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J11 Part A Palmetto GBA Processing Questions and
Answers
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Disclaimer
This presentation was current at the time it was published or uploaded onto the Palmetto GBA Web site. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
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Agenda
Medical Review/Medical Affairs Policy Questions
Claims Processing and Edit Questions Appeals Questions RAC Notification/Demand Letter Questions EDI/5010 Questions General Questions Customer Service Questions
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Medical Review/Medical Affairs Policy Questions
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PET scans being denied inappropriately
See the CMS PET scan NCD Providers are advised to review the article
“Additional Billing Clarification for Positron Emission Tomography (PET)”
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Claims billed according to LCDs are being denied inappropriately
Assure applied the LCD in effect for the dates of service of the claim
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Claims Processing and Edit Questions
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Review why all MUEs can’t be published
MLN publication ICN 006973 CMS will not publish all MUE values because
of fraud and abuse concerns
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Publish and update Medicare reject code cross walk
Providers advised to review the article “Reason Code Differences Between Palmetto GBA and NGS: Virginia and West Virginia Providers”
Reason Code Resource Tool
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When to Submit a Clerical Error Reopening Form
Human or mechanical errors on the part of the party or the contractor, such as: Mathematical or computational mistakes Transposed procedure or diagnostic codes Inaccurate data entry Computer errors Incorrect data items, such as provider number, use of a
modifier or date of service
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When to Submit a Clerical Error Reopening Form
If there is a medically denied line item on the claim, the provider wants to change something OTHER THAN the denied line and FISS does not allow an adjustment, the provider should submit a hard copy adjustment using the Clerical Error Reopening Request
A contractor shall NOT grant a reopening to add items or services that were not previously billed
Clerical Error Reopening Request Form
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Slow processing of clerical error reopening requests
Allow 30 days for the processing Depending on the number of requests
received, the processing time may vary
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Too many claims go in ‘S’ Suspense status and hold there
Some type of claims intervention is required Claims can require intervention for a variety of
different reasons: MSP development Adjustment requests with claim change reason codes D4,
D8 and D9 Claims in ‘S’ status are worked daily Wait for the claim to move to a finalized status
before another claim is submitted
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Are providers required to use the GZ modifier?
Providers should use appropriate modifiers for the accurate assignment of liability
CR 7228 effective for dates of service on or after July 1, 2011: The GZ modifier indicates that an ABN was NOT issued Signifies that the provider expects denial due to a lack of medical
necessity based on an informed knowledge of Medicare policy. Medicare contractors will automatically deny claim line(s) submitted
with a GZ modifier Reflect a Claim Adjustment Reason Code of 50 (These services are non-
covered services because this is not deemed a “medical necessity” by the payer) and
Group Code of CO (Contractual Obligation) to show provider/supplier liability
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Condition Code 44 Use
In cases where a hospital utilization review committee determines: Hospital may change the beneficiary’s status from
inpatient to outpatient Submit an outpatient claim (TOBs 13x, 85x) for
medically necessary Medicare Part B services with Condition Code 44
If ALL of the following conditions are met: Change made PRIOR to discharge or release Hospital has NOT submitted an inpatient claim; Physician concurs with the utilization review committee’s
decision; and Concurrence documented in the medical record
Condition Code 44 Use Continued
Submits a 13x or 85x bill and report Condition Code 44 on the outpatient claim
When an inpatient admission is determined not to be medically necessary for inpatient AFTER a patient was discharged, the hospital may submit ancillary charges on the 12X bill type after the original paid amount is recovered
There should be no beneficiary responsibility for these instances.
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Inappropriate claim denials for overlap
Billing Disputes Resolution Requests Providers should ensure eligibility reviewed before
patient is admitted If records reflect that care is or was being provided by
another provider, and the previous provider has not finalized their billing, the receiving provider is responsible for contacting the existing/previous provider to request that they complete their billing
Should a dispute arise, both agencies are required under Medicare regulations to make an attempt to resolve
If the agencies are unable to resolve the dispute, Palmetto GBA may be contacted for assistance
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MSP Billing With Value Code 44
Provider report Value Code 44 to indicate the ALLOWED amount they are obligated to accept from primary payer
Only use value code 44 if: Balance due from patient and provider has contractual
agreement with primary payer The amount received is less than total charges, or The amount received from the primary payer is less than the
contracted amount. Note: The provider should NOT report if the allowed
amount is more than the total charges
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Understanding “D” adjustment codes
The following chart provides information on claim change reason condition codes.
Only one claim change reason code can be used on each claim being adjusted.
If more than one claim change reason code is entered, the claim will reject
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Understanding “D” adjustment codes
Code Description Code Description
D0Changes to Service Dates
D6 Cancel only to repay a duplicate OIG payment
D1 Changes to Charges D7** Change to Make Medicare Secondary Payer
D2 Changes in Revenue Codes/HCPCS/HIPPS
D8 Change to Make Medicare Primary Payer
D3 Second or Subsequent Interim PPS Bill
D4 Changes in Grouper Codes
D5 Cancel to correct HICN or Provider ID
D9*** Any Other Change
E0 (zero) Change in patient Status
** Use D9 when adjusting primary payer to bill for conditional payment.
***This code is used if adding a modifier to change liability and there is no change to the covered charge amount.
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D9 Condition Code To reflect any other changes to be made to a claim that was
already processed To report an adjustment to a claim when an original claim
was rejected for MSP but Medicare is primary When the original claim was processed as an MSP or
conditional claim and a change needs to be made to the claim such as a change in the MSP value code amount If an adjusted claim is in a Return to Provider (RTP) it is important to
verify that the D9 code is being used correctly. If the D9 is the best code to use, the claim will need to include remarks indicating the reason for the adjustment. If remarks are not submitted, then the Medicare will RTP the claim using reason code 37541
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Reminder About Adjustments on Claims with Medically
Denied Lines If a line item on a claim is medically denied (status location = D B9997)
and the provider has medical evidence that he or she thinks should allow the denied service to be covered by Medicare, An Appeal must be filed
If there is a medically denied line item on the claim, but the provider needs to adjust the claim to make a change to something OTHER THAN the denied line item, The provider may key the adjustment in the system on the claim Once adjusted, the claim will go to an S 'suspense' status and location to be
reviewed by the claims department before processing Note: If there is a medically denied line item on the claim, and FISS
DOES NOT allow the provider to complete the adjustment electronically, In this instance the provider should submit a hard copy adjustment using the
Clerical Error Reopening Request form
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Understanding why claims go to SMRADJ status
SMRADJ is a status and location for mass adjustments
Claims go into ‘S’ or Suspense status when some type of claims intervention is required
If providers feel a claim is in S status for a prolonged period of time, they may contact the PCC for assistance with getting the claim finalized Providers are encouraged to ask for a tracking number
each time they contact the PCC Providers are advised to review the article “Claim
Status and Location Hints”
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Claims in SMTIME status are mainly credit balance adjustments done after
normal timely filing period If you have a claim that needs to have timely filing
overridden to process and pay back an overpayment, If the claim is still online you just need to adjust it and put
in remarks the reason is to repay the overpayment If it is offline, call the PCC to request it be placed back
online so you can then make the adjustment with remarks This will assure the claim processes and you know
the amount to pay back. The only time you report it on the credit balance
report is if the claim did not get adjusted that quarter
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Extension on the time limit for claims
For other claims that meet the CMS requirements to have timeliness overridden please follow the job aid posted on Palmetto GBA’s Web site
According to CR 7270, there are four exceptions where providers can request an extension on the time limit for claims Administrative Error Retroactive Medicare Entitlement Retroactive Medicare Entitlement Involving State Medicaid
Agencies Retroactive Disenrollment from a Medicare Advantage (MA)
Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization
Timely Filing Job Aid
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Hospitals are receiving RTPs with reason code W7050 for Revenue
Code 0637
FISS narrative for reason code W7050 is, “non-covered under any Medicare outpatient benefit, based on statutory exclusion”
Providers should assure they are appending the GY modifier to the line with Revenue Code 0637 for billing self administered drugs
Providers should review the article “Instruction on Billing for Non-covered Items/Services”
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Claims in RB7516 Status and Location
CMS IOM Publication 100-05, Chapter 5, Section 60.1.3.2.1, B “Cost avoidance savings may not duplicate
savings reported as full or partial recoveries and may not be shown where Medicare ultimately makes primary payment”
“The CMS prefers cost avoidance savings only after 75 days have elapsed”
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Claims in RB7516 Status and Location Continued
Claims in S/LOC “R B7516” are not finalized Must remain in R B7516 for 75 days to become
final Adjusting claims before final (R B9997 or P
B9997) receive the 30928 reason code Post-pay claim can be finalized by contacting
the PCC if and when the term date of the MSP record is prior to the dates of service of the claim
The Coordination of Benefits Contractor (COBC) should be contacted to delete/term MSP record
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Claims in RB7516 Status and Location Continued
If Medicare is secondary Submit an adjustment Claim must sit 75 days
If adjusting to make Medicare primary Indicate in Remarks that services are NOT related to an
open workers’ comp, liability, no-fault, or black lung record
Next, contact the PCC to finalize the claim Once the claim is finalized, the provider can submit the
adjustment and it should process
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Claims in RB7516 Status and Location Continued
Reminders: Do not attempt to adjust claims until final or until
CWF is updated Request processing if CWF is updated prior to your
75-day hold If claim has been in R B7516 longer than 75 days,
contact the PCC for assistance with processing the claim
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Increase in the number of claims RTP’d for Present on Admission
(POA) indicator Providers should refer to the job aid, “Present on
Admission (POA) Indicator: Troubleshooting RTP Claims”
If RTP’d with a reason code associated with the POA indicator, please verify the claim information against the job aid before contacting the PCC
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Claims rejecting for National Drug Code (NDC)
One NDC issue and it has been resolved An issue has been identified with Version 5010
National Drug Code (revenue code 0636) All providers who bill DMAP drug codes for
outpatient services need to report the NDC for the drugs administered
Hospitals are required to submit the NDC for outpatient services only
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Issues with billing secondary claims to Medicare
Two MSP claims issues still pending: A system release incorrectly affected the Release of
Information (RI) field for the payer ID Medicare Secondary Payer (MSP) claims are returning
to the provider (RTP) incorrectly with reason code 33981.
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How will a provider get feedback from the COBC regarding
Condition Code 08? Providers have a variety of sources that can be used to obtain a
beneficiary’s other health insurance information. Direct Data Entry (DDE) system and Online Provider Services (OPS) portal
Used when a beneficiary refuses to give other health information The provider should also enter information in the Remarks The claim will be submitted to Medicare as primary Condition Code 08 flags the COBC for development of the other
insurance information The COBC will contact the beneficiary to determine whether insurance
coverage exists Depending on the results of the inquiry, the COBC should:
Notify the provider of the insurance coverage or Bill the beneficiary
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Clarification on the use of modifier AY
As per Change Request (7064), the AY modifier is used if the services are NOT related to the beneficiary’s ESRD dialysis treatment.
This will allow for separate payment outside of the ESRD PPS
The AY modifier should NOT be used if the service IS related.
In that case, the service will be considered part of the bundled PPS payment
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How can a provider resolve reason code 15202 when we have not received a system
generated request for an outlier code? To resolve reason code 15202 the provider must
enter on the claim: Occurrence Code 47 and Date the outlier began
The date the outlier began is included in the cost report days
Cost report days must match accommodation days When cost report days and accommodation days
match, reason code 15202 does not occur
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Why do we have to give the date and amount of the outlier?
It is not the practice of Palmetto GBA to calculate outliers for providers
Medicare requirements are that the provider must make this determination
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Appeals Questions
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How would we be able to follow-up on RAC appeals
Providers can check the status of ANY first level redetermination/appeal by calling the PCC at 866-830-3455
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Determining to Appeal
Providers can appeal a claim or claim line that receives a full or partial medical denial
If a claim or line item is medically denied (status location = D B9997) and the provider has medical evidence that the service should be covered by Medicare, an appeal may be submitted by using the First Request: Redetermination Request Form.
To access this form, go to www.PalmettoGBA.com/J11A and select Forms from the Top Links box on the left navigation
Redetermination Request Form
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Appeals in relation to MUEs
If there is a “charge denial” (MUE) that a provider is requesting an appeal on, they can move this item to the covered column if they are sending an adjustment bill.
Most of the MUE denials are bundled services, but not all. If the MUE is a bundled item, the review must be performed to assure that the provider actually orders and provided the number of units billed.
In most cases, the provider has billed more units than they have ordered and provided to the patient. Here again, they do not need to send in an adjustment bill, the appeals team can review and adjust accordingly all types of denial.
Providers should also refer to the MUE job aid for more information on MUEs
MUE Job Aid
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Tips for Filing Appeals
Do not show the items as both covered and non-covered on the adjustment
Move the specific line item from the non-covered column to the covered column. They should not move all items to the covered column
The appeals department does not need an adjustment bill to adjust a claim. In fact, if they don’t send an adjustment bill, the appeals team will review their requested item only
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Tips for Filing Appeals
Providers are not required to submit an adjusted UB04 if there are no changes, it is actually better if they don’t.
They must specify what they are requesting the appeal for. If the provider has not requested an item on the reconsideration or redetermination appeal request, then the appeals team does not have authority to review the item.
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Tips for Filing Appeals
Please attach all documentation that you would like included in the redetermination.
Examples of supporting documentation would include: Medical records for the dates of service appealed Certifications/Recertifications for the appropriate dates of
service Office records/progress notes Treatment plan/plan of care Physician’s orders
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What Should NOT Be Appealed?
Requests for timely filing extensions Provider overlap billing disputes Items NOT denied due to medical necessity Adjustments that can be handled online Clerical errors
Note: Contractors shall treat the request as a request for reopening and transfer it to the reopenings unit for processing
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Appeals are taking more than 60 days for Palmetto to process
Rapid escalation in workload receipts far in excess of historical levels or projections
Caused a delayed in processing appeals Implemented processes and technology
improvements and are preparing additional staff
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RAC Notification/Demand Letter Questions
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How the process works between the RAC and Palmetto GBA
Recovery Audit Program MAC-Issued Demand Letters Effective date: January 1, 2012 Implementation date: January 3, 2012
Medicare’s Recovery Audit Contractors (RACs) no longer issue demand letters
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How the process works between the RAC and Palmetto GBA
Why Was This Change Made? To avoid any delays in demand letter issuance
What Is The New Process? When a RAC finds that improper payments have been
made to you, they will submit claim adjustments to your claims processing Medicare MAC, Palmetto GBA
Palmetto GBA will then establish receivables and issue automated demand letters to you for any RAC identified overpayment
We will follow the same process as is used to recover any other overpayment from you
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How the process works between the RAC and Palmetto GBA
RAC Responsibilities Identify improper payments Submit claim adjustment to the MAC Respond to any audit specific questions you may have, such as
their rationale for identifying the potential improper payment
MAC Responsibilities Issue demand letters Perform the adjustments based on the RAC’s review Handle administrative concerns such as timeframes for payment
recovery and the appeals process Include the name of the initiating RAC and their contact
information in the related demand letter
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How the process works between the RAC and Palmetto GBA
The RAC demands will be sent to the same address as any other demand letter that is sent from the MAC
The address that is used to mail RAC demand letters is the provider’s physical address
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How will we be able to identify RAC adjustments?
When a RAC or CERT adjustment is made the type of bill (TOB) will show as XXH
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Example of how RAC automated accounts will appear on the RA
•RAC adjustments are identified by remark code N432
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What address is the MAC using to mail the RAC demand letters?
RAC demand letters sent to the same address (physical address) that is used for any other demand letter
MAC Regulations Regarding Provider Specific Contact Information
A provider will NOT be able to specialize the address and contact person for a demand letter as they currently do with the RAC
RAC Regulations Regarding Provider Specific Contact Information
A provider will still be able to specialize the address and contact person for development letters, requesting records and review results letters with the RAC
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Electronic Data Interchange (EDI)/5010
Questions
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Late notifications of 277 CA
An article was published on the Palmetto GBA Web site on 12/20/2011 in reference to 277CA issues that were resolved:
277CA Issues Resolved-Two recent system corrections have resulted in smoother processing of 5010 claims Some submitters experienced the overlay of 277CA files. This issue
has been corrected. Sporadic delivery of 277CA files has been resolved
We are not aware of any other 277CA issues at this time Please contact the Palmetto GBA Technology Support Center
(TSC) at (866) 749-4301
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General Questions
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Why can’t Palmetto GBA work with SSA to make eligibility
updates? MACs are not authorized to intervene on
eligibility issues The patient or their authorized representative
must communicate with the SSA to resolve any eligibility issues
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Does Palmetto GBA follow the first in first out process?
Yes All workload received is stamped with a
receipt date and scanned into our system when it arrives in our mail room
It is worked in the order in which it is received
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IVR doesn’t allow providers to verify primary insurance for a specific date of
service or provide the HMO’s name We do not currently offer this option in our
IVR We are exploring adding this functionality We will furnish more information once a
target date for this modification is identified
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Customer Service Questions
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PCC Process
The PCC should be contacted for: General coverage questions Claim denial System issues not on the Claims Processing
Issues Log Appeals status Provider overlapping claim disputes Timely filing extension requests
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PCC’s tier/triage process
Tier I Tier II Supervisor Tracking Numbers
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Hospitals are reporting an inability to get the Part A
benefits exhaust date The ANSI reason codes on the Medicare RA will indicate if
benefits have exhausted CMS does not require MACs to report the date benefits
exhausted IF your patient exhausts his/her benefits at your facility, you
will have that date as well as the necessary denial to send to another insurer on your RA
If benefits exhausted at another facility aside from yours, when you submit your claim as covered to Medicare and if the benefits are exhausted, the claim will be denied with the ANSI reason code stating benefits are exhausted and indicate what the beneficiary or their supplement insurer owes
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Palmetto GBA gives the provider number of the overlapping provider,
but not the provider name CSRs have been educating the provider on
how to locate the name of the other provider using the CMS Web site.
Effective November 14, 2011, we revised our practice to include furnishing the provider name as well
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What can we do if a CSR does not give an accurate response?
If you feel you have received inaccurate information, please let us know by contacting us via email Go to www.PalmettoGBA.com/Medicare, Click on “Contact Us”, Select “J11 Part A MAC”, Scroll down to the PCC section and Click on the hyperlink to send us an email
Please include the CSR’s name and the tracking number
Note: Please do NOT include Protected Health Information
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Never get a call back from the PCC
We are addressing the process and timeliness of callbacks
CMS requirement is 10 business days If not received, contact the PCC with the
tracking number to inquire about the status
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Still receiving limitations of 3 inquiries per call
The only time we limit the number is if we are experiencing an abnormally high volume of calls
Inquire about setting up an appointment or receiving a call back
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Questions?
