Important Information About Your Appeal Rights For Medical Services
What if I need help understanding a denial? Contact us at 850-383-3311 or 1-877-247-6512 if you need assistance understanding this notice or our decision to deny you a service or coverage.
What if I dont agree with this decision? You have a right to appeal any decision not to provide or pay for an item or service . You may appeal this decision up to 180 days after the date on your notification.
How do I file an appeal? Submit your appeal in writing, explaining the subject of the appeal and the reason you believe your request should be approved. Send the written appeal to CHP Appeals, P. O. Box 15349, Tallahassee, FL 32317 or submit in person to Member Services at 1264 Metropolitan Blvd, 3rd floor, Tallahassee, FL 32312. You may securely fax the information to 850-383-3413. See also the Other resources to help you section of this form for assistance filing a request for an appeal.
Who may file an appeal? You, your treating provider or someone you name to act for you may file an appeal. If someone other than you or your treating provider files an appeal on your behalf, a signed Appointment of Representative form must be included with the appeal. You may obtain a copy of the form by calling Member Services at 850-383-3311 or 1-877-247-6512 or visiting our website at www.capitalhealth.com. The form is located here .
Other resources to help you: You may contact the Florida Department of Financial Services, Division of Consumer Services at 1-877-693-5236.
Supplementing Internal Recovery Programs
Most health plans prefer to audit paid claims data internally before assigning them to a third party recovery organization for a secondary review. The Rawlings Group has extensive experience building these types of supplemental recovery programs to ensure that our efforts complement, not conflict with, your internal efforts.
Medicare Cob Under A Non
An Employer Plan frequently will describe the procedures United will follow when it coordinates benefits with Medicare. The following discussion is a more detailed description of the three steps United takes to determine the benefit under many Employer Plans which have adopted the non-dup methodology to coordinate benefits with Medicare when Medicare is the Primary Plan.
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If You Enroll In A Medicare Supplement Plan
Primary: Original Medicare Parts A & B Secondary: Medicare Supplement plan
This is where we more commonly see Medicare beneficiaries have medical claims denied, because Medicare thinks its not the primary coverage. What you need to is call the Medicare Benefits Coordination & Recovery Center at 798-2627. Explain to the representative that your claims are being denied, because Medicare thinks another plan is primary . The representative will ask you a series of questions to get the information updated in their systems. About 1-2 weeks later, you can have your medical providers resubmit the claims and everything should be okay moving forward.
How Does Medicare Know If I Have Other Coverage
Medicare doesnt automatically know if you have other coverage. But your insurers must report to Medicare when theyre the primary payer on your medical claims.
In some situations, your healthcare provider, employer or insurer may ask questions about your current coverage and report that information to Medicare.3 You also may be asked about other coverage at the time of enrollment.
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How Medicare Works With Other Insurance
If you have
and other health insurance , each type of coverage is called a payer. When theres more than one payer, coordination of benefits rules decide who pays first. The primary payer pays what it owes on your bills first, and then sends the rest to the secondary payer to pay. In some rare cases, there may also be a third payer.
Medicare Cob When Medicare Does Not Pay The Provider
In some circumstances, Medicare does not make an actual payment to the members provider, either because a Medicare-eligible member is not enrolled in Medicare or the member visited a provider who does not accept, has opted-out of or for some other reason is not covered by the Medicare program. When a provider does not accept, has opted-out of or is not covered by the Medicare program, that means that the provider is not allowed to bill Medicare for the providers services and that the member may be responsible for paying the providers billed charge as agreed in a contract with the doctor that the member signs.
For example, if a providers billed charge is $200, the Medicare coverage percentage is 80%, and the Employer Plans coverage percentage is 100%, Uniteds methodology would result in a secondary benefit payment of $40 . By contrast, if the Medicare fee schedule were used to determine the Allowable Expense and it was $100 for that same procedure, then the Employer Plans secondary benefit payment would be $20 .4
*Includes Oxford. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Oxford HMO products are underwritten by Oxford Health Plans , Inc. and Oxford Health Plans , Inc.
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Before You Call The Medicare Phone Number
Before calling 1-800-MEDICARE, have your Medicare card ready in case the representative needs to know your Medicare number. If you are calling with a question about a claim or a bill, have the bill or the Explanation of Benefits handy for reference.
It can also be helpful to keep a pen and paper ready to write down any important information your Medicare representative may share, such as additional phone numbers, dollar amounts, dates and more.
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These materials contain Current Dental Terminology, is copyright by the American Dental Association. Â© 2012 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
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IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED âI DO NOT ACCEPTâ AND EXIT FROM THIS COMPUTER SCREEN. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, âYOUâ AND âYOURâ REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.
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CPT codes, descriptions and other data only are copyright 2012 American Medical Association . All Rights Reserved. Applicable FARS/DFARS Clauses Apply.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services . You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA Web site, .
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User License Agreement And Consent To Monitoring
End User Agreements for Providers
Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes.
Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. If you choose not to accept the agreement, you will return to the Noridian Medicare home page.
THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. BY CLICKING ABOVE ON THE LINK LABELED I Accept, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS.
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IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THESE AGREEMENTS CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, YOU AND YOUR REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.
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Medicare Coordination Of Benefits
Coordination of benefits determines who pays first for your health care costs. This comes into play if you have insurance plans in addition to Medicare. For example, your other health insurance, through an employer or other source, may have to pay for a portion of your care before Medicare kicks in.
Senior Financial Writer and Financial Wellness Facilitator
Terry Turner has more than 30 years of journalism experience, including covering benefits, spending and congressional action on federal programs such as Social Security and Medicare. He is a Certified Financial Wellness Facilitator through the National Wellness Institute and the Foundation for Financial Wellness and a member of the Association for Financial Counseling & Planning Education .
Matt Mauney is an award-winning journalist, editor, writer and content strategist with more than 15 years of professional experience working for nationally recognized newspapers and digital brands. He has contributed content for ChicagoTribune.com, LATimes.com, The Hill and the American Cancer Society, and he was part of the Orlando Sentinel digital staff that was named a Pulitzer Prize finalist in 2017.
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Jerrad Prouty is a licensed agent at Insuractive with a specialization in selling Medicare insurance. He is licensed to sell insurance in more than 15 states.
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Medicare Secondary Payer Contractor Fact Sheet
The Centers for Medicare & Medicaid Services has embarked on an important initiative to further expand its campaign against Medicare waste, fraud and abuse under the Medicare Integrity Program. CMS awarded the Medicare Secondary Payer contract to consolidate the activities that support the collection, management and reporting of other insurance coverage of Medicare beneficiaries.
- The MSP Contractor provides many benefits for employers, providers, suppliers, third party payers, attorneys, beneficiaries and federal and state insurance programs
- All Medicare Secondary Payer claims investigations are initiated and researched by the MSP Contractor. This is no longer the function of your Medicare contractor.
- Implementing this single-source development approach will greatly reduce the amount of duplicate MSP investigations. This will also offer a centralized, one-stop customer service approach for all MSP-related inquiries, including those seeking general MSP information but not those related to specific claims or recoveries that serve to protect the Medicare Trust Funds.
- The MSP Contractor provides customer service to all callers from any source, including, but not limited to, beneficiaries, attorneys and other beneficiary representatives, employers, insurers, providers and suppliers
Information GatheringProvider Requests and Questions Regarding Claims PaymentMedicare Secondary Payer Auxiliary Records in CMS’s DatabaseWhen Should I Contactthe MSP Contractor?
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Benefits Coordination & Recovery Center
BCRC Customer Service Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays, at toll-free lines: 1-855-798-2627 .
Medicare And Commercial Coordination Of Benefits
Rawlings provides comprehensive Medicare and Commercial COB claims review and recovery services. We focus on the most complex and difficult to identify investigations. We combine our state of the art technology platform and legal and industry expertise to deliver outstanding financial results to our clients. In addition, the updated Medicare and commercial primacy information we provide allows our clients to pay claims properly and save millions of dollars through future cost avoidance.
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Unitedhealthcare Senior Care Options Plan
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.
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Coba Trading Partner Contact Information
The Coordination of Benefits Agreement Program establishes a nationally standard contract between CMS and other health insurance organizations that defines the criteria for transmitting enrollee eligibility data and Medicare adjudicated claim data. CMS has provided a COBA Trading Partners customer service contact list as an avenue for providers to contact the trading partners. The COBA Trading Partners document in the Download section below provides a list of automatic crossover trading partners in production, their identification number, and customer contact name and number. For additional information, click the COBA Trading Partners link.
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Managed Care And Third Party Liability
The contract language between the State Medicaid agency and the Managed Care Organization dictates the terms and conditions under which the MCO assumes TPL responsibility. Generally, TPL administration and performance activities that are the responsibility of the MCO will be set by the state and should be accompanied by state oversight.
There are four basic approaches to carrying out TPL functions in a managed care environment.
Point And Click License For Use Of Current Dental Terminology
End User License Agreement
These materials contain Current Dental Terminology, Fourth Edition , copyright Â© 2002, 2004 American Dental Association . All rights reserved. CDT is a trademark of the ADA.
THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED “I ACCEPT”, YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.
IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED “I DO NOT ACCEPT” AND EXIT FROM THIS COMPUTER SCREEN.
IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, “YOU” AND “YOUR” REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.
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If You Enroll In A Medicare Advantage Plan
Primary: Medicare Advantage plan provides Part A, Part B, and potentially Part D benefits Secondary: N/A – just use Medicare Advantage plan, NOT your Medicare card
Typically, when you enroll in a Medicare Advantage plan, Medicare updates its database to reflect this changeand you dont have to take any action to ensure claims are processed correctly.
But sometimes we see issues where Medicare still thinks you have your previous health insurance. If this happens, contact the Medicare Benefits Coordination & Recovery Center at 855-798-2627. Explain to the representative that your claims are being denied, because Medicare thinks another plan is primary to your Medicare Advantage plan. The representative will ask you a series of questions to get the information updated in their systems. About 1-2 weeks later, you can resubmit claims and everything should be okay moving forward.
NOTE: We hear on occasion that making this call doesnt always fix the issue on the first try. Just be aware, you might have to do this twice to make it stick.
Still have questions? We at Medicare Mindset are here to help. CONTACT US for guidance.
Determining Which Plan Is Primary
If you or your dependents are covered by more than one Benefit Plan, United will apply theterms of your Employer Plan and applicable law to determine that one of those Benefit Plans will be the Primary Plan. The Primary Plan is the Benefit Plan that must pay first on a claim for payment of covered expenses. The Primary Plan is the plan that must determine its benefit amount as if no other Benefit Plan exists. Other Benefit Plans that cover you or your dependent are Secondary Plans. Any Secondary Plan may pay certain benefits in addition to those paid by the Primary Plan. For example, if your spouse covers you under her Employer Plan and you are also covered under a different Employer Plan, your Employer Plan is the Primary Plan for you, and your spouses Employer Plan is the Secondary Plan for you.
COB also applies when you or your dependents have health coverage under Medicare, workers compensation or motor vehicle or homeowners insurance. Your Employer Plan will often have a specific section entitled Order of Benefit Determination Rules which sets forth how your Employer Plan identifies the Primary Plan.
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