed based on your condition.

• Prosthetic devices needed to replace an internal bodypart or function

• Therapeutic shoes or inserts for people with diabeteswho have severe diabetic foot disease The doctor who treats your diabetes must certifyyour need for therapeutic shoes or inserts. Apodiatrist or other qualified doctor must prescribethe shoes and inserts. A doctor or other qualifiedindividual like a pedorthist, orthotist, or prosthetistmust fit and provide the shoes. Medicare helps payfor one pair of therapeutic shoes and inserts percalendar year. Shoe modifications may besubstituted for inserts.

What You Pay

You pay 20% of theMedicare-approved amount afteryou pay your Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. These amounts may bedifferent if the supplier doesn’taccept assignment. See page 8.

Corrective Lenses What Medicare Covers

• Prosthetic Lenses —Cataract glasses —Conventional glasses and contact lenses after

surgery with an intraocular lens —Intraocular lenses An ophthalmologist or an optometrist mustprescribe these items. Important: Only standard frames are covered.Eyeglasses and cataract lenses are covered even ifyou had the surgery before you had Medicare.Payment may be made for lenses for both eyes evenif cataract surgery involved only one eye.

What You Pay

You are covered for one pair ofeyeglasses or contact lenses aftereach cataract surgery with anintraocular lens. You pay 20% ofthe Medicare-approved amountafter you pay the Medicare Part Bdeductible for the year ($135 in2009). Medicare pays the other80%. Costs may be different ifthe supplier doesn’t acceptassignment. See page 8. If youwant to upgrade the frames, youpay any additional cost.

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What is covered, and how much does it cost? (continued)

8

What is “assignment” in Original Medicare and whyis it important? Assignment is an agreement between you (the person with Medicare),Medicare, and doctors or other health care providers, and suppliers of healthcare equipment and supplies (like durable medical equipment and prostheticor orthotic devices). Doctors, providers, and suppliers who agree to acceptassignment accept the Medicare-approved amount as full payment. After youhave paid the Part B deductible ($135 in 2009), you pay the doctor orsupplier the coinsurance (usually 20% of the approved amount). Medicarepays the other 80%.

Suppliers who agree to accept assignment on all claims for durable medicalequipment and other devices are called “participating suppliers.” If a durablemedical equipment supplier doesn’t accept assignment, there is no limit towhat they can charge you. In addition, you may have to pay the entire bill(Medicare’s share as well as your coinsurance and any deductible) at the timeyou get the durable medical equipment. The supplier will send the bill toMedicare for you, but you will have to wait for Medicare to reimburse youlater for its share of the charge.

Important Note: Before you get durable medical equipment, ask if thesupplier is enrolled in Medicare. If the supplier is not enrolled in Medicare,Medicare won’t pay your claim at all. Then, ask if the supplier is aparticipating supplier in the Medicare Program. A participating supplier mustaccept assignment. A supplier that is enrolled in Medicare, but isn’t“participating,” has the option whether to accept assignment. You will have toask if the supplier will accept assignment for your claim.

To find suppliers who accept assignment, visit www.medicare.gov and select“Find Suppliers of Medical Equipment in Your Area.” You can also call1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.

How will I know if I can buy durable medicalequipment or whether Medicare will only pay forme to rent it? If your supplier is a Medicare-enrolled supplier, they will know whetherMedicare allows you to buy a particular kind of durable medical equipment,or just pays for you to rent it. Medicare pays for most durable medicalequipment on a rental basis. Medicare only purchases inexpensive orroutinely purchased items, such as canes; power wheelchairs; and, in rarecases, items that must be made specifically for you.

Words in redare definedon pages12–13.

http://www.medicare.gov

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How will I know if I can buy durable medical equipment orwhether Medicare will only pay for me to rent it?(continued) Buying equipment If you own Medicare-covered durable medical equipment andother devices, Medicare may also cover repairs and replacementparts. Medicare will pay 80% of the Medicare-approved amountfor purchase of the item. Medicare will also pay 80% of theMedicare-approved amount (up to the cost of replacing the item)for repairs. You pay the other 20%. Your costs may be higher if thesupplier doesn’t accept assignment.

Note: The equipment you buy may be replaced if it’s lost,stolen, damaged beyond repair, or used for more than thereasonable useful lifetime of the equipment.

Renting equipment If you rent durable medical equipment and other devices,Medicare makes monthly payments for use of the equipment. Therules for how long monthly payments continue vary based on thetype of equipment. Total rental payments for inexpensive orroutinely purchased items are limited to the fee Medicare sets topurchase the item. If you will need these items for more than afew months, you may decide to purchase these items rather thanrent them. Monthly payments for frequently serviced items, suchas ventilators, are made as long as the equipment is medicallynecessary. The payment rules for other types of rented equipment,called “capped rental items,” are on page 10. Medicare will pay80% of the Medicare-approved amount each month for use ofthese items. You pay the other 20% after you pay the MedicarePart B deductible ($135 in 2009).

The supplier will pick up the equipment when you no longerneed it. Any costs for repairs or replacement parts for the rentedequipment are the supplier’s responsibility. The supplier will alsopick up the rented equipment if it needs repairs. You don’t haveto bring the rented equipment back to the supplier.

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New Rules for How Medicare Pays Suppliers for OxygenEquipment Changes in law require Medicare to change the way it pays suppliers for oxygenequipment and supplies. You will still be able to get your oxygen equipment.However, you should know about the new rules that start January 1, 2009.Previously, the law stated that you would own the oxygen equipment after yourented it for 36 months. Under the new law, the rental payments will end after 36months, but the supplier continues to own the equipment. The new law thenrequires your supplier to provide the oxygen equipment and related supplies for 2additional years (5 years total), as long as oxygen is still medically necessary.

How does Medicare pay for oxygen equipment and related suppliesand what do I pay?The monthly rental payments to the supplier cover not only your oxygenequipment, but also any supplies and accessories such as tubing or a mouthpiece,oxygen contents, maintenance, servicing and repairs. Medicare pays 80% of therental amount, and the person with Medicare is responsible for any unpaid Part Bdeductible, and the remaining 20% of the rental amount.

What happens with my oxygen equipment and related services afterthe 36 months of rental payments?Your supplier has been paid over 36 months for furnishing your oxygen andoxygen equipment for up to 5 years, and your supplier is required to continue tomaintain the oxygen equipment (in good working order) and furnish theequipment and any necessary supplies and accessories, as long as you need it untilthe 5 year period ends. The supplier can’t charge you for performing these services.If you use oxygen tanks or cylinders that need delivery of gaseous or liquid oxygencontents, Medicare will continue to pay each month for the delivery of contentsafter the 36-month rental period. The supplier that delivers this equipment to youin the last month of the 36-month rental period must provide these items, as longas you medically need it, up to 5 years.

Will Medicare pay for any maintenance and servicing after the 36-month period ends?If you use an oxygen concentrator or transfilling equipment (a machine that fillsyour portable tanks in your home), for 2009 only, Medicare will pay for routinemaintenance and servicing visits every 6 months starting 6 months after the end ofthe 36-month rental period.

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New Rules for How Medicare Pays Suppliers for OxygenEquipment (continued)

What happens to my oxygen equipment after 5 years?At the end of the 5-year period, your supplier’s obligation to continuefurnishing your oxygen and oxygen equipment ends, and you may elect toobtain replacement equipment from any supplier. A new 36-month paymentperiod and 5-year supplier obligation period start once the old 5-year periodends and the new oxygen and oxygen equipment you require is furnished.

What if I’m away from home for an extended period of time or Imove to another area during the 36-month period?If you travel away from home for an extended period of time (several weeks ormonths) or permanently move to another area during the 36-month rentalperiod, ask your current supplier if they can help you find a supplier in thenew area. If your supplier can’t help you locate an oxygen supplier in the areawhere you are visiting or moving to, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What if I’m away from home for an extended period of time or Imove to another area after the 36-month period? If you travel or move after the 36-month rental period ends, your supplier hasbeen paid for furnishing your equipment for 5 years and is generallyresponsible for ensuring that you are provided with oxygen and oxygenequipment in the new area. Your supplier may choose to make arrangementsfor a different supplier in your new area to provide the oxygen and oxygenequipment. However, a supplier may not charge you for the equipment,supplies, accessories or other services identified above that are provided afterthe 36-month rental payment period. The only exceptions to this rule arenoted above.

What if my supplier refuses to continue providing my oxygenequipment and related services as required by law?If your supplier is not following Medicare laws and rules, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. A customer service representative will refer your case to the appropriate area.

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Words to know

Assignment—An agreement between a person with Medicare, adoctor or supplier, and Medicare. Doctors or suppliers who acceptassignment from Medicare agree to accept the Medicare-approvedamount as full payment.

Capped rental item—Durable medical equipment (like oxygen,nebulizers, and manual wheelchairs) that costs more than $150,and is rented to people with Medicare more than 25% of the time.

Certificate of Medical Necessity—A form required by Medicarethat your physician must complete to get Medicare coverage forcertain medical equipment.

Coinsurance—An amount you may be required to pay for servicesafter you pay any plan deductibles. In Original Medicare, this is apercentage (like 20%) of the Medicare-approved amount. You haveto pay this amount after you pay the Part A and/or Part Bdeductible.

Deductible—The amount you must pay for health care orprescriptions, before Original Medicare or other insurance begins topay. For example, in Original Medicare, you pay a new deductiblefor each benefit period for Part A, and each year for Part B. Theseamounts can change every year.

Durable Medical Equipment—Medical equipment that is orderedby a doctor (or, if Medicare allows, a nurse practitioner, physicianassistant, or clinical nurse specialist) for use in the home. A hospitalor nursing home that mostly provides skilled care can’t qualify as a“home” in this situation. These medical items must be reusable,such as walkers, wheelchairs, or hospital beds.

Medically Necessary—Services or supplies that are needed for thediagnosis or treatment of your medical condition.

Medicare Advantage Plan (Part C)—A type of Medicare planoffered by a private company that contracts with Medicare toprovide you with all your Medicare Part A and Part B benefits. Alsocalled Part C, Medicare Advantage Plans are HMOs, PPOs, PrivateFee-for-Service Plans, or Medicare Medical Savings Account Plans.If you are enrolled in a Medicare Advantage Plan, Medicare servicesare covered through the plan, and are not paid for under OriginalMedicare.

Medicare-Approved Amount—In Original Medicare, this is theamount a doctor or supplier that accepts assignment can be paid.It includes what Medicare pays and any deductible, coinsurance,or copayment that you pay. It may be less than the amount adoctor or supplier charges for the item.

Medigap Policy—Medicare Supplement Insurance sold byprivate insurance companies to fill “gaps” in Original Medicarecoverage. Except in Massachusetts, Minnesota, and Wisconsin, allMedigap policies must be one of 12 standardized Medigappolicies labeled Medigap Plan A through Plan L. Medigappolicies only work with Original Medicare.

Nebulizers—Equipment that delivers medicine in a mist form toyour lungs.

Original Medicare—Original Medicare has two parts: Part A(Hospital Insurance) and Part B (Medical Insurance). It is afee-for-service health plan. After you pay a deductible, Medicarepays its share of the Medicare-approved amount, and you payyour share (coinsurance and deductibles).

Orthotics—Devices that correct or support the function of bodyparts. Examples include leg, arm, and neck braces.

Patient Lifts—Equipment designed to move a patient from abed or wheelchair.

Prostheses—Devices that substitute for a missing body part.Examples include artificial legs, arms, and eyes.

Prosthetic Devices—Medical equipment (other than dental)that replaces all or part of an internal body organ.

Words to know

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850

Official Business Penalty for Private Use, $300

CMS Publication No. 11045 Revised December 2008

To get this publication in Spanish, call1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048.

Para obtener este folleto en español,llame GRATIS al 1-800-MEDICARE(1-800-633-4227). Los usuarios de TTYdeben llamar al 1-877-486-2048.

Medicare’s Wheelchair and Scooter BenefitIf your doctor submits a written order stating that you have a medical need for awheelchair or scooter for use in your home, Medicare will help cover any of thetypes listed below. Generally, Medicare will pay 80% of the Medicare-approvedamount, after you have met the Part B deductible. You pay 20% of the Medicare-approved amount.

Wheelchairs (both manual and power) and scooters are also known as “mobilityassistive equipment.”

Medicare will help cover your wheelchair and scooter, if you meet all of the following conditions:

• You have a health condition that causes difficulty moving around in your home.

• You’re unable to do activities of daily living (like bathing, dressing, getting in orout of a bed or chair, or using the bathroom) even with the help of a cane, crutch,or walker.

• You’re able to safely operate, and get on and off the wheelchair or scooter, or havesomeone with you who is always available to help you safely use the device.

Also, the equipment must be usable within your home (for example, it’s not too bigfor your home or blocked by things in its path).

Types of Mobility Assistive Equipment:

Manual WheelchairIf you can’t use a cane or walker safely, you may qualify for a manual wheelchair. The manual wheelchair you choose can’t be a high strength, ultra-lightweight wheelchair that you could buy without renting first.

Rolling Chair/Geri-chairIf you need more support than a wheelchair can give, you may qualify for a rollingchair. These chairs have small wheels that are at least 5 inches in diameter. Therolling chair must be designed to meet your medical needs due to illness or otherimpairment.

★★

★★

★★

CENTERS FOR MEDICARE & MEDICAID SERVICES

Power-Operated Vehicle/ScooterIf you can’t use a cane or walker, or can’t operate a manual wheelchair, you may qualify for a power-operated scooter.

Power WheelchairIf you can’t use a manual wheelchair in your home, or if you don’t qualify for apower-operated scooter because you aren’t strong enough to sit up or to work thescooter controls safely, you may qualify for a power wheelchair.

Before you get either a power wheelchair or scooter, you must have a face-to-faceexam by your doctor. The doctor will review your needs and help you decide ifyou can safely operate the device. If so, the doctor will submit a written ordertelling Medicare why you need the device and that you’re able to operate it.

Remember, you must have a medical need for Medicare to cover a power wheelchairor scooter. Medicare won’t cover this equipment if it will be used mainly for leisure orrecreational activities, or if it’s only needed to move around outside your home.

Also, in some areas, you may need to get your power wheelchair or scooter from specific suppliers approved by Medicare. Visit www.medicare.gov/supplier or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call1-877-486-2048.

Note: If you don’t need a power wheelchair or scooter on a long-term basis, you maywant to rent the equipment to lower your costs. Talk to your supplier to find outmore about this option. Some wheelchairs must be rented first, even if you eventuallyplan to buy them.

FraudMost doctors, health care providers, suppliers, and private companies who work withMedicare are honest. However, there are a few who aren’t. For example, some suppliers of medical equipment try to cheat Medicare by offering expensive powerwheelchairs and scooters to people who don’t qualify for these items. Also, some suppliers of medical equipment may call you without your permission, even though“cold calling” isn’t allowed. Medicare is trying harder than ever to find and preventfraud and abuse by working more closely with health care providers, strengtheningoversight, and reviewing claims data.

★★

http://www.medicare.gov/supplier

★★

How to Spot Fraud and AbuseYou can help Medicare stop fraud and abuse by watching for the following examplesof possible Medicare fraud:

• Suppliers offer you a free wheelchair or scooter.

• Suppliers offer to waive your copayment.

• Someone bills Medicare for equipment you never got.

• Someone bills Medicare for home medical equipment after it has been returned.

What to Do if You Suspect Fraud and AbuseIf you suspect billing fraud, contact your health care provider to be sure the bill iscorrect. If your doctor, health care provider, or supplier doesn’t help you with yourquestions or concerns or if you can’t contact them, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For More InformationMedicare is here for you 24 hours a day, every day. To get more information, visitwww.medicare.gov or call 1-800-MEDICARE. For more information aboutMedicare’s fraud and abuse activities, visit www.stopmedicarefraud.gov.

CMS Product No. 11046Revised January 2011

http://www.medicare.govhttp://www.stopmedicarefraud.gov

Comparison of the Parts A, B, C, and D Appeal Processes

1Starting in 2005, the AIC requirement for an ALJ hearing and Federal District Court will be adjusted in accordance with the medical care component of the consumer price index.

AIC = Amount in controversy ALJ = Administrative Law Judge Contractor = Fiscal Intermediary, Carrier or Medicare Administrative Contractor (MAC) IRE = Independent Review Entity

MA-PD = Medicare Advantage-Prescription Drug MMA = Medicare Prescription Drug, Improvement & Modernization Act of 2003 PDP = Prescription Drug Plan QIC = Qualified Independent Contractor

Initial Decision

SecondLevel ofAppeal

ThirdLevel ofAppeal

FourthLevel ofAppeal

Final Appeal

Level

FirstLevel ofAppeal

ContractorDetermination

Contractor Redetermination60 day time limit

120 days to file

60 days to file

60 days to fileMAC may decline review

60 days to file

Quality ImprovementOrganization

Redetermination72 hour time limit

Standard ProcessPart A and B

Expedited Process(Some Part A only)

Notice of Dischargeor Service Termination

Qualified IndependentContractor

Reconsideration60 day time limit

Qualified IndependentContractor

Reconsideration72 hour time limit

180 days to file

Noon the next calendar day

Noon the next calendar day

Office of Medicare Hearings and Appeals

AIC=> $12090 day limit

Medicare Appeals Council90 day time limit

for processing

Federal District CourtAIC=> $1,220

Parts A & B (Fee-for Service) Process

60 days to file

60 days to fileMAC may decline review

60 days to file

OrganizationDetermination

Part C (MA) Process

MA Org. ReconsiderationPre Service: 30 day time limitPayment: 60 day time limit

60 days to file

IRE ReconsiderationPre Service: 30 day limitPayment: 60 day limit

Automatic IRE review if MA

Org. upholds denial

MA Org. Reconsideration72 hour time limit

Pre Service: 14 day time limit

Payment: 60 day time limit

IRE Reconsideration 72 hour time limit

Expedited ProcessStandard Process

72 hour time limit

Office of MedicareHearings and Appeals

AIC=> $120No statutory time limit for processing

Medicare Appeals CouncilNo statutory time limit

for processing


Part D (Drug) Process

IRE Reconsideration 72 hour time limit

60 days to file

CoverageDetermination

60 days to file

72 hour time limit 24 hour time limit

MA-PD/PDPRedetermination7 day time limit

60 days to fileMA-PD/PDP

Redetermination72 hour time limit

IRE Reconsideration7 day time limit

60 days to file

60 days to file

Medicare Appeals CouncilNo statutory time limit

for processing


Office of MedicareHearings and Appeals

AIC=> $120No statutory time limit for processing

Expedited ProcessStandard Process

MASSACHUSETTS SENIOR LEGAL

HELPLINE 1-866-778-0939

The Helpline provides FREE legal information, advice and referral services for Massachusetts senior citizens (60 years or older) in most areas of civil law, including: Social Security/SSI Veterans Benefits Mass Health Medicare Consumer issues Public Benefits Unemployment Foreclosures

Guardianship Powers of Attorney Bankruptcy Evictions Landlord/Tenant Utilities Family law Nursing Home

We provide interpretation services in many languages.

If you get our voicemail, please leave your name, telephone number and the town where you reside and we will return your call within 2 business days. The Massachusetts Senior Legal Helpline is a project made in collaboration with the Massachusetts Office of Elders Affairs, the Legal Advocacy & Resource Center, the Massachusetts Justice Project and the Massachusetts legal services providers. This project is made possible with a grant from the U.S. Department of Health and Human Services, Administration on Aging.

Day 5 – 2014 1

Case Study — Mr. Felix DeKatt Felix has diabetes and has been seeing a podiatrist for the past three months for foot care. Recently Felix changed doctors and was asked to pay $75 for the office visit. Felix was sure that Medicare paid for these services since he had never received a bill from his previous podiatrist. When Felix questioned the billing clerk in the doctor’s office, he was told that Medicare does not cover routine foot care. How would you help him?

Day 5 – 2014 2

Case Study — Mr. Cal Asthenik

Cal was having a hard time walking. He received a call from a company that sells wheelchairs. He ordered a wheelchair after the salesperson assured him that Medicare would reimburse him for the expense. He was surprised to find that Medicare would not pay for it. What would you tell him about the procedure for getting a wheelchair under Medicare? How would you help him with this situation?

Day 5 – 2014 3

Case Study — Fran Tikk

Fran comes to see you at the SHINE office. She is 71 years old and on a federal employee group retiree plan with Blue Cross/Blue Shield (BCBS) for which she is paying a premium of over $150/month. She has had numerous health problems in the past few years, and her plan does not provide full coverage. When Fran turned 65 in 2005, she called Social Security to see about enrolling in Medicare. She was told that she was not eligible for Medicare because she had not worked under Social Security. In 2007 a rep at her federal BCBS plan told her she would be eligible for Medicare under her ex-spouse who had worked under Social Security. (They had been married for more than 10 years.) Fran then went to her local SS office to inquire. The SS worker confirmed that she indeed was eligible under her former spouse but would now face a penalty for not signing up back in 2005. Fran refused Medicare at that point because she could not afford it with the penalty. (Fran’s gross income is under $1000/month, and over the past few years she has spent down her savings on medical bills.) Fran was recently told by member services at her federal BCBS plan that if she could get Medicare A&B, her BCBS would act as a supplement providing full coverage at a lower cost. She could then drop down to a plan that would cost far less than what she is currently paying.

Day 5 – 2014 4

Claims Processing, Appeals, Fraud & Abuse Quiz

1. While driving to work Josephine has a minor traffic accident. As a precaution Josephine was transported to the hospital in an ambulance and was examined by a physician in the emergency room. Josephine gave the emergency room clerk her Medicare and Medigap insurance information. Several weeks later Josephine received a denial from Medicare for the services. Who pays first?

□ Insurance □ Health Plan □ Medicare □ Employer Health Plan

2. Harriet has been in the hospital for 4 days recovering from gall bladder surgery. The hospital staff has informed her that she is being discharged the following day. Harriet does not feel strong enough to return home and wants to appeal this discharge. To whom should she direct her appeal?

□ Medicare Advocacy Project □ Medicare Part B □ Mass PRO □ Surgeon General

3. What are the guidelines for an Expedited Appeal? 4. Mary Jones bas been receiving home health services for the past 6 weeks. She calls you because the home health agency informed her today that she will be discharged from receiving these services next week. Mary feels she still needs physical therapy. How would you help her?

Day 5 – 2014 5

Case Study — Jack R. Abbot Mr Abbot is retired and having problems with his insurance covering his medical bills. He keeps getting denial notices for many of the services he receives. He wants to meet with you to get some help with resolving the situation. What information would you ask Mr. Abbot to bring to your meeting? How would you help him?

Day 5 – 2014 6

Case Study — Mr. Perry Scope Mr. Scope fell and broke his hip. Since his discharge from the hospital he has been receiving physical therapy services in his home. He was told by his physical therapist, however, that the therapy will end next week. Mr. Scope thinks that he needs more therapy. How would you help him?

Day 5 – 2014 7

Case Study — Barbie Que

Barbie calls you at the SHINE office. She tells you she has been covered under Blue Cross/Blue Shield’s Medex Gold plan because she takes a lot of medications. She is very satisfied with the Gold plan but is finding it difficult to pay the premium on top of the expenses she has maintaining her home. Barbie looked into the program through Social Security that helps pay for prescription costs, but tells you her monthly income of $1,725 and assets of $40,000 make her ineligible. How would you help her?

Day 5 – 2014 8

Case Study — Al Falfa

Al meets with you at the SHINE office. He will be 65 next month and is retiring. He has just returned from Social Security and will receive Medicare A and B. His neighbor has a Medigap Supplement 1 plan, so he also signed up effective on the first of next month when his Medicare begins. He

claims/appeals/fraud topics to highlight handouts/case ...case study – barbie que (gap downgrade)...

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