When a Part A claim is processed by Medicare, Medicare pays the provider directly for the service rendered by the provider. On the other hand, in a Part B claim, who pays depends on who has accepted the assignment of the claim. In certain cases, the provider will decline the assignment of the claim, and Medicare will assign payment directly to the patient.
In cases like this, the patient, as opposed to the payer, must reimburse the provider for their services. You should be aware, as well, that Parts A and B of Medicare have monthly and annual premiums, in addition to coinsurance arrangements depending on what kind of service the patient receives.
These deductibles, premiums, co-pays, and coinsurance rates are fixed by CMS, but they can vary greatly between patients and procedures. Part of the challenge of filing a claim with Medicare is getting the proper number for each patient. Creating claims for Medicaid can be even more difficult than creating claims for Medicare.
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Because Medicaid varies state-by-state, so do its regulations and billing requirements. As such, the claim forms and formats the biller must use will change by state. In general, the medical biller creates claims like they would for Part A or B of Medicare or for a private, third-party payer.
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The claim must contain the proper information about the place of service, the NPI, the procedures performed and the diagnoses listed. The claim must also, of course, list the price of the procedures. Be aware when billing for Medicaid that many Medicaid programs cover a larger number of medical services than Medicare, which means that the program has fewer exceptions. One final note: Medicaid is the last payer to be billed for a service.
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