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Medical Review Frequently Asked Questions - January 2003

The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly quarterly "Frequently Asked Questions" related to coverage and local coverage determination issues. Providers may submit questions to the Web site at http://www.cignagovernmentservices.com/customer_service/disclaimer.html.

  1. How can I check on the dates of my patient's eligibility for Medicare?
  2. How do I check claim status electronically?
  3. How do I check the status of my patient's deductible?
  4. Will Medicare give prior approval for a service before it is rendered?
  5. On an Advance Beneficiary Notice (ABN), do you have to be specific as to why you think a claim may be denied?
  6. How can we tell if the beneficiary is enrolled in the Original Medicare Plan, a Medicare Health Maintenance Organization (HMO) or Medicare "Part C"?
  7. How do I find the Local Medical Review Policies (LMRPs)?
  8. I am a provider who would like to enroll in Medicare. What should be my first step?
  9. How long does it take to process a Provider Enrollment application?
  10. What is the FAX number and address for Provider Enrollment?
  11. We received a denial code CO 52 for our provider, what do we need to do?
  12. May I FAX my provider enrollment application?
  13. How do I begin filing my claims electronically?
  14. I've heard that as of January 2001, I will be charged $1.00 for duplicate electronic claims and all paper claims. Is this true?
  15. If I file electronic claims and I do not receive payment within 7-10 days, can I file a duplicate electronic claim instead of waiting for payment?
  16. How will I know when I have been set up to conduct electronic billing?
  17. What is the Electronic Submitter number of my client, Dr. ____________?
  18. Did you receive my electronic transmission?
  19. What is the Health Insurance Portability and Accountability Act?
Q1. How can I check on the dates of my patient's eligibility for Medicare?
A.

Medicare eligibility information along with deductible status may be obtained from a customer service representative. The eligibility information is not available on the Automated System. You will need to provide the customer service representatives with the following information:

  • Beneficiary last name, and first initial;
  • Beneficiary date of birth;
  • Beneficiary Health Insurance Claim (HIC) number, and,
  • Beneficiary gender.

*Please note these items must match exactly.

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Q2. How do I check claim status electronically?
A. Claim status cannot be checked via our Web site. You may use our automated response system to check claim status via telephone. Call our provider line (TN 615.24.5680 / ID 866.502.9051 / NC 866.238.9651) to access this information. Be prepared to enter your provider number, your patient's Medicare number and the date of service. Electronic billers may check claim status through their EDI Claim Status Inquiry System.

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Q3. How do I check the status of my patient's deductible?
A. Deductible status cannot be checked via our Web site. (If you are a participating provider) You may use our automated response system to check deductible status via telephone. Call our provider line (TN 866.502.9056 / ID 866.502.9051 / NC 866.238.9651) to access this information. Be prepared to enter your provider number and your patient's Medicare number.

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Q4. Will Medicare give prior approval for a service before it is rendered?
A. Medicare Part B does not give prior approval or approve a service before it has been rendered. After the service is provided, file a claim with Medicare and a coverage decision will be made based on the information submitted with the claim.

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Q5. On an Advance Beneficiary Notice (ABN), do you have to be specific as to why you think a claim may be denied?
A. Yes. In order to be protected under the Limitation of Liability Provision, a provider must submit a proper ABN for each service that is believed to likely be denied as not medically necessary. There must be a specific, identifiable reason to believe that Medicare may not pay for certain items. General statements such as "I never know if Medicare will deny payment," are not acceptable. For more information about the Advanced Beneficiary Notice, see the September October 1998 Medicare Bulletin article or get a sample ABN Form.

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Q6. How can we tell if the beneficiary is enrolled in the Original Medicare Plan, a Medicare Health Maintenance Organization (HMO) or Medicare "Part C"?
A. Ask the beneficiary to see all of his/her medical insurance cards. If the beneficiary does not have cards indicating current enrollment or does not know which type of insurance he/she has, please advise the beneficiary to call the Social Security Administration at 1.800.772.1213 to see how he/she is enrolled.

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Q7. How do I find the Local Medical Review Policies (LMRPs)?
A. Prior to accessing the Local Medical Review Policies, you will be required to read and agree to the "AMA License for the Use of Physicians' Current Procedural Terminology." Once there, choose the state in which you would like policy information. For quick reference in the future, bookmark the Part B Home Page which provides a Local Medical Review Policy link.

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Q8. I am a provider who would like to enroll in Medicare. What should be my first step?
A.

If you provide services in North Carolina, Tennessee, or Idaho, you can contact the Provider Enrollment department for an enrollment package. You may reach them by calling 615.782.4509 or writing to:

CIGNA Government Services
Provider Enrollment Department
P.O. Box 25226
Nashville, TN 37202

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Q9. How long does it take to process a Provider Enrollment application?
A. A first time submission takes 45 days to process from the date we receive it. A return application takes 30 days to process from the date we receive it.

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Q10. What is the FAX number and address for Provider Enrollment?
A.

FAX number is 615.782.4662.

Mailing Address:
CIGNA Government Services
Provider Enrollment Department
P. O. Box 25226
Nashville, TN 37202

Physical Address for Accepting Overnight Deliveries:

CIGNA Government Services
Provider Enrollment Department
2 Vantage Way
Nashville, TN 37228

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Q11. We received a denial code CO 52 for our provider, what do we need to do?
A. Fax a copy of your license to Provider Enrollment at 615.782.4662 ATTN: Correspondence

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Q12. May I FAX my provider enrollment application?
A. No. Original signatures must accompany provider enrollment applications.

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Q13. How do I begin filing my Medicare claims electronically?
A. The EDI Helpline is the best resource for information regarding questions about electronic billing. If you provide services in the state of North Carolina, please call 866.352.1608, if you provide services in Tennessee or Idaho, please call 615.782.4505. For more information about EDI or visit HCFA's EDI Section where you can also download HCFA's EDI Enrollment form.

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Q14. I've heard that as of January 2001, I will be charged $1.00 for submitting duplicate electronic claims and all paper claims. Is this true?
A. No. HCFA has proposed legislation to charge fees for submitting duplicate claims and paper claims, however it is only a proposal and legislation has not been passed. For more information about EDI visit HCFA's EDI Section.

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Q15. If I file electronic claims and I do not receive payment within 7-10 days, can I file a duplicate electronic claim instead of waiting for payment?
A. Electronic claims must be held at CIGNA Government Services for a minimum of 13 days before payment can be released. You won't be paid until they have cleared this federal payment floor. Filing the same claim again only burdens the claim payment process and you will receive denials for those duplicate claims. If proposed legislation is passed, you could also be charged for those duplicates. For more information about EDI visit HCFA's EDI Section.

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Q16. How will I know when I have been set up to conduct electronic billing?
A. Upon completion of the EDI application process, you will receive a confirmation identifying your submitter identification. For more information about EDI visit HCFA's EDI Section.

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Q17. What is the Electronic Submitter number of my client, Dr. ____________?
A. Federal Law prohibits the release confidential in which information over the phone. Please have your client contact the EDI department of the state in which they will be providing services. For more information about EDI visit HCFA's EDI Section.

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Q18. Did you receive my electronic transmission?
A. You will receive a Receipt List in approximately 5 working days or you can download the list one day after your transmission. For more information about EDI visit HCFA's EDI Section.

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Q19. What is the Health Insurance Portability and Accountability Act?
A. HIPAA is legislation that will ultimately improve the way the health care industry communicates and that means improved communication with your insurers. Be sure to attend a Medicare workshop or visit HCFA's Web Site for more information.

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