Wiki Medicare non-par

Create Wiki
C

CMBA4

Contributor
Messages
21
Best answers
0
Hey everyone,

Hoping someone can help.

I have a provider who does not accept Medicare, but he does accept their secondary insurance. Normally I would submit to the primary get a non-par denial then forward that to the secondary for processing. However, the clearinghouse won't let me submit to Medicare since he does not participate with the insurance. If I submit to the secondary won't they deny the claim as missing primary EOB? Or is there another way to submit to the secondary for payment so that they are aware that we do not participate with Medicare and process the claim for payment.

Any input is helpful.

Thank you!!
 
Non-Par

I read a question similar to this at a CMS website. They said that the provider has to contact the plan and ask how to bill.
 
Is the provider non-par or has he opted out of Medicare? There is a differenece. Non-par providers must still submit claims to Medicare, they will then pay the patient directly. If a provider is non-par he can decide on a case by case basis if he will accept assignment for a particular claim, he must also follow all of CMS' regulations and can only bill the pateint up to the limitng charge.

If he has opted out neither he nor the patient can send any claims to Medicare (except in very limited emergency situations). In this case the patient would be entirely responsible for the bill. If this is the case then as the above poster suggested you need to contact the secondary insurer regarding how to bill, otherwise you need to contact your clearinghouse and expalin the difference between non-par and opted out because you can still submit claims if you are non-par.
 
Right now the provider is participating. I believe that they will be Opting out of Medicare in a couple months. So I will have to look into the secondaries regarding how to bill.

Thank you!!
 
I have a similar scenario-we have a dietician on staff she does not par with medicare. Some secondary's like bcbs cover this service. so are they not billable because we do not par medicare? Like you said-these claims don't even make it through clearinghouse for the denial to send over? We do have patients sign ABN and self pay for dietary at time of service-but we always get a phone call or upset patient in office saying their oxford (or which ever ins is 2) should cover.
 
You must log in or register to reply here.
Top