National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007- 09B, September 2007

Clarification for Billing Medigap Insurance Information on the CMS-1500 Claim Form

As part of the standardization of the New York Part B claims processing system, (See our announcement at http://www.empiremedicare.com/partbny/billing/mcs_ann.htm), we need to clarify the submission of Medigap information on the CMS-1500 claim form and the electronic claims transactions.

When reporting the Medigap supplementary insurance information please complete your submissions using the correct information described below. Failure to do so will result in your claims not being forwarded to the supplemental insurance carrier for processing.

Item 9

Only participating physicians and suppliers are to complete Item 9 and its subdivisions and only when the patient wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier.

Item 9 and its subdivision should only be completed when the provider is a participating physician or supplier, and when the patient wishes to assign his/her benefits under a Medigap policy to the participating physician or supplier.

Participating providers sign an agreement with Medicare to accept assignment of Medicare benefits for all Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under a Medigap policy to a participating provider is called a mandated Medigap transfer.

Enter the last name, first name, and middle initial of the enrollee in a Medigap policy, if it is different from that shown in Item 2.

OR

Enter the word, “SAME,” when the patient’s name is the same, as it appears in Item 2.

OR

Leave blank, if no Medigap benefits are assigned.

Definitions: Medigap - A Medigap policy meets the statutory definition of a “Medicare supplemental policy” contained in 1882(g) (1) of Title XVIII of the Social Security Act and the definition contained in the NAIC Model Regulation which is incorporated by reference in the statute. It is a health insurance policy or other health benefit plan offered by a private entity to those persons entitled to Medicare benefits and is specifically designed to supplement Medicare benefits. It fills in some of the “gaps” in Medicare coverage by providing payment for some of the charges for which Medicare does not have responsibility due to the application of deductibles, coinsurance amounts, or other limitations imposed by Medicare. It does not include limited benefit coverage available to Medicare beneficiaries such as “specified disease” or “hospital indemnity” coverage. Also, it explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.

Item 9a

Enter the policy and/or group number of the Medigap insured-preceded by MEDIGAP, MG, or MGAP.

Note: If you enter a policy and/or group number in Item 9a, then Item 9d and Item 13 must also be completed.

Item 9b

Enter the Medigap enrollee’s eight-digit birth date (MM DD CCYY) and check the appropriate box for the patient’s sex.

Item 9c

Leave blank if a Medigap Payer ID is entered in Item 9d. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter state postal code, and Zip code copied from the Medigap insured’s Medigap identification card.

Note: Disregard “employer’s name or school name” which is printed on the form.

Example:

The city name should not be included.

Disregard “employer’s name or school name” which is printed on the form. Enter the claims processing address for the Medigap insurer. Use an abbreviated street address, two letter state postal code, and ZIP code copied from the Medigap insured’s Medigap identification card. For example:

1257 Anywhere Street
Baltimore , MD 21204

is shown as “1257 Anywhere St MD 21204.”

Note : If a carrier assigned unique identifier of a Medigap insurer appears in Item 9d, Item 9c may be left blank.

Item 9d

When billing National Government Services of New Jersey (NJ):
Enter the five-character local Medigap Insurer Identifier Code of the Medigap insurer.

(Example: MB001) When billing National Government Services of New York (NY):

Enter the nine-digit local Other Carrier Name Address (OCNA) number of the Medigap insurer.

If no local number exists, then enter the Medigap insurance program or plan name. If the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, the participating provider of service or supplier must accurately complete all of the information in Items 9, 9a, 9b, and 9d.

Enter the name of the Medigap insured’s insurance company or the Medigap insurer’s unique identifier provided by the local Medicare carrier. If you are a participating provider of service and (or) supplier and the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandated Medigap transfer, all of the information in Item 9 and its subdivisions must be complete and correct. Otherwise, the claim information cannot be forwarded to the Medigap insurer.

Completion of Items 9a through 9d are conditional for insurance information related to Medigap.

Item 13

The signature in this Item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 and its subdivisions.

The patient or his/her authorized representative signs this Item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

Completion of this item is conditional for Medigap.

Note: If you wish to report the statement “Signature on File” in Item 13 in lieu of the patient’s actual signature, the following statement must be signed and dated by the patient and maintained in your records.

SAMPLE: (Medigap Authorization on Provider’s Letterhead)