Medicare Supplement vs. Medicare Advantage/Replacement Plans:
Patients who have Medicare Part B insurance have the following options concerning their insurance plan:
1. Medicare only – Patients with Medicare Part B have a $203.00 annual deductible in 2021. Once the deductible is met, the plan pays 80% of the Medicare-allowed amount. Claims are filed directly to, and paid by, Medicare to either the provider or the patient, contingent on the enrollment status of the provider.
2. Medicare Supplement – Patients with Medicare Part B may also choose a supplemental plan to cover their 20% co-insurance. Supplemental plans are offered by many carriers, including AARP (through UnitedHealthcare [UHC]), Mutual of Omaha, or Tricare for Life. While all supplemental plans should cover the 20% Medicare coinsurance, some plans will also cover the annual deductible.
a. Medicare Supplement Plan F will cover Part B deductible and Part B co-insurance
b. Medicare Supplement Plan G will ONLY cover Part B co-insurance (not Part B deductible)
Claims are filed directly to and paid by Medicare to either the provider or the patient, contingent on the enrollment status of the provider. Upon the processing of the claim by Medicare, it should automatically “cross-over” to the supplemental plan. Payment for the 20% co-insurance should then be issued by the supplemental plan. If the claim does not cross-over, mail a claim on paper to the supplemental plan with a copy of the Medicare EOB.
3. Medicare Advantage/Replacement plans – A patient may elect to have their Medicare coverage administered by a different insurance carrier. Claims are filed to, and paid by, the insurance carrier directly (e.g., UHC, Humana, Blue Cross Blue Shield). These plans may be either a PPO type plan that will not require referrals or an HMO type that will require referrals. Some Medicare Advantage/Replacement Plans may include additional benefits that are not covered by traditional or Part B Medicare. (Many patients will also provide you a copy of their traditional Medicare card; if the patient has a Medicare Advantage/Replacement plan, traditional Medicare should not be entered in since it has been replaced.)
Choosing the Correct Insurance
The first step in getting a claim paid is to ensure that it is received by the correct insurance carrier. The most common reason for claims submitted to an incorrect insurance is when the claim is billed to Medicare when the patient has a Medicare Advantage/Replacement plan.
When a patient provides a copy of their Medicare ID card along with a secondary insurance ID card, you should confirm whether the secondary insurance ID card is for a Medicare Supplement Plan or a Medicare Advantage/Replacement Plan. Below are examples of three UHC Insurance ID cards, for Commercial Insurance Plan, Medicare Supplement Plan, and Medicare Advantage/Replacement Plan.
Some of the larger insurance carriers, such as Aetna, CIGNA, and UHC have other insurance carriers and plans that are affiliated with the network. In some cases, the claims are submitted to and processed by the larger/parent network. In other cases, the claims are submitted to and processed by the affiliated network with Aetna, CIGNA, or UHC being accessed only for the pricing/contractual discount.
In order to determine which insurance to choose, you will need to look closely at both the front and back of the insurance card to confirm if the claim needs to be submitted to the issuer of the insurance card or to the larger/parent network. A claim submitted to an incorrect insurance carrier may be rejected within a few days, but it may take 30-45 days depending on the insurance.
The new Aetna Medicare Plan – Advantra Freedom PPO shows Aetna Network, but claims are submitted to the Coventry EDI Payer ID/claims mailing address:
Tips on Entering Patient Insurance Information
- Enter the patient’s name exactly as it is listed on their primary insurance card
- Enter the insurance ID number without any spaces or punctuation
- Enter the payment source/payer type as per the listing below. This is required to ensure that the claim is submitted correctly and following the electronic claim guidelines for the plan type. Claims are rejected and/or denied when an incorrect payment source/payer type is used.
- Traditional Medicare only = Medicare
- Blue Cross, Blue Shield and Blue Cross Blue Shield = Blue Cross Blue Shield
- Traditional Medicaid only = Medicaid
- All other insurances = Commercial
If you’re in need of additional advice or tips, reach out to your Strategic Business Unit or learn about our billing and coding services for Audigy members.