decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Answer_Book / Limiting_Charge / Limiting_charge_applies_to_private_claims
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Article Overview
This article covers how the limiting charge applies when a physician bills a primary insurer other than Medicare and Medicare is secondary. It outlines the general limit, situations involving assignment or payment-in-full requirements, and the limited exceptions that may affect whether Medicare can be billed. The discussion is aimed at physicians, billing staff, and coders who handle Medicare Secondary Payer situations and private insurance claims.
Why This Topic Matters
Correct handling of limiting charge issues affects claim compliance, patient balance billing exposure, and coordination of benefits when Medicare is secondary. The article helps billing teams understand when a primary insurer payment may require adjustment or documentation before further billing action.
What You Will Learn
- How the limiting charge concept applies when Medicare is secondary to another insurer.
- What general conditions affect whether billing above the limiting charge is permitted.
- What broad documentation is associated with the exceptions discussed in the article.
- How claim handling can differ when the primary payer’s payment is applied in different ways.
Who Should Read This
- Physicians
- Medical billing staff
- Medical coders
- Practice managers
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