Eligibility
Why is it important to check a patient’s insurance eligibility before submitting a claim?
To ensure that the claim is covered by the patient’s insurance and to avoid denials or delays in payment
What is the minimum age at which most people become eligible for Medicare?
65 years old
What documentation is generally required to prove eligibility for Medicare?
Social Security Number, proof of age, medicare number and proof of citizenship or legal residency.
What type of Medicare plan combines coverage from Medicare Parts A and B and often includes additional benefits such as vision and dental?
Medicare Advantage plan (Part C)
What can happen if a claim is submitted for a patient who is not eligible for their insurance coverage?
The claim may be denied, leading to delayed payment and potential financial liability for the patient or healthcare provider
Which type of Medicare coverage is automatically provided to individuals who are eligible due to age or disability?
Medicare Part A (Hospital Insurance). Part B needs active enrollment
What happens if a person is eligible for Medicare but does not enroll during their Initial Enrollment Period?
they may face late enrollment penalties and delayed coverage start dates
If someone is eligible for both Medicare and Medicaid, which program typically covers the costs of care not covered by Medicare?
Medicaid
What is one common reason claims are denied due to eligibility issues?
incorrect or outdated insurance information( incorrect policy number, name, dob..)
What condition must a person meet to qualify for Medicare if they are under the age of 65?
Having a qualifying disability or being diagnosed with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS)
What does Medicare Part A cover?
hospital inpatient care, skilled nursing facility care, hospice care, and some home health care (the stay itself)
Which cost-sharing amount is a fixed fee you pay for covered services, like doctor visits?
Copayments
How can incorrect eligibility information affect a patient’s financial responsibility?
it can lead to unexpected bills if the patient’s insurance coverage does not cover the services provided( although it can be billimg mistake!!)
What is the name of the initial enrollment period for Medicare?
The 7-month period that begins 3 months before the individual turns 65, includes the month they turn 65, and ends 3 months after.
The need of flexibility: ensuring coverage can begin as soon as an individual turns 65.
3 months after turning 65 purpose is: Offers additional time for individuals who may have missed the earlier part of the period or need more time to decide.
Also, the patient can choose HMO plan
If an individual chooses a Medicare Advantage plan, what coverage are they replacing?
Original Medicare (Parts A and B)
What is Medigap insurance designed to do for individuals with Medicare?
cover out-of-pocket costs not paid by Original Medicare, such as copayments, coinsurance, and deductibles
What steps should a biller take if a claim is denied due to eligibility issues?
Review the denial reason, correct any errors, and resubmit the claim with accurate information
What is the term for the process through which Medicare beneficiaries can switch from one Medicare Advantage plan to another?
the Medicare Advantage Open Enrollment Period (January 1 to March 31)
What is the main difference between a Medicare PPO plan and an HMO plan?
PPO plans offer more flexibility with providers and do not require referrals, whereas HMO plans require use of network providers and referrals
If the patient insured by both Medicare and Medicaid, which payer should be billed primary?
Medicare