Medicare HMO Billing Instructions
for Professional Providers
(New CMS-1500 Claim Form)
- Blocks 11 and 11a through 11c – Enter the information applicable to the recipient's Medicare HMO in these blocks.
- Block 19 – Enter Attachment Type Code 09. Use a second attachment type code to indicate the result of billing the Medicare HMO. To indicate that the Medicare HMO made a payment, enter Attachment Type Code 10 and complete and attach the required Commercial Insurance Attachment Form (MA-538). All other fields will be completed as per the current published billing instructions. If some services were paid by the Medicare HMO and some services were denied, you must submit the denied services on a separate claim.
- The "printable" Commercial Insurance Attachment Form (MA 538) is available at the following link:
Commercial Insurance Attachment Form
- Follow your provider specific billing guide for all other fields on the "New" CMS-1500 Claim Form.
Medicare HMO Billing Instructions for Professional Internet Claims
Other Insurance Section – Enter Medicare Part B and the recipient's applicable Medicare HMO. The first 'Other Insurance must be Medicare Part B, using Carrier Code 100 and Claim Filing Indicator MB. Click on 'Add' and enter the second (2) other insurance segment. Use on of the applicable 500 series Medicare HMO Carrier Codes to denote the recipient's Medicare HMO with Claim Filing Code 16 (Health Maintenance Organization – HMO).
Service Adjustment for Service Line fields:
Click on the first claim detail and go to 'Service Adjustment for Service Line 1'. The first segment on the service adjustment line should be for Medicare B. The first two drop-down fields need to contain PR/50 for Medicare B (Carrier Code 100). The third field must contain the billed amount for the applicable claim detail. The 'Paid Date' field must contain the date of the Medicare HMO Explanation of Benefits (EOB) Statement. The 'Paid Amount' fields and Medicare Approved Amount fields must be left blank when indicating a Medicare denial.
Add a second adjustment by clicking on 'Add Adjustment'. The second adjustment must be used to indicate the results of billing the Medicare HMO. Enter PR in the first drop-down, Reason Code 1 (Deductible), 2 (Coinsurance), or 3 (Copay) in the second dropdown. The third field must contain the amount of deductible, coinsurance, or copayment due from the recipient. The 'Paid Date' must contain the date of the Medicare HMO EOB. Enter the amount the Medicare HMO paid in 'Paid Amount' field.
If there is a second and or subsequent claim detail, click on the claim detail and repeat the actions noted above. When a second or subsequent detail is selected, the title of the service adjustment line will reflect the specific detail (e.g., click on the second claim detail and the service adjustment line reflects 'Service Adjustment for Service Line).
Medicare HMO Billing Instructions for the PES Professional Transaction
- On the "Hdr 3" screen make sure that the Other Insurance Ind field is "Y", this will display the "OI" screen. •
- On the "OI" screen, fill out Policy Holder information for Medicare "B" (carrier code 100) and Medicare HMO/Advantage Plan (use the correct carrier code for the plan).
- Use claim filing indicator code "MB" for Medicare B and "16" for the Medicare HMO/Advantage plan.
- Complete all other fields as you normally would
- On the "Srv 3" screen make sure that the "Service Adjustment Ind" field is "Y", this will display the "Srv Adj" screen for the detail that you are completing.
- When completing the "Srv Adj" screen for Medicare Part B indicate a denial by using adjustment reason code "50" (enter the amount you would have billed Medicare in the next field). The current version of PES may ask you to complete the "Paid Amt." field when indicating a denial. When this occurs, go to the field and type in 0.00. The field will display .00 but should let you save the claim. You should also complete the Paid Date field using the date that Medicare denied the claim.
- Also on the "Srv Adj" screen complete the payment information for the Medicare HMO/Advantage plan. Use adjustment reason codes "1" for deductible (enter amount of deductible in the next field), "2" for coinsurance (enter coinsurance amt. in next field) or "3" copay (enter amount of copay in the next field). Also, complete the Paid Date/Amount fields.