Question

Explain the guidelines for processing claims for patients that have Medicare primary coverage.

Answer 1

Medicare is a federal healthcare program created in 1965 with the passage of the Social Security Amendments to ensure that citizens 65 and older as well as younger persons with certain disabilities have access to quality healthcare. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). CMS manages Medicare programs by selecting official Medicare administrative contractors (MACs) to process the Medicare claims associated with various parts of Medicare. Medicare as a healthcare plan is divided into different parts, each of which cover a specific healthcare service:

Part A (Medically necessary services): Part A of Medicare covers basic healthcare necessary to treat a pressing medical condition. Covered services may include hospital care, skilled nursing care, nursing home care, hospice care, and other support deemed essential to treating an illness or a condition.

Part B (Preventive Care): Services covered in Part B include services or supplies needed to treat or prevent a medical condition. Part B of Medicare also covers some preventive care services such as inpatient/outpatient mental health, clinical research, and ambulance services.