License For Use Of Physicians’ Current Procedural Terminology Fourth Edition
End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association . All Rights Reserved . CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related 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 here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.
How Medicare Works With Other Insurance
If you have
and other health insurance , each type of coverage is called a “payer.” When there’s 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.
What Does Primary And Secondary Payer Mean
Each type of coverage you have is called a payer. When you have more than one payer, there are rules to decide who pays first, called the coordination of benefits. The primary payer pays what it owes on your bills first and sends the remaining amount to the second or secondary payer. There may also be a third payer in some cases.1
Important facts to know include:
- The primary payer pays up to the limits of its coverage.
- The secondary payer only pays if there are costs the first payer didnt cover.
- The secondary payer might not pay all of the uncovered cost.
- If Medicare is the primary payer and your employer is the secondary payer, youll need to join Medicare Part B before your employer insurance will pay for Part B services.
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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.
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Licensed Agent at Insuractive
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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What If My Private Insurance Doesn’t Cover A Service
Some services not covered by private insurance may be covered by Apple Health or your managed care plan. To make sure there are no problems, always show your private insurance card, ProviderOne services card, and managed care plan card. If you have lost your Provider One card or if you have lost your managed care card.
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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.
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.
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State Medicaid Programs And Use Of Contractors For Data Matching
State Medicaid programs may enter into data matching agreements directly with third parties or may obtain the services of a contractor to complete the required matches. When the state Medicaid program chooses to use a contractor to complete data matches, the program delegates its authority to obtain information from third parties to the contractor.
Third parties should treat a request from the contractor as a request from the state Medicaid agency. Third parties may request verification from the State Medicaid agency that the contractor is working on behalf of the agency and the scope of the delegated work.
Is There A Medicare Advantage Phone Number
Medicare Advantage plans are offered by private insurance companies, so you may want to call your plan provider directly with any questions about your Medicare Advantage plan. For general information about Medicare coverage, you can still call 1-800-MEDICARE, even if you are enrolled in a Medicare Advantage plan.
Are you considering switching to a Medicare Advantage plan, changing your current Medicare Advantage plan or enrolling in Medicare Advantage for your first time? A licensed insurance agent can help answer any questions you have about Medicare Advantage plans and can help you compare plans that may be available in your local area.
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Coordination Of Benefits & Recovery Overview
Additional Web pages available under the Coordination of Benefits & Recovery section of CMS.gov can be found in the Related Links section below.
The Medicare Secondary Payer program is in place to ensure that Medicare is aware of situations where it should not be the primary, or first, payer of claims. If a beneficiary has Medicare and other health insurance, Coordination of Benefits rules decide which entity pays first. There are a variety of methods and programs used to identify situations in which Medicare beneficiaries have other insurance that is primary to Medicare. Activities related to the collection, management, and reporting of other insurance coverage for beneficiaries is performed by the Benefits Coordination & Recovery Center .
CMS has made available computer-based training courses , flowcharts, presentations and other informational material to assist you in understanding COB& R. It is recommended you always scroll to the bottom of each Web page to see if additional information and resources are available for access or download.
Mcos And Data Matching
State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs to perform third party discovery and recovery activities. The Medicaid program may authorize the MCO to use a contractor to complete these activities.
When TPL responsibilities are delegated to an MCO, third parties are required to treat the MCO as if it were the State Medicaid agency, including:
- Providing access to third party eligibility and claims data to identify individuals with third party coverage
- Adhering to the assignment of rights from the state to the MCO of a Medicaid beneficiarys right to payment by such insurers for health care items or services
- Refraining from denying payment of claims submitted by the MCO for procedural reasons
Third parties may request verification from the state Medicaid agency that the MCO or its contractor is working on behalf of the agency and the scope of the delegated work.
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Ama Disclaimer Of Warranties And Liabilities
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
Coordination Of Benefits Process
Coordination of benefits allows insurers to know what their responsibilities are when it comes time to pay for your health care services.
The insurers know when they have to pay and what their share of payment will be if you are covered by more than one health care plan.
How the Coordination of Benefits Process Works
- Ensures Claims Are Paid Correctly
- The COB process identifies what Medicare benefits are available to you. From there, it can coordinate the payment process for your health care claims. This ensures that the primary payer whether its Medicare or other insurance pays first.
- The process ensures that this data gets to your other insurers. It also lets them know how much Medicare paid toward the claim and what their share is if they are the secondary payer.
- Prevents Duplicate Payments
- The process makes sure that Medicare and other payers do not exceed 100 percent of the claim.
- Coordinates Part D Drug Benefits
- It determines the correct primary payer and makes sure pharmacy claims are sent to each insurer in the proper order. It also exchanges your drug coverage information between insurers and prescription drug assistance programs in which you are enrolled so they can coordinate their share of payments.
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American Disabilities Act Notice
In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 , UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.
Termination And Deletion Of Msp Records In Cms’s Database
Medicare claims paying offices can terminate records on the CWF when the provider has received information that MSP no longer applies . Termination requests should be directed to your Medicare claims payment office. MSP records that you have identified as invalid are reported to the BCRC for investigation and deletion.
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Applied Behavior Analysis Medical Necessity Guide
The Applied Behavior Analysis Medical Necessity Guide helps determine appropriate levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered for a particular member. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.
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.
IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK 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 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.
LICENSE FOR USE OF “PHYSICIANS’ CURRENT PROCEDURAL TERMINOLOGY”, FOURTH EDITION
Consent to Monitoring
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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.
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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What Happens If Your Health Coverage Changes
If your health coverage changes, your insurers have to report it to Medicare. But it can take a long time to be posted to Medicares records in some cases.
To avoid problems, you should call the Benefits Coordination & Recovery Center toll-free at 1-855-798-2627 as soon as your health coverage changes.
Information to Have Ready When Calling the BCRC
- The name and address of your health insurance plan
- Your policy number
- The date your coverage changed, was added or stopped and why
You should also let your doctor and other health care providers you use know that your coverage has changed.
Finally, call your insurer and make sure they reported the changes to Medicare so that your records are up to date and there wont be problems with your claims.
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 .
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