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PRECISE EXPERIENCED SKILLED PROFESSIONALS





TERM FREQUENTLY ASKED QUESTIONS

Billing:

Q. As a group in a facility setting, do we have to hold the same managed care contracts as that facility?
A. This will depend on your contract with that facility. There are facilities that require the groups to hold the same contracts so the patients are participating with all entities within the facility. However, there are some facilities which allow the group to participate in the managed care contracts they feel are fair and reasonable to their providers.


Q. If a patient has Medicare coverage, is it always primary?
A. No, Medicare will not be primary if the individual or his/her spouse is still employed and covered under an employer group health plan.


Q. Explain CHIP Insurance?
A. CHIP, or Children's Health Insurance Program, is a plan designed for families who earn too much money to qualify for Medicaid but who cannot afford to buy private insurance for their children. To qualify, a child must be under age 19, a Texas resident and a U.S. citizen or legal permanent resident, and be living in a family with assets below established levels.


Q. If you are a Medicare provider why are you sending me a bill?
A. Medicare Part B has a yearly deductible and only pays at 80%, therefore if a patient does not have a secondary insurance to absorb these costs, a bill must be sent to the patient. Additionally, there are some services that are not covered by Medicare and would be the patient’s responsibility.


Q. Does each provider in a group need an NPI or does the group NPI cover all providers in that group?
A. Per the Final Rule (45 CFR Part 162) from the Department of Health and Human Services, each provider, including Mid Level Providers, will need their own NPI.


Q. When billing to Medicare Secondary what information will be needed from them on the electronic submission?
A. In the electronic submission Medicare Secondary requires the billed amount, the primary allowed amount, the OTAF (obligated to accept financially) amount, the primary payment, and the CAS segment code or a comment as to why a particular procedure code was denied by the primary.