Medicare is a Health Insurance Program for people age 65 or older, certain qualified disabled people under age 65, and people of all ages with end-stage renal disease (ESRD) (permanent kidney failure treated with dialysis or a transplant). For the official site for people who qualify for Medicare, visit Medicare.gov. For further information, access the links listed below.
Beneficiaries may be entitled to special medical coverage. For further information, refer to the links listed below.
Besides traditional Medicare, Congress created Medicare Advantage (MA) to let more private insurance companies offer coverage to people with Medicare, giving them more choices. MA plans (sometimes called Part C) and other Medicare plans are health plan options that provide both Part A and Part B benefits. MA Plans include:
Medicare Health Maintenance Organizations
Preferred Provider Organizations
Private Fee-for-Service Plans
Medicare Medical Savings Account Plans
Medicare Special Needs Plans
MA Plan Directory
Beneficiaries who have a terminal illness with a life expectancy of six months or less have the option of electing hospice coverage in place of the standard Medicare coverage.
Hospice reporting guidelines:
Modifier GV: "Attending physician is not employed or paid under agreement by the patient's hospice provider".
Services billed by the attending physician, who are not employed by the hospice, must report this modifier or the claim will deny.
Modifier GW: "Service not related to the hospice patient's terminal condition".
Services submitted that are not related to the patient's terminal condition must report this modifier or the claim will deny.
Condition code 07: Institutional claims must contain the condition code 07 when the service(s) is unrelated to the patient’s hospice condition.
Note: Traditional Medicare pays for medically necessary non-hospice services (i.e., services billed with the GV or GW modifier) for MA enrollees who elect hospice coverage based on applicable Medicare Part B payment and deductible rules.
For further information, refer to the links listed below.
Common Working File (CWF) is a system that contains all Medicare beneficiary information as well as claim transactions, which includes Medicare Part A, Part B and Durable Medical Equipment. The Fiscal Intermediary Standard System and Multi-Carrier System processing systems interface with CWF to process claims. CWF verifies the beneficiary’s entitlement to Medicare, deductible status, available benefits, and check claims history. For more information on CWF, please visit the CMS IOM Publication 100-04, Claims Processing Manual, Chapter 27.
CMS requires providers to use the interactive voice response (IVR) Systems to access claim status and beneficiary eligibility information. For step-by-step instructions on how to use the IVR, please visit the Self-Service Tools (JL) (JH) page of our website.
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