Insurance: Medicare Setup

Medicare is an important payer sources for many practitioners, but navigating setup with them can feel overwhelming. Setting up Medicare in your EHR involves verifying your enrollment status, configuring payer details, and aligning billing settings to ensure accurate claims submission.

The steps in the EHR are typically the same as adding commercial payers, though the payer enrollment processes are often more extensive. We've outlined an overview below.

Verify Provider Enrollment

Ensure you’re enrolled as a Medicare provider through the Provider Enrollment, Chain, and Ownership System (PECOS). Check out this CMS guide on becoming a Medicare provider. Follow the steps to obtain your National Provider Identifier (NPI) and Medicare Provider Number (PTAN).

Add Medicare as a Payer

Navigate to the Billing Settings in Sessions Health.

Go to Insurance > Payers and search for Medicare.

Locate the appropriate Medicare Part B payer for your state. For example, "TX Medicare Part B" or "OH Medicare Part B".

Complete Electronic Services (EDI) Enrollments

Some payers require additional enrollments for electronic claims, remittance advice (ERA), or eligibility checks.

Check your payer list in the EHR:

• Select Enroll next to Medicare and follow the instructions.
• Complete forms and steps as instructed and submit electronically if required.
• Enrollment for these services may take several weeks, depending on the payer.

Configure Billing and Claims Settings

• You will need to know if Medicare expects you to submit claims as an Organization using a Type 2 (group) NPI and tax ID (TIN/EIN), or if they expect you to use a Type 1 (Individual) NPI and SSN. Each one may have a different requirement based on your provider enrollment.
• Ensure that Sessions Health is set up to apply the correct combinations of these numbers for your claims.
• Also review any payer requirements involving submission of a taxonomy code or a payer-specific provider number.

Test Claims

We recommend submitting one claim first as a test claim (even though we are labeling it as a test claim, it would be an actual claim for an actual client you have had) to ensure your setup is correct. If it is, you can begin submitting the additional Medicare claims you have. If it is not, review rejections and resolve any issues with:

• Payer IDs
• Provider credentials
• Service codes or modifiers

While getting started with Medicare can seem daunting, breaking the process into clear, actionable steps makes it manageable. By following the above recommendations, you’ll be well on your way to navigating this essential payer source with confidence.

While the process may take time and attention to detail, Medicare can become a reliable and valuable payer source for your practice. Remember, patience is key as enrollments and claims adjustments are often part of the journey. With a solid setup in place, you’ll be positioned to streamline your billing and focus on delivering quality care to your clients.

FAQs

How do I resubmit a Medicare claim?

In general, Medicare claims must be filed to the Medicare claims processing contractor no later than 12 months, or 1 calendar year, from the date the services were furnished. This includes resubmitting corrected claims that were unprocessable. When resubmitting Medicare claims, you should submit them as an original submission, leaving Resubmission Information empty.

How do I know if I should bill under my individual (type 1) NPI or my organization (type 2) NPI?

This depends on your enrollment. It’s important to verify with Medicare whether they expect claims under a Type 1 (individual) or Type 2 (group) NPI. You can usually find your contracted information in your PECOS account.

What do I do if my client has a secondary payer in addition to Medicare?

For most secondary insurance payers, Medicare will send the claim on directly to the secondary payer. We still recommend including the secondary payer insurance policy information in the client's account to have that information on file.