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Madison, WI 53708-8248
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Medicare Provider Enrollment
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Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
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Medicare Provider Enrollment
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Mail audit materials:
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ATTN: Audit Supervisor
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Madison, WI 53713-1834
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Excluded Services and Providers
You currently have jurisdiction selected, however this page only applies to these jurisdiction(s): .
Medicare does not pay services when laws exclude services or provider coverage. The patient pays for all charges relating to these services.
Excluded Services
There are services the Social Security Act excludes from Medicare coverage. No matter how the provider bills the service, Medicare will not pay. Excluded services deny without appeal rights.
- Examples of excluded services include:
- Experimental or research medical procedures
- Unless in an approved trial
- Services outside the USA
- Services paid by another federal program or insurance
- Chiropractic care
- Except manual spinal manipulation
- Eye refraction
- Personal comfort items
- Routine foot care
- Personal comfort items
- Glasses
- Except one pair following cataract surgery
- Hearing aids
- Ambulance transports not meeting medical necessity
- Cosmetic surgery
- Dental services
- Services because of war
- Services with no obligation to pay
For noncovered services, Medicare excludes all associated services. For instance, a patient has a routine physical exam and the provider orders routine blood work. This is not a medically necessary service. Medicare excludes the exam, venipuncture, and blood work for this reason.
The Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 16-General Exclusions From Coverage provides detailed information.
Billing Excluded Services
Medicare does not mandate the provider to bill excluded services. The patient receives the Medicare & You handbook each year explaining the coverage exclusion.
There are times a provider may need to bill Medicare for an excluded service. These include:
- The patient’s request.
- The patient has primary insurance, and the insurance needs a Medicare denial.
Bill the claim line item with one of the following modifiers:
- Modifier GX: Excluded service Advance Beneficiary Notice of Noncoverage (ABN) issued.
- The ABN is for informational purposes.
- Medicare does not need a provider to issue an ABN.
- Modifier GY: Excluded service, no ABN issued.
If you choose not to use a modifier, Medicare may deny the claim. Also, the claim processing can take longer. We always recommend including a modifier.
To learn more about providing the Advance Beneficiary Notice of Noncoverage, view:
- CMS Beneficiary Notices Initiative (BNI) web page
- WPS Government Health Administrators Advance Beneficiary Notice of Noncoverage (ABN) web page
Part A Claims
When applicable, providers billing on a UB-04 or electronic equivalent may use one of the following condition codes:
- Condition Code 21
- Provider deems all services on a claim as non-covered or excluded.
- The provider needs a denial to bill a Medicare supplemental insurer.
- Condition Code 20
- Provider deems the Skilled Nursing Facility (SNF) inpatient stay is not medically necessary.
- Patient requests billing of a non-covered inpatient SNF stay.
- Medicare reviews the documentation and determines if the stay meets medical necessity.
Excluded Providers
Medicare excludes services by professionals not meeting enrollment criteria. Patients can see these providers but are responsible for payment.
If a provider has legal action, then Medicare may exclude their services. To see providers excluded for legal action, visit the Office of Inspector General’s Exclusion Program web page.
Medicare is not able to process claims for excluded providers. The provider does not have a Medicare Provider Transaction Number (PTAN). Medicare revokes the number or deactivates the number. These denials are not appealable.
global-tags: J8A,J5A,Coverage Criteria,J8B,J5B,Claims
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General Inquiries:
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Claim Status/Patient Eligibility:
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Claim Status/Patient Eligibility:
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