Advance Payments to Providers of Part B Services: Updated Summary of the Requirements
Palmetto GBA and the Centers for Medicare & Medicaid Services (CMS) will consider, in limited circumstances, an advance payment for Part B providers who are experiencing financial hardship due to claims that are unable to process within established time limits. This applies to claims that have been submitted, but payment has not been made due to a system malfunction. This does not apply to claims that have not paid due to claims submission errors.
Examples of problems include:
- Providers who receive rejections or denials due to National Provider Identifier (NPI) crosswalk issues
- Providers whose claims are not being paid at the correct rate due to a payment rate not being correct in the system
Issues that will not be considered for an advance payment are:
- Providers whose payments are on a hold due to an address change
- Providers whose Electronic Funds Transfer (EFT) application was not received and payments are on hold
- Providers who are having issues with clearinghouses or billing providers
Advance payment may be made if all of the following conditions are met:
- Palmetto GBA is unable to process the claim timely
- CMS determines that the prompt payment interest provision specified in section 1842(c) of the Act is insufficient to make a claimant whole
- CMS provides written approval to Palmetto GBA to make an advance payment
Advance payment cannot be made if any of the following conditions is met. The provider:
- Is delinquent in repaying a Medicare overpayment
- Has been advised of being under active medical review or program integrity investigation
- Has not submitted any claims
- Has not accepted claims' assignments within the most recent 180-day period preceding the system malfunction
If you meet all required conditions and would like to request advance payments, you must submit the following:
- A written letter on company letterhead that includes:
- Ptan/Provider Number – Group and Individual
- NPI number – Group and Individual
- CCN number – If the provider is waiting on a Provider Enrollment application please include the CCN reference number
- A brief explanation of the problem, including the reason your cash balance is seriously impaired
- Who can we can speak to about the request
- Signed by an authorized person
- Financial information to show hardship in the format below:
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a. Cash on hand as of ________
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$_____
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b. Expected payments from all sources (not including any advance payments) in the next 30 days
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$_____
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c. Expected expenses in next 30 days
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$_____
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d. Cash position in next 30 days (a + b - c)
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$_____
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If Palmetto GBA determines there is a problem, we have 30 days to fix the problem from the receipt date of the Advance Payment request or issue an Advance Payment. If an Advance Payment is needed, Palmetto GBA will calculate payment based on one of two scenarios:
- Average past payment history
- Claims in approved to pay status. Palmetto GBA will recommend 70 percent of the amount calculated. The request for payment will be forwarded to CMS for approval.
If approved, you agree that Palmetto GBA will recover the advance payment by applying the amount due to future payments. The decision to approve an advance payment and the amount of the payment are at CMS's discretion and are not subject to review or appeal.
The complete listing of the requirements for advance payments for Part B services are found in the Federal Register at www.gpoaccess.gov/cfr/index.html. Click on 'Retrieve by CFR Citation' and type 42 in the Title box, 421 in the Part box and 214 in the Section box. Then click on 'Go.'
J1 advance payment requests should be sent or faxed to:
J1 MAC – Palmetto GBA
Attn: Vicky Bowers AG-325
'MSC J1-4084'
17 Technology Circle
Columbia, SC 29203-9591
Fax number: (803) 763-5575