How to Process a Medicare Part B Claim

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1 How to Process a Medicare Part B Claim Manual by Chris Harris

3 Table of Contents iii Table of Contents Table of Contents... iii Introduction... v Who should use this Manual?... v What should you know about Medicare?... v What materials are needed?... v What is included in this manual?... v Obtaining the Prescription... 3 What should you ask for?... 3 What needs to be included on the prescription?... 3 What is required from the physician?... 5 Where can I find a list of items covered by Medicare?... 5 What s next?... 5 Processing Medicare Part B... 9 How do I enter Medicare information?... 9 How do you validate Medicare?...11 What is left to do?...13 Frequently Asked Questions...17 Conclusion...17 Index...19

... 3 What needs to be included on the prescription?... 3 What is required from the physician?... 5 Where can I find a list of items covered by Medicare?

5 Introduction v Introduction Who should use this Manual? You must be a registered pharmacy technician, pharmacy technician trainee, or a pharmacist and employed with Walmart in order to use Connexus to process Medicare Part B. What should you know about Medicare? Medicare is a federal government social insurance program that guarantees access to health insurance for certain Americans and legal residents aged 65 and older, and younger people with disabilities. Medicare has four parts, listed below, and as technicians we are primarily concerned with Part B and D. In this manual, we will solely address Medicare Part B. Figure 1 shows a sample Medicare Part B card. Part A: Hospital Insurance Part B: Supplementary Medical Insurance Part C: Medicare Advantage plans Part D: Prescription drug plans Figure 1. Medicare card example What materials are needed? The following items will be required in order to process a claim on Medicare part B. Medicare card (Figure 1) Prescription with required information (detailed in Chapter 1) Supplemental Insurance (if applicable) What is included in this manual? This manual is divided into three chapters, obtaining the prescription, processing Medicare, and frequently asked questions. Frequent concepts are referenced in the index and you can use the table of contents to navigate to a specific section.

9 Obtaining the prescription 3 Obtaining the Prescription What should you ask for? It is very important that the pharmacy have all necessary patient data on file. There are several steps you should follow to properly obtain patient data. 1. Obtain the patients date of birth 2. If the patient is 65 years of age or older, ask if they have Medicare Part B 3. Ask if patient has secondary coverage to be billed in conjunction with Medicare Part B 4. Input any data received from the patient into Connexus What needs to be included on the prescription? Please ensure the following items are present on any Medicare part B prescription. Patient Name Product/Mediation name Specific, quantifiable directions for use (use as directed not acceptable) Specific quantity to dispense Numerical diagnosis code Prescriber signature Date of prescription

Ask if patient has secondary coverage to be billed in conjunction with Medicare Part B 4. Input any data received from the patient into Connexus What needs to be included on the prescription?

11 Obtaining the prescription 5 What is required from the physician? Prescriptions must be hard copy, faxed or electronic, and must contain all required information and documentation before they can be billed to Medicare Part B. A prescription, once signed and dated, may not be altered in any way. The only remedy that allows for incomplete or improperly documented prescriptions is a newly written prescription with all of the required information. Where can I find a list of items covered by Medicare? Walmart is only accredited to bill Medicare Part B for the following categories Diabetic Supplies Nebulizer Solutions Oral Chemotherapy and Anti-Nausea Medications Short-Acting Insulin when administered via pump Immunosuppressants What s next? After securing a prescription with the required information you may input the prescription and process the Medicare. This procedure is further detailed in the next chapter.

A prescription, once signed and dated, may not be altered in any way.

15 Processing Medicare Part B 9 Processing Medicare Part B You need to do several things during the prescription filling process in order to correctly file a claim for Medicare part B. How do I enter Medicare information? Follow these steps to enter Medicare Part B insurance information ( Figure 2). 1. Open Third Party edit in patients profile 2. Enter OMN (OmniSYS) in the carrier field 3. Select Medicare in the plan field 4. Enter the card number in the card id field 5. Enter patients first and last name 6. Enter group number (NOC for no other coverage or the supplemental id) Figure 2. Third party edit screen to enter Medicare Part B

17 Processing Medicare Part B 11 How do you validate Medicare? Once you have input the item for the prescription a verification box will appear on the drop off screen. (Figure 3). In this box you will need to verify that the prescription has directions for use and a diagnoses code written on the prescription. Then you must enter the diagnoses code and the accept button will populate after the information is entered (Figure 4). Figure 3.Prescription Input screen Figure 4. Medicare Validation screen

In this box you will need to verify that the prescription has directions for use and a diagnoses code written on the

19 Processing Medicare Part B 13 What is left to do? Now that the Medicare Part B information is entered there are a few more processes to ensure the claim will be processed. 1. Press F10 to bring up the Third Party screen (Figure 4) 2. Select 3 under Prior Auth Type 3. Under Prior Auth No. enter the number of times per day the drug will be used. 4. Press Accept. (Claim will finalize) Figure 4. Third Party Extra Info screen If you are processing a prescription for diabetic test strips, you must enter the date that the patient received their meter in the claim detail screen under plan ID. (Figure 5) Figure 5. Claim Detail screen

Press F10 to bring up the Third Party screen (Figure 4) 2. Select 3 under Prior Auth Type 3. Under Prior Auth No.

23 Frequently Asked Questions 17 Frequently Asked Questions Figure 7 contains a table of some of the most popular questions asked by technicians. Question Answer What is the Medicare Part B deductible? The Medicare deductible for 2014 will be $ Why, if the patient has Since the secondary/supplemental is secondary/supplemental coverage do actually contracted with Medicare and they still have to pay up front for their not Walmart, we cannot submit the deductible? secondary claim. Medicare will send What are all these Third Party and Claim Detail codes for? What happens if a drug s quantity exceeds the allowable days supply? Figure 7. Frequently asked questions reimbursement after 3-6 weeks. OMN does not receive certain fields on the claim that contain information necessary for billing; because of this we send the necessary information in Third Party and Claim Detail. For prescriptions that exceed the plans allowed limit, lower the quantity as much as possibly while billing for the largest day supply possible. Conclusion If you have any additional questions, the wire is a great resource for processing Medicare Part B claims. Each patient plan is different so other issues can possibly arise; please refer to the wire for troubleshooting help.

25 Index 19 Index Claim 1, 13, 17 Figure v, 9, 11 Insurance v, 13 Medicare 1, v, 3, 5 Prescription 3, 5, 9, 11

27 Works Cited 21 Works Cited bucks.blogs.nytimes.com

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