Medigap insurance is specifically designed to supplement Medicare's benefits. Medigap is regulated by federal and state laws and must be clearly identified as Medicare supplemental insurance.

Not all supplemental insurance is Medigap. A policy or plan offered by an employer, former employer or a labor organization to members or former members is not considered a Medigap plan. A Medigap policy is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits. It provides reimbursement for charges not payable by Medicare because of deductible, co-insurance or other limitations.

If you are a participating provider of service or supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information on the claim must be complete and accurate. Otherwise, the Medicare carrier cannot forward the claim information to the Medigap insurer.

The participating provider should determine whether a patient's supplemental plan is a true Medigap policy.

Hardcopy Claim Submission

1. Item 9a. Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP.

   Note: Item 9d must be completed if you enter a policy and/or group number in Item 9a.

2. Item 9b. Enter the Medigap insured's birth date and sex.
   
   
3. Item 9c. Enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter state code and zip code copied from the insured's Medigap identification card. For example:

          1257 Anywhere Street         is shown as:
          Baltimore, MD 21204          1257 Anywhere St MD 21204

4. Item 9d. Enter the nine-digit local Other Carrier Name Address (OCNA) number of the Medigap insurer (see local OCNA list). If no local OCNA number exists, then enter the Medigap insurance program or plan name.

Electronic Claim Submission

Empire Medicare Services (EMS) can accept electronic claims which indicate Medigap insurance. If the Medigap insurer data is entered correctly, EMS will send the claim to the Medigap insurer after the Medicare Part B claim has processed. The following information provides the electronic submission requirements for Medigap billing using the National Standard Format (NSF). Claims may also be submitted via the ANSI ASCX12.837 format specified in the standard Health Care Financing Administration implementation guides.

Medigap claims require the entry of multiple DA0 (Payor Data) records. The DA0 record for Medicare Part B is always prior to the Medigap payor DA0 record (e.g., claim has two payors: Medicare Part B is entered in DA0 sequence 01 and the Medigap payor data in DA0 sequence 02). The correct sequencing of the DA0 records is critical.