The Medicare Administrative Contractors (MACs), intermediaries and carriers are responsible for processing claims submitted for primary or secondary payment. When to Contact the BCRC: The BCRC should be contacted to: Report employment changes, or any other insurance coverage information
What is a Medicare Fiscal Intermediary?
The Medicare fiscal intermediaries (FIs) are private insurance companies that serve as the federal government's agents in the administration of the Medicare program, including the payment of claims. There are two primary functions for the FI--reimbursement review and medical coverage review.
What are the functions of a home health intermediary?
There are two primary functions for the FI--reimbursement review and medical coverage review. Hospital-based home health agencies relate to the hospital's FI for reimbursement purposes. All home health agencies are assigned to a special FI, the Regional Home Health Intermediary (RHHI), for medical review issues.
Who are the approved Medicare intermediaries for home health and hospice claims?
As of December 2020, the approved Medicare intermediaries for home health and hospice claims and the states and territories they work in are: National Government Services, Inc.
Who is responsible for processing Medicare claims?
Medicare Contractors - Medicare contractors (i.e., MACs, Intermediaries, and Carriers) are responsible for processing claims submitted for primary or secondary payment. These entities help ensure that claims are paid correctly when Medicare is the secondary payer.
What is a Medicare carrier?
Carriers are private insurance companies acting under contract with the Health Care Financing Administration (HCFA) to processclaims by beneficiaries and providers for services or supplies covered under Medicare Part B. While most Stateshave jurisdiction for one State, a few carriers handle more than one State.
What is the main function of Medicare administrative contractors?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
What is a fiscal intermediary and what function does it perform?
A Fiscal Intermediary (FI) is an organization that assists you to implement your Individual Support Agreement and to manage financial accountability and employer responsibilities. Fiscal Intermediaries are not service providers.
What is the primary function of Medicare and Medicaid?
The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.
What is the role of Medicare administrative contractors quizlet?
Insurance companies that process claims are called Medicare administrative contractors (MACs). Providers are assigned to a MAC based on the state in which they are physically located. Durable Medical Equipment (DME) MACs handle claims for durable medical equipment, supplies, and drugs billed by physicians.
What is the role of Medicare independent contractor in the claims process?
These Medicare contractors handle most of the administrative burden for managing the Medicare program, including: Processing and accounting for Medicare payments to individuals and providers. Handling redetermination requests, the first stage of the Medicare appeals process.
What are Intermediaries?
Definition: Intermediaries are individuals or organizations that undertake the role of mediators or linkage between two parties. Intermediaries are third parties and fill a function that is needed by two other parties to make a deal or to execute a given task.
What is a fiscal intermediary healthcare?
A fiscal intermediary is a private company contracted by Medicare to pay bills – such as hospital expenses – for Medicare Part A and Part B.
What is Department of Health Care Services fiscal intermediary?
A fiscal intermediary, sometimes called a Medicare Administrative Contractor, works with the federal government to help administer certain Medicare benefits and services. Learn more about how these companies work with federal programs like Medicare and Medicaid.
What was the purpose of Medicare and Medicaid quizlet?
Medicare provides health care for older people, while Medicaid provides health care for people with low incomes.
What are the responsibilities of the Centers for Medicare and Medicaid Services CMS?
The CMS oversees programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the state and federal health insurance marketplaces. CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.
What is an insurance carrier quizlet?
A company that provides insurance plans.
What is a fiscal intermediary?
A fiscal intermediary (FI) is a privately held company that serves as an intermediary between two parties that are trying to work together to resolve conflicts. For Medicare beneficiaries, a fiscal intermediary might make determinations on how local providers may cover a specific service or piece of medical equipment for local beneficiaries, ...
What is MAC in Medicare?
A MAC is a “private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.” 1. CMS uses this network of MACs to serve as “the primary operational contact between the Medicare FFS program ...
What's a MAC and what do they do?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
DME MACs
The DME MACs process Medicare Durable Medical Equipment, Orthotics, and Prosthetics (DMEPOS) claims for a defined geographic area or "jurisdiction", servicing suppliers of DMEPOS. Learn more about DME MACs at Who are the MACs.
Relationships between MACs and Functional Contractors
MACs work with multiple functional contractors to administer the full FFS operational environment. Learn more about the relationships between the MACs and the functional contractors by viewing the diagram of MACs: The Hub of the Medicare FFS Program (PDF) and reading about what the functional contractors do at Functional Contractors Overview (PDF).
What states are Medicare intermediaries?
As of December 2020, the approved Medicare intermediaries for Parts A & B claims and the states and territories they work in are: MAC Jurisdiction DME A (Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont)
What is fiscal intermediary?
What is a fiscal intermediary, and what do they do? A fiscal intermediary is a business contracted by the federal government to administer a program and process its payments in a specific geographic location, such as a metro area or a state.
What is Medicare Administrative Contractor?
A Medicare Administrative Contractor (MAC) is a type of fiscal intermediary that works with the Medicare program. After the passing of the Medicare Prescription Drug Improvement and Modernization Act of 2003, the Centers for Medicare and Medicaid Services (CMS) replaced its Part A fiscal intermediaries and Part B carriers with MACs who perform all ...
What are the functions of a health care provider?
They can perform several functions, including: Administering claims for government programs, including Medicare and Medicaid, and making payments to health providers. Informing people who perform subsidized services, such as health providers, about government programs and billing requirements.
Do Medicare beneficiaries have MACs?
Most Medicare beneficiaries don't have relationships with MACs, although a MAC may approve subsidies for your services without you ever knowing.
What is BCRC in Medicare?
The Benefits Coordination & Recovery Center (BCRC) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The BCRC takes actions to identify the health benefits available to a Medicare beneficiary and coordinates the payment process to prevent mistaken payment ...
Who is responsible for pursuing recovery from a liability insurer?
The CRC is responsible for pursuing recovery directly from a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity. For more information on the processes used by the CRC to recover conditional payments, see the Insurer NGHP Recovery page.
What is Medicare investigation?
The investigation determines whether Medicare or the other insurance has primary responsibility for meeting the beneficiary's health care costs. Collecting information on Employer Group Health Plans and non-group health plans (liability insurance ...
What is BCRC in Medicare?
Benefits Coordination & Recovery Center (BCRC) - The BCRC consolidates the activities that support the collection, management, and reporting of other insurance coverage for beneficiaries. The BCRC takes actions to identify the health benefits available to a beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims, nor does it handle any GHP related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.
What is the purpose of the MSP?
To report employment changes, or any other insurance coverage information. To report a liability, auto/no-fault, or workers’ compensation case. To ask a general MSP question. To ask a question regarding the MSP letters and questionnaires (i.e. Secondary Claim Development (SCD) questionnaire.)
Does Medicare pay a claim as a primary payer?
Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as a primary payer and will return it to the provider of service with instructions to bill the proper party.
Does BCRC cross over insurance?
Note: An agreement must be in place between the Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurers he ...
When does Medicare use secondary payer?
The COB Contractor will use a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare. In such situations, the other health plan has the legal obligation to meet the beneficiary's health care expenses first before Medicare. The table below describes a few of these methods and programs.
What is CMS contractor outreach?
Effective February 5, 2004, the CMS implemented an initiative known as “Consistency in Medicare Contractor Outreach” or CMCOM. This initiative provides clear concise instructions to contractors regarding new or changed Medicare policy. Contractors informed their provider communities of this initiative and where this provider outreach material is located. This outreach material is written in provider-friendly language by clinicians and medical coding/billing specialists and posted as articles at www.cms.hhs.gov/Medlearn/Matters. These articles are prepared concurrent with the process for clearing and releasing a related change request (CR) to allow sufficient time to implement.
What is CMS COB?
To consolidate the activities that support the collection, management, and reporting of other insurance coverage of Medicare beneficiaries , CMS awarded the Coordination of Benefits (COB) contract.