Medicare Eligibility Requirements

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By law, you’re allowed to sign up for any Medigap policy in your state as long as you enroll during the initial window, even if you have medical issues that would otherwise prevent you from getting covered. An insurer has to charge you the same premium rate as a healthy person, too, so enrolling during this initial period is essential if you need the extra coverage. Your guarantees under the initial enrollment window expire once that 6-month eligibility period ends. Outside of the initial eligibility window, you may not find Medigap coverage at all. And if you do, it will probably cost a lot more.
Source: medicare.net

Ohio Department of Insurance

Medicare Advantage plans are options approved by Medicare but run by private companies. They are part of the Medicare Program. With Medicare Advantage plans you generally get all your Medicare-covered health care through that plan. Coverage can include prescription drug coverage. You may get extra benefits, such as coverage for vision, hearing, dental, and/or health and wellness programs. You may have to use the plan’s doctors and hospitals to get services. You don’t need to buy a Medigap policy. These plans may require a monthly premium in addition to your Part B premium.
Source: ohio.gov

Beneficiary Eligibility Denials

Denial Reason, Reason/Remark Code(s) PR-26: Expenses incurred prior to coverage PR-27: Expenses incurred after coverage terminated Resolution/Resources: Verify patient eligibility prior to submitting claims to Medicare through the Palmetto GBA Online Provider Services (OPS) tool or Interactive Voice Response (IVR) unit. We have to check the eligibility information through the insurance website or by calling the payer. Once we got the information we have to check the billed Date Of Service, if it prior or after the coverage then we can very well go ahead and bill the patient without any hesitation. Online Eligibility Verification through eServices All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so. Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI. Online Eligibility Verification through OPS
Source: medicarepaymentandreimbursement.com

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