 Providers |  |
| J1 WPS Transition | |
| LA & MS Part A EDI | |
| J1 WPS Transition | |
| Appeals | |
| Audit/Reimbursement | |
| Claim Processing | |
| EFT | |
| FAQs | |
| Medical Affairs and LCDs | |
| Medical Review | |
| Provider Enrollment | |
| Appeals | |
| View FAQ Documents | |
| View FAQ Documents | |
| How do we follow up on a claim already in the appeals process? | |
| How will the Recovery Audit Contractor (RAC) and other appeals be filed: to the old FI or the new MAC? | |
| If we get a denial, how do we address it? | |
| If we have a claim that was processed in July 2009 that needs to be appealed, will Palmetto GBA handle the appeals process for us after cutover? | |
| Regarding the old RAC audits that were recouped by NGS in 2007, will the repayment for these come from Palmetto GBA? | |
| What is the RAC adjustment code? | |
| What will happen with the current reopenings and appeals that we have filed? Will we receive a letter from the outgoing contractor or Palmetto GBA notifying us that the reopening/appeal is being transitioned over and is still pending? | |
| Will supporting documentation be required for paper and electronic claim adjustments? | |
| Audit/Reimbursement | |
| View FAQ Documents | |
| View FAQ Documents | |
| How do I change the contact information when mailing Provider Audit items? | |
| I have questions on my overpayment status, checks, withhold and other finance-related issues. Who do I contact? | |
| I need a PS&R report. Where do I request this information? | |
| Please provide some general information on the Medicare Provider Audit and Reimbursement area, First Coast Service Options, Inc., and Palmetto GBA. | |
| We have questions on desk reviews, audits, existing appeals, reopenings and other audit-related items. Who do we contact? | |
| Where should we send our PRRB appeals correspondence? | |
| Where will the Medicare cost reports be filed and when should I change the location in the Medicare cost reports? | |
| Who will be responsible for rate setting, payments, cost/charge ratios, etc.? | |
| Claim Processing | |
| View FAQ Documents | |
| View FAQ Documents | |
| Are pain medications administered post-operative separately billable on an inpatient acute (11X) claim? | |
| Are skilled nursing facilities (SNFs) subject to SNF consolidated billing as it relates to telehealth services? | |
| Are we required to obtain documentation of a face-to-face evaluation prior to providing a sleep study? | |
| Can the new Advance Beneficiary Notice (CMS-R-131) be revised to suit our needs? | |
| Do the daily nursing notes for a Skilled Nursing Facility (SNF) have to be done by a Registered Nurse (RN) or can they be done by a Licensed Practical Nurse (LPN)? | |
| For a date of service on or after January 1, 2009, how would a provider bill for an implanted prosthetic device that is furnished to a Medicare beneficiary who is a hospital inpatient, but does not have Part A coverage? | |
| For beneficiaries located at qualifying originating sites which require consultative input of physicians who are not available for a face-to-face encounter, what follow-up inpatient telehealth Healthcare Common Procedure Coding System (HCPCS) codes should be used? | |
| How should hospitals identify the emergency room (ER) encounter-related services that hospitals provide on a subsequent service date to beneficiaries in Type A Skilled Nursing Facility (SNF) stays? | |
| I am a biller for Method II Critical Access Hospital. Can we bill for physicians charges if they waive their rights to bill to the Medicare carrier? | |
| I am billing a claim for non-End Stage Renal Disease (ESRD) services. On one of the lines I am billing HCPC code J0885 with the EC modifier. Is this appropriate billing and is there reimbursement for that HCPC code? | |
| I am searching for the new RUGS rates that went into effect on October 1, 2008. Where can I go to find this information? | |
| I have a claim editing for reason code 31715 stating that the units of service are exceeding the medically reasonable daily allowance. What do I need to do to get this claim to process? | |
| I have a claim that has line denials for reason code C7251 stating that my outpatient claim is overlapping a Skilled Nursing Facility (SNF) inpatient (21X) claim. How can I tell whether this service is on the consolidated billing exclusion list? | |
| I have a claim that rejected for reason code 34002 stating that this beneficiary has coverage through an employer's group health plan that is primary over Medicare. We show that Medicare is the primary insurance. The Common Working File (CWF) has been updated to show that Medicare is primary. Can I adjust my claim now that the CWF is updated? | |
| I have a claim that rejected for reason code 39721 stating that the requested non-medical information was not received timely. How do I correct this claim? | |
| I have a claim that rejected for reason code T5052 stating that Common Working File (CWF) records indicate the beneficiary record is not on file. The claim was billed with the wrong Health Insurance Claim (HIC) number. Can I resubmit my claim with the correct HIC number? | |
| I have a claim that returned back to me for reason code W7072 stating to remove or update the non-billable HCPCS code. How can I find out which HCPCS code on my claim is non-billable? | |
| I have a claim that was rejected with reason code 34293 stating that the beneficiary has coverage through an employer group health plan that is primary to Medicare. The claim was rejected by the group health plan. How do I indicate this on my claim? | |
| I have a claim that was returned to me for reason code 32206 stating that the revenue code is invalid for this type of bill. Where can I verify what revenue codes are valid for the type of bill? | |
| I have a claim that was returned to me with reason code 31153 stating that therapy revenue codes 42X, 43X and 44X must be billed with an appropriate HCPCS modifier of GN, GO or GP. How do I correct my claim? | |
| I have a claim that was returned to me with reason code 31153 stating that therapy revenue codes 42X, 43X and 44X must be billed with an appropriate HCPCS modifier of GN, GO or GP. How do I correct my claim? | |
| I have an inpatient Part A SNF claim that rejected for reason code 11503 stating that admission date is greater than 30 days after the through date of the qualifying hospital stay. This patient was admitted more than 30 days after their 3-day qualifying hospital stay because their condition prevented them from being able to begin treatment. How do I bill this claim? | |
| I have an outpatient claim that denied with reason code C7050 because the dates of service fall within the dates of service of an inpatient hospital claim. What do I do? | |
| I have an outpatient claim that denied with reason code C7080 because the dates of service fall within the dates of service of an inpatient hospital claim (i.e. the outpatient date is 09/15/09 and the inpatient claim is from 09/01/09 through 09/20/09). What do I do? | |
| I need some clarification on the condition code 44. If we have a patient that discharges on Sunday and then on Monday morning the utilization review committee determines that the patient does not meet inpatient criteria. Can we bill an outpatient claim with the condition code 44? | |
| I submitted a MSP claim. The claim returned to me for reason code 77745 stating that Medicare's primary. How can I correct my claim? | |
| If an Inpatient Psychiatric Facility (IPF) must send a patient to another facility for care or treatment (e.g., dialysis), how does the IPF get reimbursed? | |
| If the admitting physician agrees that a patient should have been placed in observation instead of being admitted as an inpatient, does the case still have to go to Utilization Management (UM) committee to agree before utilizing the condition code 44? | |
| In order for providers to properly claim a bad debt and be reimbursed under the Medicare program, providers must follow all of the criteria for allowable bad debt. Where can providers locate this information? | |
| Our facility is a Part A outpatient rehabilitation facility. Do we need a signed signature on each plan of cares or can the doctor stamp his name? | |
| Under the hospital outpatient Prospective Payment System (PPS), how should a provider report more than one EKG performed in the same day? | |
| We are a critical access hospital and are providing patients with cardiac rehabilitation services. Should these services be billed monthly or daily? | |
| We are a Critical Access Hospital (CAH) that provides outpatient physical therapy. Is it appropriate for us to bill two 85X claims with the same dates of service for physical therapy? | |
| We are a Method II Critical Access Hospital. This year we qualify for the CRNA pass-through payments. Where can I find out how to bill for this service? | |
| We are a Part A outpatient rehabilitation facility. Are we required to bill all of our outpatient therapy services on one claim? | |
| We had a patient come to our acute hospital from an SNF. They were receiving Part A benefits at the time and received a blood transfusion which will be billed with HCPCS code 36430. Is this HCPCS code excluded from consolidated billing? | |
| We have a patient who came into our acute hospital with chest pain. During the course of treatment we repeated the cardiac enzymes test three times resulting in three venipunctures. Are we able to bill for all three of these venipunctures? | |
| We have had several claims reject because our mammography certification is not on file. How can we get these claims to process? | |
| We have received several claim denials with reason code W7009 stating non-covered service, line item denial. After further review it was determined that we submitted one item as non-covered with the GY modifier and the whole claim has denied. How do I get my claim to process? | |
| What are the financial limits on outpatient therapy services for a date of service of March 1, 2008? | |
| What are the Medicare Part B payment allowances for influenza and pneumococcal vaccines? | |
| What authentication elements must be present on a provider inquiry on letterhead? | |
| What condition code should be used for services for billing periods after the therapy cap has been exceeded, which are not eligible for exceptions? | |
| What is the Ambulance Inflation Factor (AIF) for Calendar Year 2008? | |
| What is the date of service that should be used on a claim for a laboratory test on a specimen for which the collection period spanned two calendar days? | |
| What is the definition of the Present on Admission (POA) indicator? When are hospitals required to report POA information? | |
| What procedure code is used when a patient is admitted to inpatient hospital care for less than eight hours on the same calendar date? | |
| When the Medicare contractor has revoked a provider's billing privileges, how long must the provider wait before re-applying for participation in the Medicare program? | |
| Where can I find a list of the 2009 inpatient only procedures? | |
| Where can I find information on how to bill the shingles vaccine? | |
| Where can I find out how many Diabetes Self Management Training (DSMT) hours a beneficiary has used? | |
| EDI | |
| View FAQ Documents | |
| View FAQ Documents | |
| I currently submit directly to WPS. Will I have to enroll with you and will I use my same IDs that I use with WPS? | |
| I currently use Direct Data Entry (DDE). Will I still be able to access DDE? | |
| I currently use PRO32 as my billing software. Will I be able to continue to use that or will I have to get new software? | |
| EFT | |
| View FAQ Documents | |
| View FAQ Documents | |
| Am I required to fill out all information on the form? | |
| Can I fax the CMS 588 Form to Palmetto GBA? | |
| Can we update our banking information on the CMS 588 Form we are sending to Palmetto GBA? | |