Guidelines for Medicare Medical Claims Billing

As the single largest healthcare payor in the nation, Medicare guidelines and regulations carry a lot of weight, and it is important for any medical biller to stay informed of any changes to Medicare reimbursement rules. Medicare is divided into lettered parts: Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage Plans), Part D (Prescription Drug Plans). Medical billers and coders are only concerned with Part A and Part B since those have to deal with the generation of medical claims for services rendered. Medicare billing requirements are different, depending on whether the claims are Part A or B.

Due to the influential nature of Medicare, all medical claims billing is considered either Part A or Part B billing. As a general rule of thumb, all medical claims that are generated at a facility with regards to an inpatient stay are Part A, and are filed on a UB-04 medical claim form. All medical claims generated for a provider’s services in an outpatient setting are Part B and filed on a HCFA-1500 (or CMS-1500) medical claim form. Part A and Part B billing are very different, and most medical billing software is focused on one or the other. Likewise most medical billers and coders, and most third-party medical billing companies, have the ability to do both, but tend to specialize in either Part A or Part B billing. (note: PracticeAdmin was designed for Part B billing, but also allows some Part A billing. Click Here for more information on creating UB-04 claims with PA.)

To add an additional level of complexity, billing claims to Medicare involves dealing with one of their private company contractors. CMS contracts with insurance companies to act as intermediaries between the government and medical providers. Medical billers and coders spend a large amount of time dealing with CMS contractors involved in medical claims payment processing and clinician enrollment (i.e. Blue Cross Blue Shield, Cigna, Aetna, etc.). These private company contractors have their own rules and regulations which must be followed in addition to the Medicare guidelines. One of the most difficult tasks faced by medical billing offices is keeping up with the ever-changing rules and requirements of Medicare and their contractors.