Please Complete Your Assurance of Payment (AOP) Form
The Centers for Medicare & Medicaid Services (CMS) requires that Palmetto GBA must determine if a provider has received payment from any other source prior to making any payment as a result of a reconsideration for a previously denied claim.
An AOP form is sent with the determination letter when a favorable reconsideration decision is made. This form must be completed and returned to the Appeals Department before the claim can be forwarded to the Claims Department for payment.
Currently there are more than 100 claims pending for providers who have not returned the AOP form. Effective July 21, 2003, the Appeals Department will print the AOP form on blue paper and mark the envelope that is sent to a provider with a time sensitive stamp. This process will ensure and increase the timely receipt of AOP Forms. In addition, there will be a copy of an AOP Form placed under the South Carolina Part A Intermediary and Regional Home Health & Hospice Intermediary (RHHI) Forms sections of the Palmetto GBA Web site, in the event that the original form is misplaced.
Providers are encouraged to complete and return the forms in a timely manner, to ensure prompt payment for appealed claims. Attached is a copy of the form.