As health care professionals and staff, you already understand the importance of data-based decision making. This concept is important to Palmetto GBA as well. Without data, we would be unable to effectively manage our funding and other resources, measure our successes and identify opportunities for improvement.
The Centers for Medicare & Medicaid Services (CMS) conducts surveys each year to gather data from you on how well we are meeting your needs and expectations. In this survey, many of you commented on the timeliness of our service. In some areas, such as claims processing, we received very positive feedback. In other areas, you have told us that we aren't as quick as you would like.
CMS has standards for contractors, including Palmetto GBA. CMS expects us to meet certain requirements. Here are a few examples:
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Activity
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CMS Requirement
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Process claims
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- Process all 'clean claims' within 30 days of the date of receipt. Palmetto GBA may pay interest on claims that are processed outside of this timeframe, with some exceptions
- The 30-day standard is not the same as the payment floor. The payment floor is the minimum amount of time that contractors must hold a claim prior to making payment.
- The payment floor for electronic claims is 13 days. Palmetto GBA may not pay electronic claims before at least 13 days from the date the claim is received. This does not mean that Palmetto GBA must make payment within 13 days; the key is that we may not pay the claim sooner than 13 days.
- The payment floor for paper claims is 29 days
- For more information on claims processing requirements, refer to the CMS Medicare Claims Processing Manual (PDF, 1.59 MB) (Pub. 100-04), chapter 1 section 80.2.2.1 and 80.2.2.2
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Process redeterminations (first level of appeal)
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- Complete 100 percent of redetermination requests within 60 days of the date of receipt
- For more information on redetermination requirements for Medicare contractors, refer to the CMS Medicare Claims Processing Manual (PDF, 585 KB) (Pub. 100-04), chapter 29 section 60.11.4.A
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Answer telephone inquiries
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- Calls referred to Customer Service Representatives (CSRs): each month, 85 percent of calls answered within 120 seconds or less
- Resolving questions during calls: at least 90 percent of calls completely resolved during the initial call
- For more information on telephone inquiry requirements, refer to the CMS Medicare Contractor Beneficiary and Provider Communications Manual (PDF, 680 KB) (Pub. 100-09), chapter 6, section 60.2
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Answer written inquiries (including
e-mail)
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- All written inquiries must be answered (either by telephone or in writing) within 45 business days. Palmetto GBA may send an interim response if we cannot answer the inquiry within this timeframe.
- Palmetto GBA will respond in writing to some complex inquiries that are received via telephone
- For more information on telephone inquiry requirements, refer to the CMS Medicare Contractor Beneficiary and Provider Communications Manual (PDF, 680 KB) (Pub. 100-09), chapter 6, section 60.3
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Our work as a Medicare contractor is driven by CMS. Palmetto GBA is constantly working to meet CMS requirements and your expectations within the real-world constraints of resources (people and funding). We are able and willing to assist you with any questions or concerns you have regarding this article specifically or about other aspects of the Medicare program. Here are a few of the resources Palmetto GBA provides to assist you in navigating Medicare guidelines:
- Topic- and specialty-specific articles, computer based training and free educational materials on the Palmetto GBA Web site
- Palmetto GBA e-mail updates: register through our Web site (no cost). We fully protect your privacy. E-mail updates are the most efficient means we have to deliver the latest Medicare news directly to you.
- Interactive Voice Response (IVR): call (877) 567-9232 (Ohio and West Virginia) or (866) 238-9654 (South Carolina Part B) to obtain information on claim status and payment amounts, plain English explanations of Medicare remark codes, and beneficiary eligibility
- Other questions: speak with a CSR by calling (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B). We are available from 8:30 a.m. to 4 p.m. EST Monday through Friday, excluding holidays and scheduled internal training. Please note: CSRs will be happy to assist with your questions; however, we cannot provide you with information that is available through the IVR.
Your Feedback
If you are selected to receive a Medicare Contractor Provider Services Survey in the future, we strongly encourage you to complete the survey and provide us with your feedback. Letting us know what we are doing well and telling us what we can do to continue to improve our service to you, will enable us to better meet your needs and expectations. The Medicare program has changed drastically over the last several years and will continue to do so. One constant is Palmetto GBA's commitment to providing excellent customer service to you.