One Stop Shopping
This section provides an overview on topics associated with submitting claims or billing GHI Medicare. It is intended for providers that are new to the Medicare environment and for those who plan to submit claims to GHI Medicare for the first time.
Topics Covered
The topics have been sequenced in a logical order to help get a practice up and running:
- Enrolling in the Program – The process of enrolling a provider or practice to submit claims to GHI Medicare; receiving/updating a Provider Identification Number (PIN) can take up to 60 days so please plan accordingly
- CMS 855 Series – Forms you need based on the specifics of your practice
- CMS 460 – The Medicare Participating Physician or Supplier form is an agreement provides a 5% premium to the fee schedule for those providers willing to accept assignment for covered services
- Be aware that enrollment changes take place during a limited window (i.e., Mid-November to December 31st of each calendar year)
- Consider submitting this form with the CMS 855 during enrollment
- CMS 588 – The Authorization Agreement for Electronic Funds Transfer (EFT) allows the practice to receive electronic payment to directly to a specific account; this form can be submitted during or after enrollment
- Preparing to Submit – there are two primary methods to submit a claim to GHI Medicare:
- Electronic Data Interchange (EDI) – Allows a practice to submit claims through the GHI Medicare Bulletin Board System (BBS). This tried and true technology is a time saver that expedites processing and payments
- CMS-1500 Form – An industry standard that is available from numerous sources. GHI Medicare accepts the CMS-1500 form but encourages providers to shift away from paper-based submission methods
- Creating a Claim – Once a provider or practice has enrolled and determined how to submit claims, the next consideration is how to effectively document the details of the patient encounter to generate claim data. The following sources will help any practice submit the required data to support the adjudication of a claim:
- Following-up on Claims Submissions – Once the provider or practice has submitted claims, the practice should review the resulting Medicare correspondence. There are many information sources to support this process:
- Customer Service – Our call center team will help with administrative (e.g., enrollment, appeals) and claim related calls with care and attention
- Customer Service Presentation – An overview of service functions performed by GHI Medicare along with caller hints and tips
- IVR User Guide – A user guide for practical IVR use; the IVR is the starting point of all customer service calls, learn how to navigate and save time
- Electronic Remittance Advice (ERA) – A source for field descriptions and definitions of the ERA
- CERT - A program to help ensure that claims are paid accurately the first time; this program creates requirements for both the provider community and GHI Medicare
- CERT – An executive summary of the CERT program and program instructions
- CERT Presentation – An overview presentation with suggestions of how to best comply with CERT
- CMS CERT Information – A link to CERT resources on the CMS site
- Remittance Advice Reason Codes – A link to a complete list of reason and remark codes
- Reason codes explain the basic reason for a denial or reduction of a claim for service
- Remark codes are used to clarify a reason code
- Appeals – Instructions, forms, and helpful hints for redetermination and appeal requests
- Voluntary Refunds – A form to return monies to the Medicare program; use of the form will ensure these checks are credited accurately
- Publications and Newsletters – A source for Medicare program information and to review or request copies of the GHI Newsletter
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