what to highlight and handouts listcase study – barbie que (gap downgrade) case study – al falfa...

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)

□ 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

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

Initial Decision

SecondLevel ofAppeal

ThirdLevel ofAppeal

FourthLevel ofAppeal

Final Appeal

Level

FirstLevel ofAppeal

Fiscal Intermediary (FI),Carrier, or Medicare

Administrative Contractor(MAC) Determination

FI, Carrier, or MedicareAdministrative Contractor

Redetermination60 day time limit

120 days to file

60 days to file

60 days to file

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 => $140B

90 day limit

Medicare Appeals Council90 day time limit

for processing

Federal District CourtAIC => $1,400B

Parts A & B (Fee-for-Service) Process

InitialDecision

60 days to file

60 days to file

60 days to file

OrganizationDetermination

Part C (MA) Process

Health Plan 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 planupholds denial

Health Plan Reconsideration72 hour time limitPayment requests

cannot be expedited

Pre-Service: 14 day time limit

Payment: 60 day time limitA

IRE Reconsideration 72 hour time limitPayment requests

cannot be expedited

Expedited ProcessStandard Process

Pre-Service: 72 hour time limit

Payment requestscannot be expedited

Office of MedicareHearings and AppealsALJ Hearing Decision

AIC => $140B No statutory time limit for processing

Medicare Appeals CouncilNo statutory time limit

for processing


Part D (Drug) Process

Part D IREReconsideration

72 hour time limit

60 days to file

60 days to file

60 days to file

CoverageDetermination

60 days to file

72 hour time limitC 24 hour time limitC

MA-PD/PDPRedetermination

7 day time limit

60 days to file

MA-PD/PDPRedetermination

72 hour time limit

Part D IRE Reconsideration

7 day time limit

Medicare Appeals CouncilExpedited Decision

10 day time limit

Office of Medicare Hearing and AppealsALJ Hearing Decision

AIC => $140B

90 day time limit

Office of Medicare Hearing and Appeals

ALJ Hearing Decision AIC => $140B

10 day time limit

Medicare Appeals Council

90 day time limit


Expedited ProcessStandard Process

AIC = Amount in Controversy MA-PD = Medicare Advantage Prescription Drug A Plans must process 95% of all clean claims from out-of-network providers within 30 days. All other claims must be processed within 60 days. ALJ = Administrative Law Judge MMA = Medicare Prescription Drug, B The AIC requirement for all ALJ hearing and Federal District Court is adjusted annually in accordance with the medical care component of the Consumer Price Index. The chart reflects Contractor = Fiscal Intermediary, Carrier or Improvement & Modernization Act of 2003 the CY 2013 AIC amounts. Medicare Administrative Contractor (MAC) PDP = Prescription Drug Plan

C A request for a coverage determination includes a request for a tiering exception or a formulary exception. A request for a coverage determination may be filed by the enrollee, the IRE = Independent Review Entity QIC = Qualified Independent Contractor enrollee’s appointed representative, or the enrollee’s physician. The adjudication time frames generally begin when the request is received by the plan sponsor. However, if the request involves as exception request, the adjudication time frame begins when the plan sponsor receives the physician’s supporting statement.

Comparison of the Parts A, B, C, and D Appeal Processes Revised March 2013

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 has three prescriptions: one is a brand, Advair, and the other two are generics. He has heard negative things about Part D, so he tells you he may just pay for his prescriptions out of pocket. His only income will be $11,900/year from Social Security, and he currently has $8000 in the bank. How would you help him?

Day 5 – 2014 9

Case Study - Jen Teal

Jen meets with you to talk about her prescription coverage. She joined a Part D plan last year but wants to find out if there is a better plan she can join this year. She takes a few expensive brands which she paid for in full during the donut hole at a cost of several hundred per month. A friend told her she should have signed up for the plan that covers brands during the donut hole, so she wants to know if that’s what she should do this year. She explains that although her only income is Social Security of $1,450 per month, she has assets that make her ineligible for benefit programs. She lives in her own home and wants to stay there for as long as she can afford to. Although her assets prevent her from getting any assistance, she uses her assets to help with her prescription costs and to maintain her home. How would you help her?

Handouts and What to Highlight Day 5.pdfSample Part A MSNSample Part B MSNABNDME and Medicare11046 Medicare's Wheelchair and scooter benefitAppealsProcessFlowchartMass Senior Legal Helpline flyerCase Studies - Day 5 2014

what to highlight and handouts listcase study – barbie que (gap downgrade) case study – al falfa...

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