Health Insurance Payers, Medicare, Medicaid & Prior Auth FAQ
Navigating regional Medicare Administrative Contractors, Medicaid Managed Care, commercial PPO/HMO edits, and prior authorizations.
Detailed Questions & Answers
Prior Authorization & Payer ManagementWhich government and commercial payers does VOPSS bill?
We bill all 50-state regional Medicare Part A/B MACs, all 4 DME MAC jurisdictions, state Medicaid programs and Medicaid MCOs, TRICARE, VA Community Care, Workers' Compensation, auto/PIP carriers, and national/regional commercial plans (BCBS, UHC, Aetna, Cigna, Humana, Kaiser, Molina, Centene).
Why do Medicare Advantage (Part C) claims follow different rules than Original Medicare?
Although Medicare Advantage plans must cover Medicare Part A/B benefits, they are administered by private carriers (such as UHC, Humana, or Aetna) with their own prior-authorization lists, clearinghouse Payer IDs, timely-filing windows, and commercial appeal portals.
How do you manage complex prior authorizations for imaging, surgery, and biologics?
Our prior-auth team verifies CPT-level authorization requirements via payer portals (Availity, Evicore, Carelon/AIM, Cohere Health), attaches clinical medical necessity notes, tracks pending reference numbers, and logs approved auth IDs in EHR claim Loop 2300.
How does Coordination of Benefits (COB) work for dual Medicare-Medicaid (Medi-Medi) patients?
Medicare pays primary (either Original Medicare or a Dual-Eligible Special Needs Plan / D-SNP), and state Medicaid or the Medicaid MCO processes secondary cost-sharing up to the state's Medicaid allowable ceiling—with strict federal prohibitions against balance billing Qualified Medicare Beneficiaries (QMBs).
Can practices balance bill Qualified Medicare Beneficiaries (QMBs)?
No. Federal law prohibits Medicare providers from billing QMB individuals for Medicare Part A or Part B deductibles, coinsurance, or copayments, even if state Medicaid pays zero on the secondary crossover claim.
How does the federal No Surprises Act affect outpatient and hospital-based practices?
The No Surprises Act bars out-of-network balance billing for emergency care and non-emergency ancillary/surgical care rendered at in-network hospitals or ASCs (routing payment disputes through federal Independent Dispute Resolution) and mandates Good Faith Estimates for uninsured/self-pay patients.
What are timely filing deadlines across major insurance carriers?
Original Medicare allows 365 days from date of service, whereas many commercial HMO/PPO and Medicare Advantage plans enforce strict 90-day, 120-day, or 180-day initial filing limits (and 60-to-180-day corrected claim/appeal limits).
Do you handle Workers' Compensation and Personal Injury Protection (PIP) billing?
Yes. We verify open claim numbers, adjuster contact details, date of injury, state Workers' Comp fee schedules, and required clinical progress/work-status attachments (such as DWC-73 or state equivalents) on every submission.
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