Wiki Medicare primary payer - Obtaining a denial EOB

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sarahncoventry@gmail.com

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Hello -

I work for a company that does facility billing for SA/MH services. The facilities we bill for typically do not accept Medicare. We had a patient admit and receive services with Medicare Part B as his primary and an Anthem Blue Cross policy as his secondary. For the secondary to process claims, we need the denial EOB's from Medicare. Can anyone give me any tips on submitting claims to Medicare as a non-Medicare provider in order to receive denials?

Hope that makes sense.
 
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If the service is not covered per Medicare, you may not get the secondary to pay. Below is a link to Noridian Medicare for Non Participating providers with Medicare, but you need to find out which is your MAC based on your location. The Medicare Administrative Contractor(MAC) will help with the required billing instructions.

https://med.noridianmedicare.com/web/jeb/enrollment/nonparticipation#:~:text=In other words, a non- participating%20provider%20may%20bill,the%20billed%20amount%20and%20the%20primary%20payment%20amount.
 
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That's a really interesting question. I know the exact answer if the PROVIDER is involved, but I've never run across if the FACILITY is involved. Trying to research this didn't come up with a whole lot. Here is one article that is vaguely related: https://www.timesrecordnews.com/sto...ow-unable-accept-medicare-medicaid/100782240/

In that, they point out an important point that I often tell patients: If your primary insurance doesn't accept the claim, the secondary won't either. In other words, your primary needs to process the claim (not REJECT the claim), and put the total to patient responsibility in order for the secondary to pay. You have to follow the rules of the primary. Only once in my career have I seen a secondary pay without the primary accepting the claim, and I think that was only paid because the insurance company was tired of the patient calling and yelling at them.

I think if you bill Medicare, they are just going to reject the claim, which isn't going to help you.

I'm really interested in the answer to your question (because of my insatiable curiosity).

Edited to add: You said you're biling for FACILITY but then said Medicare part B. Are you billing facility (part A) or physicians (part B)?
 
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I have not had this issue in a number of years but several years back I had a couple clients that had been seen in the office for a number of years. They were each approved for medicare but also had BCBS secondary and also another client with medicare primary and tricare secondary. We only had LCMHC in the office at the time as you know LCMHC can not bill medicare. I called medicare to see if or how I could get reimbursement for services provided to these clients seeing as the clients had been seen in our office and there was a long relationship established. Medicare said they could write me a blanket letter stating that LCMHC could not bill medicare and that they other insurance would have to process as primary, BCBS and tricare both
paid for these clients and continue to do so. I have to submit a paper claim attaching that medicare letter but they paid as primary. Now if it is a medicare supplemental plan they
will not pay for example AARP etc.
 
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Is the ANTHEM a supplemental plan secondary to Medicare? If so, it will follow Medicare and deny.
If the ANTHEM is not supplemental (which is probably not the case) the secondary does not always follow primary and may consider the claim for payment with the denial from the primary.
Hope this helps!
 
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