1. Eligibility and Enrollment
✔ Verify the patient’s Medicare Part A, B, C, or D coverage
✔ Confirm the provider is enrolled and approved by Medicare
✔ Use the correct payer ID and submit through accepted channels
2. Billing and Coding Standards
✔ Follow CMS billing rules for CPT, HCPCS, and ICD-10
✔ Include place-of-service codes and required modifiers
✔ Use Medicare Fee Schedules for pricing accuracy
3. Claim Submission Guidelines
✔ Submit claims within 12 months of service date
✔ Ensure CMS-1500 (for providers) or UB-04 (for facilities) is complete
✔ Attach supporting documentation for medical necessity
4. Audit and Compliance Protocols
✔ Maintain signed documentation and treatment plans
✔ Respond promptly to Medicare Additional Documentation Requests (ADRs)
✔ Keep billing records for at least 6 years
5. Common Challenges & Fixes
| Challenge | Fix |
| Claim rejections due to errors | Use pre-submission scrubbing and validation tools |
| Incomplete provider enrollment | Check PECOS and revalidate on schedule |
| Delayed payments | Track claim statuses weekly and follow up early |
| Complex rules and frequent updates | Subscribe to CMS updates and train staff monthly |
