Type of Medicare Advantage Plan in which the member may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what the patient pays for the services. The patient may pay more or less for Medicare-covered benefits. The patient may have extra benefits the Original Medicare Plan does not cover.

Written guidelines that reflect the principles, values, and priorities for the Medicare Integrity Program. The primary principle of program integrity is to pay claims correctly.

National administrative code set used in the X12 835 claim payment and remittance advice transaction. It provides either claim-level or service-level Medicare-related messages that cannot be communicated with a claim adjustment reason code.

Paper-summarized statement for providers including payment information for one or more beneficiaries; equivalent to the electronic remittance notice (ERN) . See also electronic remittance notice (ERN), remittance advice (RA) , and explanation of benefits (EOB) .

Agreement between Medicare and a federally qualified HMO or competitive medical plan that provides Medicare-covered services for enrollees, receives monthly capitated payments from Medicare, and assumes insurance risk for its enrollees.

State Medicaid programs that help pay some or all Medicare premiums and deductibles if an individual meets certain income limits criteria.

Primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before Medicare is sent a claim. MSP may involve aged or disabled patients who are under group health plans and cases related to end-stage renal disease, black lung disease, workers’ compensation, automobile accidents (e.g., medical no-fault and liability insurance), and individuals receiving benefits under the Department of Veterans Affairs and Medicare. For a Medicare patient suffering from end-stage renal disease (ESRD), MSP is the payer for the first 30 months that the beneficiary is entitled to benefits.

Medicare edit on inpatient, outpatient, and physician insurance claims that indicates Medicare is the secondary payer. The outpatient code editor (OCE) marks claims with specific trauma diagnosis codes to identify claims about accidents because patients may be covered under other liability insurance that would be a primary payer. The insurance carrier places these claims in suspense for additional review and determination.