I am currently not a Medicare Provider but would like to start accepting Medicare claims. What do I need to do?
You will need to apply for an NSC number from Medicare. After you've received your NSC number you can then sign up for CareCLAIM and begin filing claims electronically. A copy of the application you will need to complete, along with a helpful cheat sheet, can be found here.

Are claims submitted electronically or on paper?
All claims are processed electronically. CareCLAIM was designed to be paperless.

Are both assigned and non-assigned claims allowed?
Yes. Participating pharmacies must accept assignment on all claims. Non-participating pharmacies have the option to accept assignment for individual patients or on a claim-by-claim basis with the exception of mandatory assignment acceptance for Medicare Part B covered drugs.

How are reversals handled?
Pharmacies have a "reversal window" after which claims are sent to Medicare for payment. The typical reversal window is three days. However it can be customized per pharmacy.

Are rejected claims visible to the pharmacist?
Yes, like any other third-party prescription, rejected responses are returned immediately to the pharmacist along with the reason for the rejection. Paid responses include the estimated dispensing fee and any coinsurance deductible amounts to be collected from the patient.

How are estimated fees and coinsurance amounts calculated for both assigned and non-assigned claims?
Reimbursement is based on the Medicare Allowable Price (MAP) for each item. Pharmacies send the U&C price to CareCLAIM where it is compared against the MAP. If the U&C differs from the MAP, then the pharmacist is advised of the difference.

How is Narrative Record Information transmitted to Medicare?
Additional information can be faxed to CareCLAIM using a Supplemental Information Request Form.

How does CareCLAIM handle the patient’s deductible?
If the patient has already met their calendar year deductible it is indicated on the first claim. When the deductible has not been met, CareCLAIM accumulates deductible costs and automatically transitions to the 80-20% rule.

How are crossover claims handled?
Automatically when the secondary insurance is Medicaid, or a participating Medigap insurer. A list of Medigap insurers is included in the Medicare Regional DMEPOS Supplier Manual.

How are secondary non-cross over insurance claims handled?
For secondary insurance that doesn’t automatically crossover, CareCLAIM prints a CMS 1500 Form that can be mailed to the secondary insurance carrier.

How is the correct DMERC submission determined?
CareCLAIM pharmacies are registered with all of the Regional DMERC’s to ensure claims are paid. Claims are submitted directly to the DMERC region that covers the State of the patient’s permanent residence during the past six months

Who receives Medicare payments? Patient, OmniSYS, LLC., or Pharmacy?
Payments are sent to either the patient or the pharmacy based on whether assignment was accepted for the claim.

What does Medicare cover?
Medicare Part B coverage includes: Canes, Crutches, Commodes, Blood Glucose Monitors, Test Strips, Lancets, Control Solution, Spinal Orthotics, Oral Anti-Cancer Drugs, Walkers, Ostomy Supplies, Surgical Dressings, Erectile Aids, Transplant Drugs, Prosthetics, Nebulizer Medications, Seat Lift Mechanisms, Oral Anti-Emetic Drugs, Oral Anti-Cancer Drugs and more...

What items are NOT covered by Medicare
Some examples of items NEVER covered by Medicare include: Alcohol Wipes, Syringes, Insulin, Peroxide, Surgical Stockings, Alcohol, Adult Diapers, Urine Test Strips, Betadine, Cotton Swabs, Iodine Wipes, Wigs, Ramps, Bath Aids, Air Conditioners, Stair Lifts, Grabbers, Hearing Aids, and most Prescribed Drugs. This is NOT a complete listing.

I'm new to Medicare. Where can I go to find more information about Medicare policies?
Palmetto GBA recently published a handbook for new suppliers which can be found here. While the handbook is designed for providers in Region C, most of the information is valid nationwide.