Medicare Denial for Secondary Insurers

Medicare may allow payment for services or items when those services or items are a covered benefit and provided by a provider or entity enrolled with Medicare. For a general description of services payable by Medicare, please access the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, Section 10.3. The IOM Publication 100-08, Chapter 15, Section 15.4.discusses those providers and suppliers eligible for Medicare enrollment.

A provider is not liable to submit a claim to the Medicare contractor for a service described as never covered by Medicare unless the patient requests it. The provider should submit the service directly to the supplemental insurance. If the other insurance requires documentation of non coverage, providers can access the references cited in this article and use a copy of this document with the claim.

Not all providers of service are eligible to enroll in the Medicare program based on their specialty and credentials. The providers listed below are not eligible to enroll in the Medicare program and may not submit Medicare claims to receive a notice of denial. These providers should submit claims for their services directly to the beneficiary's supplemental insurer. If the insurer requires documentation of Medicare ineligibility, providers may use this document along with the appropriate CMS citation.

The CMS IOM Publication 100-08, Chapter 15, Section 15.4.8 provides a list of the most common provider specialties that are not eligible to enroll in Medicare. They include:

Acupuncturist; Assisted Living Facilities ; Birthing Centers; Certified Alcohol and Drug Counselors; Certified Social Worker; Drug and Alcohol Rehabilitation Counselor; Hearing Aid Centers/Dealers; Licensed Alcoholic and Drug Counselors; Licensed Massage Therapists (LMT); Licensed Practical Nurses (LPN); Licensed Professional Counselors; Marriage Family Therapists (MFT); Masters of Social Work, Mental Health Counselors; National Certified Counselors; Occupational Therapist Assistants; Physical Therapist Assistants; Registered Nurses; Speech and Hearing Centers; and Substance Abuse Facilities.

Note: Clinical Social Workers are eligible for enrollment. Please see the CMS IOM, Publication 100-08, Chapter 15, Section 15.4.4.7(external link).

Page Last Updated: Wednesday, 14-Dec-2011 17:49:00 CST