How to Enter Secondary Medigap Insurance on CMS-1500 Medicare Claims

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How to Enter Secondary Medigap Insurance on CMS-1500 Medicare Claims

Navigating Secondary Medigap Insurance on CMS-1500 Medicare Claims

Accurately submitting claims for beneficiaries with Medigap (Medicare Supplement) insurance is crucial for healthcare providers. This comprehensive guide provides step-by-step instructions for entering secondary insurance information on the CMS-1500 form, specifically focusing on Medigap policies. Understanding proper Medigap claims submission and adherence to Medicare secondary payer rules are vital for efficient Medicare crossover claims and timely reimbursement. We’ll delve into the specifics of filling out Item 9 of CMS-1500, ensuring correct coordination of benefits.

Understanding Medigap and Its Role in Medicare Billing

Medigap, or Medicare Supplement insurance, is a health insurance policy sold by private companies to help pay some of the healthcare costs that Original Medicare doesn’t cover. These plans work by filling in the “gaps” in Medicare coverage, such as deductibles, copayments, and coinsurance amounts. This coverage can significantly reduce a beneficiary’s out-of-pocket expenses.

There are ten standardized Medigap plans, identified by letters A through N, each offering a different set of benefits. While the core benefits are standardized across plans of the same letter (e.g., Plan F from Company X offers the same benefits as Plan F from Company Y), the premiums can vary. Understanding the basics of these plans can help providers anticipate coverage and improve Medigap claim processing efficiency. For a detailed comparison of Medigap plans, refer to official resources like Medicare.gov’s Medigap policy comparison tool.

Step-by-Step Guide: Filling Out Item 9 on the CMS-1500 Form for Medigap

Correctly completing Item 9 and its subdivisions on the CMS-1500 form is essential for proper Medigap claims submission and ensuring claims are automatically crossed over to the Medigap insurer. Only participating physicians and suppliers should complete Item 9 and its subdivisions, and only when the beneficiary wishes to assign their Medigap benefits to the participating provider.

Item 9: Medigap Policy Holder Information

  • Enter the last name, first name, and middle initial of the enrollee in the Medigap policy.
  • If this information is identical to the patient’s name in Item 2, simply enter “SAME”.
  • If no Medigap benefits are assigned or if the patient does not have a Medigap policy, leave this field blank.
  • Note: This field is distinct from other supplemental coverages; do not list non-Medigap supplemental plans here.

Item 9a: Medigap Policy/Group Number

  • Enter the policy and/or group number of the Medigap insured.
  • This number must be preceded by one of the following identifiers: “MEDIGAP”, “MG”, or “MGAP”.

Item 9b: Medigap Insured’s Birth Date and Sex

  • Enter the Medigap insured’s 8-digit birth date in MM | DD | CCYY format.
  • Indicate the Medigap insured’s sex (M for Male, F for Female).

Item 9c: Medigap Insurer’s Claims Processing Address

  • Leave this field blank if a Medigap PayerID is entered in Item 9d.
  • Otherwise, enter the abbreviated claims processing address of the Medigap insurer.
  • Use an abbreviated street address, two-letter postal code, and ZIP code as found on the Medigap identification card (e.g., “1257 Anywhere St. MD 21204” for “1257 Anywhere Street, Baltimore, MD 21204”).

Item 9d: Medigap PayerID or Plan Name

  • Enter the 9-digit PAYERID number of the Medigap insurer.
  • If a PAYERID number does not exist, enter the full name of the Medigap insurance program or plan.
  • Critical: For electronic Medigap claim-based crossover processing, the participating provider must accurately complete all of items 9, 9a, 9b, and 9d. The use of the correct PAYERID or plan name in Item 9d is vital for the claim to be electronically transferred to the Medigap insurer via the Coordination of Benefits Contractor (COBC).

Coordination of Benefits (COB) and Medicare Crossover Claims

Coordination of Benefits (COB) is the process by which two or more insurance plans work together to determine which plan pays first when an individual has more than one health insurance policy. Under current Medicare secondary payer rules, Medicare is typically the primary payer for beneficiaries also covered by Medigap. Medigap then acts as the secondary payer, covering amounts Medicare doesn’t pay, such as deductibles or coinsurance.

Since October 1, 2007, Medicare Part B contractors and Durable Medical Equipment Medicare Administrative Contractors (DMACs) forward Medigap claims data to the Coordination of Benefits Contractor (COBC). The COBC then transfers this information to the appropriate Medigap insurer for processing. This streamlined electronic process, known as Medicare crossover claims, relies entirely on the accurate and complete submission of Medigap information on the CMS-1500 form, particularly in Item 9d, to facilitate the transfer of payment data.

For detailed guidance on Medicare secondary payer rules and COB, refer to the Medicare Secondary Payer (MSP) Manual, Chapter 1, and the Medicare Claims Processing Manual, Chapter 30 – Financial Liability Protections.

Common Mistakes and Troubleshooting Medigap Claims

Errors in Medigap claims submission can lead to claim rejections, delays in reimbursement, and increased administrative burden for providers. Here are some common mistakes and tips for troubleshooting:

  • Missing or Incomplete Item 9 Information: Ensure all relevant subdivisions (9, 9a, 9b, 9d) are completed accurately when a beneficiary wishes to assign Medigap benefits.
  • Incorrect PayerID in Item 9d: Verify the 9-digit PAYERID. An incorrect ID will prevent electronic crossover. If no PAYERID exists, the full plan name must be used.
  • Listing Non-Medigap Supplemental Plans: Item 9 is specifically for Medigap policies. Do not enter other types of supplemental coverage here; these require separate submission by the beneficiary or through direct arrangements with the insurer.
  • Outdated Information: Always use the most current Medigap identification card information provided by the beneficiary.
  • Failure to Accept Assignment: Remember that Medigap claim-based crossover only applies to participating providers who accept Medicare assignment.

When encountering issues, first re-verify the information entered against the beneficiary’s Medigap card and cross-reference with the latest CMS-1500 instructions. For persistent problems with Medigap claim processing, contacting the COBC or the specific Medigap insurer may be necessary.

Official Resources for Medigap Claims Submission

For the most current and authoritative guidance on CMS-1500 form completion and Medigap claims submission, always consult official CMS manuals and transmittals:

Providers should also refer to an annotated diagram or redacted screenshot of the CMS-1500 form, specifically Item 9 and its subdivisions, for visual clarity when filling out Item 9 of CMS-1500.

Conclusion: Mastering Medigap Billing for Enhanced Reimbursement

Accurate and compliant Medigap claims submission on the CMS-1500 form is fundamental for healthcare providers seeking efficient reimbursement and reduced administrative burdens. By meticulously following these guidelines for filling out Item 9 of CMS-1500, understanding Medicare secondary payer rules, and leveraging the electronic Medicare crossover claims process, providers can significantly improve their Medigap claim processing. This ensures proper coordination of benefits and minimizes delays, ultimately benefiting both practices and patients.


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