Medicare Advantage Claim Processing Requirements
Section 1833 of the Social Security Act prohibits payments to any care provider unless there is sufficient information to determine the “amounts due such provider.” We apply various claims processing edits based on:
- National and Local Coverage Determinations
- The Medicare Claims Processing Guide
- National Correct Coding Initiative (NCCI)
- Other applicable guidance from CMS, including but not limited the Official ICD-10-CM Guidelines for Coding and Reporting
These edits provide us with information to determine:
- The correct amount to pay
- If you are authorized to perform the service
- If you are eligible to receive payment
- If the service is covered, correctly coded, and correctly billed to be eligible for reimbursement
- If the service is provided to an eligible beneficiary, and
- If the service was provided in accordance with CMS guidance
Care providers in our MA network must follow CMS guidance regarding billing, coding, claims submission, and reimbursement. For example, you must report Serious Adverse Events by having the Present on Admission (POA) indicator on all acute care inpatient hospital claims and ambulatory surgery center outpatient claims.
If you do not report the “Never Event”, we try to determine if any charges filed with us meet the criteria as a Serious Reportable Adverse Event. If you do not follow these requirements, we will deny the claim. You cannot bill the member.
There may be situations when we implement edits and CMS has not issued any specific coding rules. In these cases, we review the available rules in the Medicare Coverage Center. We find those coding edits that most align with the applicable coverage rules.
Due to CMS requirements, you are required to use the 837 version 5010 format. We reject incomplete submissions.
Hospice – Medicare Advantage
When a MA member elects hospice, bill claims for
- Hospice related services to CMS
- Services covered under Medicare Part A and B (unrelated to the terminal illness) to the Medicare administrative contractor
We are not financially responsible for these claims. We may be financially responsible for any additional or optional supplemental benefits under the MA member’s benefit plan such as eyeglasses and hearing aids. Medicare does not cover additional and optional supplemental benefits.
Medicare Crossover is the process by which Medicare, as the primary payer, automatically forwards Medicare Part A (hospital) and Part B (medical) claims to a secondary payer. Medicare Crossover is a standard offering for most Medicare-eligible members covered under our commercial benefit plans. Enrollment is automatic for these members.