Frequently Asked Questions
All Answers are current as of the date noted next to the question.
- Where can I find addresses for HMO Plans? (09/25/06)
- Does Medicare require pre-certification? (09/25/06)
- I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number? (06/04/07)
- Does WPS Medicare require prior authorization or prior approval for any services? (08/20/07)
- I just called the IVR to check on a patient's eligibility and it tells me that the beneficiary has another insurance which is primary. Our files state Medicare is primary. Why is there a discrepancy? (08/20/07)
| 1. | Where can I find addresses for HMO Plans? |
Addresses for HMO Plans are located on CMS' Website.
Posted 09/25/06 Revised NA |
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| 2. | Does Medicare require pre-certification? |
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No, on an individual basis claims need to demonstrate medical necessity for the services performed to be considered for payment.
Posted 09/25/06 Revised NA |
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| 3. | I have a patient who is enrolled in the Medicare Advantage program through United Healthcare. Do you know how I can get their phone number? |
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You can refer your patient to theCMS website.
This Website has the most current listing of contact information, including phone numbers, for all Medicare Advantage plans. It is important to remember that Medicare Advantage plans work like a Health Maintenance Organization (HMO) program and replace traditional Medicare.
Posted 06/04/07 Revised NA |
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| 4. | Does WPS Medicare require prior authorization or prior approval for any services? |
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No. While a proposed treatment plan could offer insight into a patient's condition, the actual service and follow-up care provided may differ based on the patient's condition at the time the service is rendered. For this reason, the original Medicare program does not give prior authorization or prior approval for any service.
You can find general coverage guidelines for many services using the Medicare Coverage Database (MCD). This searchable database, which is maintained by the Centers for Medicare & Medicaid Services (CMS), is located on the CMS Website at the following address: http://www.cms.hhs.gov/mcd Providers can also find WPS Medicare's coverage and billing guidelines for many services using our Local Coverage Determinations (LCDs). You can locate our policies on our Website. In the absence of a local or national coverage policy, WPS Medicare determines whether coverage is available for a service on a case-by-case basis using the documentation submitted with the claim for payment. WPS Medicare may also request additional medical documentation at the time the claim is processed. Posted 08/20/07 Revised NA |
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| 5. | I just called the IVR to check on a patient's eligibility and it tells me that the beneficiary has another insurance which is primary. Our files state Medicare is primary. Why is there a discrepancy? |
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According to the Master File, this beneficiary has another insurance that is primary over their Medicare. You may want to contact the beneficiary to see if this is correct. Sometimes a beneficiary may need to contact the Coordination of Benefits (COB) contractor to have their file updated. This process takes about 72 hours from the time the beneficiary calls. Once the update takes place, you should be able to resubmit the claim for payment.
Posted 08/20/07 Revised NA |
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Page Last Updated: Thursday, 18-Mar-2010 05:55:52 CDT
