Section 1833 of the Social Security Act prohibits payments to any care provider unless there is sufficient information to determine the “amounts due to such provider.” We apply various claims processing edits based on:
These edits provide us with information to determine:
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.
When an MA member elects hospice, bill claims for:
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.