Monday, June 26, 2017
Reimbursement Medicare / Medi-Cal

Medicare / Medi-Cal News

Don't forget to check Medicare patients' eligibility! Traditional Medicare doesn't require much pre-authorization, but Medicare HMO's often do. Medicare could deny your claim if your patient switches to an HMO, then the HMO could deny your claim because you didn't have prior authorization.

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to

Avoiding Denials on Priced Per Invoice Claims

Processing Changes: Effective 9/16/13, items requiring an invoice must follow certain criteria. 


Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing

The National Coverage Determination (NCD) 20.8.3, Single Chamber and Dual Chamber Permanent Cardiac Pacemakers were revised with an effective date of August 13, 2013. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following provides coding and billing instructions for the implementation of NCD 20.8.3. (CMS policy language is in italics.) The NCD "Item/Service Description" and "Indications and Limitations" are repeated here.





Over the past year, there have been a number of changes for Medi-Cal patients and for the physicians who treat them. There will be more changes in 2014 as well. To help physicians understand the impact these changes will have on their practices, the California Medical Association (CMA) has published this Medi-Cal Survival Toolkit. The toolkit contains a summary on many of the changes, important dates, options for physicians, and links to important resources.


RACs Are on Hold

CMS's agreements with recovery audit contractors (RACs) to administer the recovery program is winding down.

Incarcerated Medicare Beneficiaries

CMS is making changes to claims processing system...

First of the Increased Medi-Cal fee-for-service Primary Care Payments to go Out This Week

CMS recently approved California's proposed implementation plan for the primary care rate increases...

What you need to know about signatures and documentation

The discovery of CERT errors may lead to increased scrutiny of future services billed to Medicare. Your support and understanding of this important issue are essential to ensuring the accuracy of Medicare claims.

Begin Reporting PQRS Now To Avoid Penalties

The Medicare Physician Quality Reporting System (PQRS) is a reporting program that uses a combination of incentive payments and payment reductions to promote reporting of quality information by eligible professionals. PQRS is mandated by federal legislation.

Sequestration FAQ

On Friday, March 1, the automatic sequestration of federal spending is scheduled to take effect. The sequester was originally set to begin on January 1, 2013, under provisions of the Budget Control Act of 2011.

Copyright 2017 by Santa Clara County Medical Association