Updates and Educational Resources for Providers

Updates and Educational Resources for Providers

Billing Qualified Medicare Beneficiaries (QMBs)

The Medicare Savings Program for QMBs available through state Medicaid assists low-income Medicare beneficiaries with paying Medicare Part A and Part B premiums and cost-sharing, including deductibles, coinsurance and copays.

Per the Centers for Medicare & Medicaid Services (CMS) and CarePlus provider participation agreements, physicians and other healthcare providers should not bill patients in the QMB program for Medicare cost-sharing. This includes plan deductibles, copayments and coinsurance and/or Medicare Part A or B deductibles and coinsurance for any Medicare-covered product or service. Individuals in the QMB program have no legal obligation to pay these fees. Please note that CMS could impose sanctions on physicians/healthcare providers who charge such fees to an individual in the QMB program. Physicians and healthcare providers may bill state Medicaid agencies for Medicare cost-sharing amounts.

To properly identify CarePlus-covered patients with QMB status, participating physicians/providers can use one or more of the following options:

You also may use the following resources when applicable:

  • The Medicare provider remittance advice, which lists new notifications and information about a patient’s QMB status. See this CMS Medicare Learning Network “Matters” PDFarticle (PDF opens in new window) for more information.
  • Medicare eligibility data provided by the Health Insurance Portability and Accountability (HIPAA) Eligibility Transaction System (HETS). Click here (link opens in new window) for more information about HETS. This is available to physicians, suppliers and authorized billing agents.

States’ online Medicaid eligibility systems or state-issued Medicaid identification cards and other documents that show the patient is enrolled in QMB.

A CMS MLN “Matters®” article addresses this topic in detail here (PDF opens in new window).

More information about the QMB program can be found on the CMS QMB webpage (link opens in new window).

If you have general questions about QMB or need assistance, please contact your designated provider services executive or call the CarePlus Provider Operations Help Line at 1-866-220-5448, Monday through Friday, 8 a.m. to 4 p.m. Eastern time.

New Medicare Member ID Numbers Begin Rolling Out in April

CMS is issuing new Medicare ID numbers and ID cards to all Medicare beneficiaries between April 1, 2018, and April 1, 2019.

Health Insurance Claim Number (HICN) Replacement with Medicare Beneficiary Identifier (MBI) effective April 2019

The Centers for Medicare & Medicaid Services (CMS) uses the HICN with multiple parties, such as Medicare providers and Medicare plans. The Medicare Access and CHIP Reauthorization (MACRA) of 2015 mandates the removal of the Social Security number-based HICN from Medicare cards to reduce the risk of medical identity theft. Per the legislative requirement, CMS must mail Medicare cards with the new MBI by April 2019.

Healthcare professionals are affected by this change. For additional information, visit (link opens in new window)http://go.cms.gov/ssnri.

Delegated Provider Resources

CarePlus and its parent company, Humana, are committed to informing you about legislative changes.

You can find information about new/revised legislation here (link opens in new window).

We encourage you to visit this site regularly and implement applicable legislatively required changes. Please note that legislative changes may become part of the delegation compliance oversight process.

Cultural and Linguistic Competency Resources

CarePlus recognizes cultural differences and the influence that race, ethnicity, language and socioeconomic status have on the healthcare experience and health outcomes. We are committed to developing strategies that eliminate health disparities and address gaps in care. Please refer to the below document for detailed information:

Tools to address cultural gaps in care (PDF opens in new window) 

Clinical Practice Guidelines

These clinical practice guidelines are taken from national organizations generally accepted in their fields as experts, including, but not limited to: the American Diabetes Association (ADA); the American College of Cardiology (ACC); the American Heart Association (AHA); the National Heart, Lung, and Blood Institute; the National Kidney Foundation and the Agency for Healthcare Research and Quality (AHRQ). Information contained in the guidelines inside the document below is not a substitute for a healthcare professional’s clinical judgment and is not always applicable to an individual. None of the information in the guidelines is intended to interfere with or prohibit clinical decisions made by a treating healthcare professional about medically available treatment options of patients.

Clinical Practice Guidelines(PDF opens in new window) 

Provider Crisis Contact/Location Information

Please complete the form below if a disaster or other crisis requires evacuation from your geographic area and/or relocation of your provider office(s). This information is needed so that the CarePlus Member Services department will have the most current information to provide to our members who may call for assistance in locating their providers during emergencies. If you have any questions on when or how to use this form, please contact your assigned CarePlus provider services executive or call the CarePlus provider services queue at 1-866-220-5448, Monday through Friday from 8 a.m. to 4 p.m.

Provider Crisis Contact/Location Information(PDF opens in new window) 

Infection Control and Prevention

CarePlus asks all contracted providers to have written policies for infection control and prevention that are readily available, updated annually and enforced. Please train all personnel in infection control and prevention policies. The Centers for Disease Control and Prevention (CDC) provides standards and guidelines that are appropriate for most patient encounters. Furthermore, the Occupational Safety and Health Administration (OSHA) requires physicians and/or facilities as employers to have processes in place to minimize the risk of their employees' exposure to bloodborne pathogens or other potentially infectious materials.

Our “Additional Resources – Infection Control and Prevention” document can assist you and your staff in locating guidelines and best practices to reduce the day-to-day risks of transmission in your office/facility setting.

Additional Resources — Infection Control and Prevention(PDF opens in new window) 

CMS Transmittals and National Coverage Determinations (NCDs)

The Centers for Medicare & Medicaid Services (CMS) issues program transmittals to communicate new or changed policies and/or procedures that are being incorporated into a specific CMS program manual. The cover page (or transmittal) summarizes the new material, specifying what has changed. CMS has developed MLN Matters® bulletins that provide Medicare coverage and reimbursement rules in a brief and easy-to-understand format.

It's important that you remain up to date on all regulatory changes as it is your responsibility to implement applicable changes.

To find specific CMS transmittals or MLN Matters® articles, please visit the CMS website using the following links:

CMS Transmittals (link opens in new window) 

MLN Matters articles (link opens in new window) 

CMS occasionally makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations (NCDs). Visit our NCD information page for details.

Sequestration Reductions for Participating Providers

As sequestration reductions have now been imposed by the Centers for Medicare & Medicaid Services (CMS), CarePlus has implemented the same reductions to network and non-network provider payments. All non-network providers and network providers who are reimbursed using a fee schedule based on the Medicare payment system, percentage of Medicare Advantage premium or Medicare allowed amount (e.g., resource-based relative value scale [RBRVS], diagnosis-related group [DRG], etc.) will have the same sequestration reduction applied in the same manner as CMS. This reduction applies to all Medicare Advantage plans.

The sequestration reduction amount for each affected claim will be identified on the explanation of remittance providers will receive from CarePlus. On paper remittances, the sequestration reduction amount will appear for each line item on all affected claims. Each affected claim also will be noted with the following description, "The amount listed in the SEQ.AMT field represents a deduction from the total claim payment. This deduction is a percentage based on the sequestration from the Budget Control Act of 2011. The member shall not be held financially responsible for the sequestration amount."

Questions may be directed to your assigned CarePlus Provider Services Executive (PSE). Additionally, participating providers may refer to the “CMS Medicare FFS' Provider e-News” (dated March 8, 2013) (PDF opens in new window)  for more information.