Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
SEPTEMBER 1998 NICA NEWS
QUESTIONS AND ANSWERS
Q. Does my physician have to submit my claim to Medicare?
A. Yes, All physicians and suppliers who treat Medicare patients are required by law (section 6102 of the Omnibus Budget Reconciliation Act of 1989 P.L. 101-239) to complete and submit Part B claims for services furnished on or after September 1, 1990.
This law not only prohibits physicians and suppliers from imposing a charge for completing and submitting a claim, but payment of assigned services not filed within 1 year are reduced 10 percent. Physicians and suppliers who fail to submit a claim or impose a charge for completing the claim are subject to sanctions.
Q. If the provider knows that Medicare is going to deny a claim because it is considered preventive/maintenance care, does the provider still have to submit it?
A. Yes. The Health Care Financing Administration maintains that the provider should still submit the claim because there may be a potential for coverage of which you are unaware.
If you think Medicare will deny a claim, make certain as a patient, a Medicare waiver has been signed.
Q. What are the basic items covered by the Durable Medical Equipment Regional Carrier, or DMERC, (CIGNA)?
A. First of all, Durable Medical Equipment is equipment that can be used over and over again. Examples include wheelchairs, walkers, hospital beds, canes, etc.
Oxygen: includes oxygen and oxygen equipment.
Prosthetics and orthotics, such as artificial limbs.
Medical supplies in certain instances. They must be used in the home. An example would be surgical dressings.
Parenteral and Enteral Nutrition supplies (PEN). Medicare will cover intravenous or tube feeding for patients with a permanent impairment that prevents them from eating normally.
Immunosuppressive drugs These are covered for the Medicare benefit period after receiving a Medicare approved organ transplant.
Home dialysis equipment and supplies when reasonably necessary for patients with end stage renal disease who are receiving dialysis at home under supervision of a Medicare approved dialysis facility.
Oral anti-cancer drugs.