Sunday, December 17, 2017

Medicare beneficiary identifier April 2018

Beginning April of 2018, the Centers for Medicare & Medicaid Services (CMS) will begin replacing Medicare ID cards for 60 million Medicare beneficiaries. This is a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft and safeguard taxpayer dollars.

Why are new Medicare ID cards important?

Personal identity theft is impacting a large and growing number of senior citizens. Between 2012 and 2014 alone, incidents among seniors increased from 2.1 million to 2.6 million. Identity theft can take not only an emotional toll on those who experience it, but also a financial one: Two-thirds of all identity theft victims reported a direct financial loss. It can also disrupt lives, damage credit ratings and result in inaccuracies in medical records and costly false claims. Because of these issues, CMS has decided to take action to further protect seniors.

What will be different?

The new Medicare cards will use a unique and random number, which will be called your Medicare Beneficiary Identifier (MBI). The MBI will replace the Social Security number that is on the current ID cards. The new MBI numbers will consist of 11 characters and will contain a combination of numbers and uppercase letters. Beneficiaries will be instructed to safely and securely destroy their current Medicare cards and keep the new MBI confidential.

Will I need to keep my old Medicare ID card?

No. Once you receive your new ID card, you will not need your old card any longer. There will be a 21-month transition period where providers will be able to use either the new Medicare Beneficiary Identifier or the old Social Security-based ID number. The transition period will begin no earlier than April 1, 2018 and last through December 31, 2019.

Saturday, September 30, 2017

Medicare offers more health coverage and decreased premiums in 2018

Medicare offers more health coverage choices and decreased premiums in 2018 

According to CMS

Medicare Advantage premiums decrease, choices increase, while enrollment hits an at all-time high

Today, the Centers for Medicare & Medicaid Services (CMS) announced that people with Medicare will have more choices and options for their Medicare coverage in 2018. As CMS releases the benefit and premium information for Medicare health and drug plans for the 2018 calendar year, the average monthly premium for a Medicare Advantage plan will decrease while enrollment in Medicare Advantage is projected to reach a new all-time high. Earlier this year, CMS announced new policies that support increased benefit flexibilities allowing Medicare Advantage plans the ability to offer innovative plans that fit the needs of people with Medicare.  

"More affordable choices lead to greater health security for those who need it most,” said Health and Human Services Secretary Tom Price, M.D. “Both Medicare Advantage and Medicare Part D are providing a higher level of health security for so many of America’s seniors precisely because they are built to be more responsive to their needs. Today's news, alongside the long-term trend of more folks choosing Medicare Advantage, is a testament to the power of a more patient-centered approach to healthcare.”

“The success of Medicare Advantage and the prescription drug program demonstrates what a strong and transparent health market can do—increase quality while lowering costs,” said CMS Administrator Seema Verma. “When Americans are empowered to choose the healthcare plans that fit their needs and the needs of their families, they demand more from their insurance plans and in turn healthcare plans, like any business, provide customers better service at a lower cost. 

CMS estimates that the Medicare Advantage average monthly premium will decrease by $1.91 (about 6 percent) in 2018, from an average of $31.91 in 2017 to $30. More than three-fourths (77 percent) of Medicare Advantage enrollees remaining in their current plan will have the same or lower premium for 2018.

Medicare Advantage enrollment is projected to increase to 20.4 million in 2018, a nine percent increase compared to 2017. More than a one-third of all Medicare enrollees (34 percent) are projected to be in a Medicare Advantage plan in 2018.

Access to the Medicare Advantage program remains strong, with 99 percent of people with Medicare having access to a Medicare Advantage plan. The number of Medicare Advantage plans available to individuals to choose from across the country is increasing from about 2,700 to more than 3,100– and more than 85 percent of people with Medicare will have access to 10 or more Medicare Advantage plans. In addition, more Medicare Advantage enrollees are projected to have access to important supplemental benefits such as dental, vision, and hearing benefits.

Medicare Part D prescription drug program access will also remain strong in 2018 with 100 percent of people with Medicare having access to a stand-alone prescription drug plan. Earlier this year, CMS announced that the average basic premium for a Medicare prescription drug plan in 2018 is projected to decline to an estimated $33.50 per month. This represents a decrease of approximately $1.20 below the average basic premium of $34.70 in 2017. The Medicare prescription drug plan average basic premium is projected to decline for the first time since 2012.

This fall, CMS is undertaking several consumer-friendly improvements for Medicare Open Enrollment so that people with Medicare can make an informed choice between Original Medicare and Medicare Advantage. Some of the improvements include:

Changes in the “Medicare & You” handbook to better explain coverage options;Establishing a help wizard on that will point to resources to help make informed healthcare decisions; andEstablishing a new email communication opportunity to improve the customer service experience through important messages and reminders.

Medicare Open Enrollment for 2018 Medicare health and drug plans begins on October 15, 2017, and ends December 7, 2017. Plan costs and covered benefits can change from year to year. People with Medicare should look at their coverage choices and decide the options that best fits their health needs. They can visit (, call 1-800-MEDICARE, or contact their State Health Insurance Assistance Program (SHIP). Those people with Medicare who do not wish to change their current coverage do not need to re-enroll in order to keep their current coverage.

For more information on the premiums and costs of 2018 Medicare health and drug plans, please visit:

For a fact sheet on Medicare Advantage and Part D in 2018, please visit:

For more information on Medicare Open Enrollment, including state-by-state fact sheets, please visit: 

Medicare beneficiaries and providers rights

Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs.

These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers:

FFS Advance Beneficiary Notice of Noncoverage (FFS ABN)

FFS Home Health Change of Care Notice (FFS HHCCN)

FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN)

and SNF Denial LettersFFS Hospital-Issued Notices of Noncoverage (FFS HINNs)

FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility  (FFS Expedited Determination Notices)

MA Denial Notices (MA Denial Notices)

MA Expedited Determination Notices (MA Expedited Determination Notices)

Important Message from Medicare (IM)

and Detailed Notice of Discharge (DND)

(Hospital Discharge Appeal Notices)
FFS Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (FFS NEMB SNF

Biosimilar modifiers for payment

 the 2016 Physician Fee Schedule Final Rule, CMS updated the regulation text found at 42 CFR 414.904(j) to make clear that effective January 1, 2016, the payment amount for a biosimilar biological drug product is based on the average sales price of all NDCs assigned to the biosimilar biological products included within the same billing and payment code. In general, this means that CMS will group biosimilar products that rely on a common reference product’s biologics license application into the same payment calculation, and these products will share a common payment limit and HCPCS code.

In order to provide CMS with the ability to track claims payment and to develop a better understanding of the use of specific biosimilar products in Medicare Part B, claims for separately paid biosimilar biological products will be required to include a modifier that identifies the manufacturer of the specific product. Modifiers will be used to distinguish between biosimilar products that appear in the same HCPCS code but are made by different manufacturers. CMS will issue HCPCS codes for biosimilar biological products and will issue and assign modifiers to specific biosimilar products in each HCPCS code. The assignments will be published on this webpage. The use of the modifiers on claims for biosimilar products that appear on this webpage is mandatory. However, if a HCPCS code and corresponding biosimilar modifier(s) do not appear on the quarterly update, then a modifier is not required to appear on claims for the code. New biosimilar products that are not adequately described by an existing unique HCPCS code may be billed under a miscellaneous code or “not otherwise classified” code such as J3590. Similarly, a “not otherwise classified” code may also be used in situations where an existing biosimilar HCPCS code is associated with a corresponding modifier that is not yet in effect in the claims processing system. The manufacturer modifier is not required on claims that use a miscellaneous HCPCS code.

Please note that the determination of the payment amount for biosimilars is not affected by the use of a modifier.

The table below lists the current biosimilar HCPCS Codes, the product(s) that are associated with each code and the corresponding required modifier that is used to identify the product. The table will be updated quarterly when new permanent HCPCS codes and modifiers are available for biosimilar products that appear on the ASP price file.

Biosimilar HCPCS CodeProduct Brand namesCorresponding Required

ModifierQ5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgramZarxioZA - Novartis/SandozQ5102 Injection, infliximab, biosimilar, 10 mgInflectraZB - Pfizer/HospiraQ5102 Injection, infliximab, biosimilar, 10 mgRenflexis

ZC –Merck/Samsung Bioepis           (see note below)

Note: The ZC modifier will become effective, that is, valid for claims submitted beginning October 1, 2017 and applies retroactively to dates of service on or after July 24, 2017.

Friday, September 29, 2017

Texas top claim submission / Reason code errors - August 2017

Texas Top Claim Submission / Reason Code Errors - August 2017


Explanation of Medicare Benefits Message





Non-covered charge.

Prior to performing or billing a service, ensure that the service is covered under Medicare. Please refer to the Centers for Medicare & Medicaid Services Internet Only Manual, 100-02, Chapter 16.



Claim not covered by this payer/contractor.

This denial indicates that the service is one that is processed or paid by another contractor.

Examples of these types of service are:

Durable Medical Equipment

Hospice related services

Medicare Advantage

You must send the claim to the correct payer/contractor.



Duplicate claim/service.

Please check claim status through the IVR to see if another claim was paid or is currently being processed. To prevent duplicate denials, allow us sufficient time to process a claim before submitting a second.



These are non-covered services because this is not deemed a 'medical necessity' by the payer.

Please ensure to follow Medicare guidelines, national and local coverage determinations for the service billed.


CMS Internet Only Manuals

CMS National Coverage Determinations Manual, Pub. 100-03

Novitas Local Coverage Determinations

Thursday, September 28, 2017

Important : BCBS New id format

All of the BCBS plans have been posting announcements about the new alpha/numeric prefixes that they’re going to be rolling out next year. Below is the announcement that Anthem put in a recent newsletter:

New member ID prefixes coming in 2018 The Blue Cross and Blue Shield Association (BCBSA) assigns member ID prefixes for all Blue Cross and Blue Shield branded Plans – Anthem Plans as well as non-Anthem Plans. There are a limited number of unused three-character, alpha only prefixes remaining, and they are expected to be exhausted in the 2nd or 3rd quarter of 2018. When that happens, the BCBSA will begin assigning prefixes that contain a combination of letters and numbers, or alpha-numeric prefixes.

What does this mean to you?

It will be even more important to ask your patients for their most recent identification (ID) card.When submitting claims, enter the identification number exactly as it appears on the member’s ID card.Check your EDI Software to make sure it can accept alpha-numeric prefixes.Check any internal documents you may have and update any references of “alpha prefix” to “prefix”.

Note: Current three-character, alpha-only prefixes will not be affected by this change. Current prefixes will still be valid once the new alpha-numeric prefixes are issued, unless there is another need to change or remove a prefix currently in use.

Tuesday, August 22, 2017

Propose new codes for telehealth Services

G0296 counselling visit for lung cancer screening
G0506 comprehensive assessment for CCM
CPT code 90785 interactive complexity
CPT code 90839 and 90840 psychotherapy for crisis
CPT codes 96160 and 96161 patient focused health risk assessment