Provider

When a patient presents a CareGuard card, it signifies their enrollment in Ametros’ professional administration service for managing their Medicare Set-Aside (MSA) account. This is a crucial step in ensuring proper management of settlement funds.

Purpose of the CareGuard Card

Your patient sustained a work-related or liability injury, resulting in a court settlement. They received funds aimed at covering future medical expenses tied to the injury.

CareGuard as the Primary Payer

Following the settlement, CareGuard is responsible for being the primary payer on all claims associated with the injury. It is essential for all medical billing related to the injury to be directed to CareGuard.

For comprehensive information on how CareGuard works within the framework of MSAs and its obligations as the primary payer, please refer to additional resources or reach out to the administering service directly.

CareGuard is not a Workers’ Compensation carrier. Instead, CareGuard serves as a professional administrator for post-settlement future medical funds. Our role does not involve the requirements typical of Workers’ Compensation carriers, such as additional documentation or reporting, and we impose no restrictions on the frequency of doctor appointments.

Understanding CareGuard's Role

CareGuard's primary function is to ensure members adhere to the constraints outlined in their settlement documentation. This makes our service distinct from traditional Workers' Compensation carriers, which have specific regulatory roles and responsibilities.

Differences From a Workers’ Compensation Carrier

Unlike insurance carriers, CareGuard focuses specifically on managing future medical expenses after a settlement. This management is done without the need for extra paperwork or reporting normally associated with other funds administrators.

Settlement Compliance

The only requirement CareGuard places on its members is compliance with their settlement documentation. This allows for more flexibility and individualized health care decisions.

For further insights into the differences between CareGuard and Workers' Compensation carriers, or for any other inquiries, you can contact us.

No, you cannot balance bill the patient when CareGuard manages post-settlement medical funds.

Role of CareGuard

CareGuard is not a Workers’ Compensation carrier. Rather, we serve as professional administrators for post-settlement future medical funds.

Patient Billing Restrictions

CareGuard does not require additional documentation or impose reporting rules. Additionally, there are no limitations placed on the frequency of doctor appointments for the member. However, it's crucial that the member adheres to the constraints outlined in their settlement documentation.

Understanding Settlement Constraints

Members must stay compliant within the specific terms outlined in their settlement agreements to ensure proper management of their medical funds.

For more detailed guidelines, we recommend reviewing settlement documentation or reaching out for professional advice.

Medicare typically acts as a secondary payer when a patient has settlement funds designated for future medical expenses through Workers’ Compensation or liability settlements. A Medicare Set Aside (MSA) is a common method to safeguard Medicare’s interests by preserving funds specifically for medical treatments and items related to the patient’s injury.

Responsibilities of Medicare Beneficiaries

Medicare beneficiaries are advised to inform their healthcare providers about their MSA. Providers should issue bills directly to the beneficiary, who should then utilize the MSA funds if:

• The treatment or prescription is related to the claimed injury or was covered by the settlement, judgment, award, or other payment.
• The treatment or prescription is typically covered by Medicare.

Provider Obligations

Providers are encouraged to document instances where patients indicate the necessity of using their settlement or MSA funds for medical services relating to their injury. Importantly, providers should accept payments directly from the professional administrator managing the Workers’ Compensation Medicare Set Aside (WCMSA) funds when applicable and refrain from billing Medicare if a third party administers the WCMSA funds.

Additional Considerations

The obligation to protect Medicare trust funds exists irrespective of whether there is a formally approved MSA amount by CMS. Beneficiaries may not always have documentation from Medicare approving the MSA amount for the physician or provider.

Source: Accepting Payment from Patients with a Medicare Set-Aside Arrangement

CareGuard ensures the payment of post-settlement claims that are related to your patient’s workers’ compensation or liability injury and must comply with Medicare guidelines.

Scope of CareGuard Coverage

CareGuard's role is to manage and pay claims for treatments and services that occur after a settlement, as long as these claims relate to the specific injury or condition resulting from the workers' compensation or liability case.

Importance of Medicare Compliance

All claims processed by CareGuard need to adhere to Medicare regulations. This ensures that the payments align with Medicare's expectations and rules regarding covered services and treatments.

To verify eligibility and benefits, including covered body parts and eligibility date for your patient, contact CareGuard at 877-905-7322.

Steps for Eligibility and Benefits Verification

When you need to verify your patient's eligibility and benefits, it's a straightforward process:

1. Contact CareGuard: Dial the dedicated helpline at 877-905-7322.
2. Provide Necessary Details: Have the patient's information ready, such as their identification number and any specific details regarding the settlement.

What Information Will You Receive?

By contacting CareGuard for eligibility verification, you can obtain:

• Confirmation of covered body parts.
• The specific eligibility date (settlement date).

Further Questions on Eligibility Verification?

If you have further questions regarding eligibility verification or specific benefits, CareGuard can provide additional support. Contact their helpline or visit their website for more detailed guidance.

CareGuard accepts claims typed on a CMS-1500 or UB-04.

When possible, we highly recommend submitting claims via our electronic payer ID, #20572.

Claims may also be mailed to the following address:

Please note, we are unable to accept faxed claims and cannot guarantee processing if the claim is submitted this way.

When you receive an Explanation of Reimbursement (EOR) with the message “Funds Exhausted, Bill Secondary,” it indicates that the available funds from the settlement for a work-related or liability injury have been depleted before the next annuity payment.

Immediate Steps to Take

At this point, you should reach out to your patient to gather information about their secondary insurance and proceed with resubmitting the claim. It's crucial to have the correct insurance details to ensure the claims process continues smoothly.

Handling Claims with Medicare

If your patient indicates that Medicare serves as their secondary insurance, submit the claim to Medicare, including a copy of the EOR. This documentation is necessary for proper processing by Medicare.

Ongoing Billing Practices

Even after receiving an EOR stating “Funds Exhausted,” continue to submit all future bills to CareGuard. This practice ensures you receive ongoing and correct EOR documentation for Medicare or other insurance providers. Once funds are replenished, CareGuard will automatically resume payments as the primary payer.

Final Details and Important References

For complicated scenarios or further guidance, consult the relevant insurance guidelines or reach out to your CareGuard contact for assistance. Continuing to follow these steps not only aids in claim processing but also prepares you for seamless transitions between insurance payers.

Maintain consistent communication with CareGuard and the patient to ensure all insurance details and claims submissions are accurate and updated.