Guidelines for Medicare Primary Billing

If an item is deemed coverable by Medicare and is otherwise not on the designatedNational Coverage Determination (NCD) for Durable Medical Equipment non covered items list: then the process for billing would be as follows:
It should be explained fully to the beneficiary before the items or services are furnished that Medicare may not cover the item or service being requested for certain medical conditions. If after advising, the beneficiary still wants to obtain the item or service, the beneficiary should sign the Advanced Beneficiary Notice (ABN) of Non-Coverage once delivered in order for a provider to be able to:
  • Bill Medicare and obtain an official decision;
  • File a claim with the beneficiary’s secondary insurer once the Medicare decision is received
  • Collect a payment or partial payment from the beneficiary for the item if Medicare and/or the secondary insurer do not pay.
Once in receipt of the Medicare decision, a provider should forward a copy of the decision along with all required billing documentation for the requested item or service to the beneficiary’s secondary insurer per their protocol for processing.
If the secondary provider denies a claim, an appeal process is available as well as the ability to bill the beneficiary if the ABN is signed.

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