General
Question: The remittance advice shows my claim denied with Contractual Obligation, CO-B7: This provider was not certified/eligible to be paid for this procedure or service on this date of service. How do we know if it is because provider was not enrolled?
Answer: Speak with your credentialing team to ensure the billing provider is enrolled with Medicare for the date of service billed. Also, verify the claim was billed in the correct state where the service was performed. Visit the Palmetto GBA Provider Enrollment webpage for more information on enrollment and revalidation requirements.
Resources
Question: Why did my claim reject due to missing/invalid rendering provider number/NPI?
Answer: Review your paper or electronic claim to verify that the correct rendering provider NPI number was entered into block 24J of the CMS-1500 claim form or in the equivalent electronic claim loop and segment. Verify that the rendering provider’s NPI was typed correctly. For additional tips on resolving this type of rejection, review the NPI: Troubleshooting Rejections article.
Resources
Question: I got a claim denial with a Group Code CO (contractual obligation) stating medical records were requested but not received. How do I correct this? I didn’t receive a request for records and why can’t I bill the patient for the denied service?
Answer:
- This type of claim denial is considered a contractual obligation and one you are not able to bill the patient for until the necessary information to adjudicate the claim has been received and reviewed. Palmetto GBA has a list of CPT® or HCPCs codes that require additional documentation be submitted with the claim. Claim rejections (no appeal rights listed on the remittance advice) must be refiled as new claims with the necessary documentation. If you sent documentation with your claim, review that documentation, and make sure is for the correct patient, date of service, and is complete. If the claim is a denial (appeal rights are listed on the remittance advice for the claim), you may submit a first level of appeal with the necessary documentation.
- Palmetto GBA may issue an additional documentation request (ADR) as part of the review process. These letters are sent to the written correspondence address on file for the provider. Providers may also request to receive ADR letters through the Palmetto GBA eService portal. This can be especially helpful in large practices/facilities to ensure the letters reach your appropriate internal department to fulfill the record request within the noted time frame.
Resources
- When You Don’t Respond to Additional Documentation Requests (ADRs) Quick Reference Guide (PDF)
- eServices: Greenmail Letters
- Jurisdiction J Part B — Medical Review: Additional Documentation Requests (ADRs)
- Jurisdiction J Part B — Services and Circumstances That Require Additional Documentation
- eServices: Greenmail Letters
Question: I saw the patient for two office visits on the same day. Why was one of them denied?
Answer: Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter. For example, an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).
Providers must provide enough detail to alert Palmetto GBA during the claim processing that each service represented two separate encounters meeting the above criteria. Two separate diagnosis codes listed on the claims is not sufficient to meet the criteria above. If your claim has been denied for two E/M visits on the same day, you may request an appeal and provide documentation to support the Medicare coverage for two E/M visits on the same day (listed above) has been met.
Resource: Medicare Claims Processing Manual, Section 30.6.7B (PDF).
Question: My claim denied for workers compensation (liability or no-fault), but this service had nothing to do with the workers' compensation on file.
Answer: Determining if a claim is workers compensation, liability or no fault related is driven by the diagnosis codes submitted on a claim. If the submitted diagnosis is the same or similar to what is on file for the workers compensation, the claim will deny.
Providers that believe their denial is incorrect are encouraged to review the diagnosis codes submitted on their denied claim for accuracy and make any corrections and resubmit the claim. Providers may also resubmit or appeal the claim with an explanation of benefits from the primary (workers compensation, no-fault, or liability) insurer that indicates the services are not covered under their plan.
Last Reviewed: 09/18/2024
Question: Some claims deny indicating contractual obligation and some denials indicate I had an invalid code or modifier combination, or the required modifier was missing or invalid. Can I charge the patient for these denials?
Answer: Billing errors are also known as "claim submission errors" or "rejections." Rejections are not the same as denials, although providers often use the terms interchangeably. You must review rejected claims and make necessary corrections, then resubmit the claims. Once that is done, Palmetto GBA can process the claim and determine patient or provider financial responsibility.
Each claim’s rejection reason is noted on your remittance advice and includes Claim Adjustment Remark Code(s) (CARCs) that explain the reason a claim is rejected. Using those details, review your claims’ CPT®/HCPCS code and confirm the code(s) are valid codes for each date of service billed, make any necessary corrections, and resubmit the claims. If the CARC indicates the code and submitted modifier are not compatible, review the CPT® code description as well as the appended modifier’s description. Make necessary corrections and resubmit the claim. In some cases, certain services require a modifier that may have been left off a claim. Review the Palmetto GBA website resources for your type of service or provider specialty under the Topics tab at the top of the web page. Search for articles related to the specific code that you are billing. Use the Palmetto GBA Modifier Lookup tool.
References
Question: When and how do I go about revalidating my provider’s enrollment status?
Answer: CMS provides a Medicare Revalidation Due Date Lookup Tool. A due date listed as TBD indicates that CMS has not set the due date for revalidation yet. Do not submit enrollment revalidations if there is not a listed due date. All unsolicited revalidation applications will be returned without processing.
When required, the preferred and fastest method of revalidating an enrollment record is by using the Provider Enrollment Chain and Ownership (PECOS) system, Revalidations (Renewing Your Enrollment) Through PECOS.
Question: Why am I getting frequency denials for some services?
Answer: There are a number of reasons why a service may be denied indicating the service was provided more frequently than allowed.
National Coverage Determinations and Local Coverage Determinations may have frequency limits related to a specific timeframe, indicating the limit applies to services by the same provider, the same group, or billed by any provider rendering a specific service to an individual beneficiary. Careful review of the policy will indicate how the frequency limit will be applied. Additionally, CMS uses the Medicare National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) edits to reduce improper payments. An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT® code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service. Not all HCPCS/CPT® codes have an MUE and although CMS publishes most MUE values on its website, other MUE values are confidential. Confidential MUE values are not releasable.
To understand frequency limits, review the resources below. If after reviewing documentation you feel the individual patient’s documentation supports an allowable exception to the MUE, you may exercise your individual claim appeal rights and provide the necessary supporting documentation with your appeal request.
References
Question: What does "CO" mean on my remittance advice?
Answer: "CO" is a group code. Group codes assign financial responsibility for the unpaid portion of a claim balance e.g., CO (contractual obligation) assigns responsibility to the provider and PR (patient responsibility) assigns responsibility to the patient. Medicare beneficiaries may be billed only when group code PR is used with an adjustment. CARCs provide an overall explanation for the financial adjustment. Group codes CO or PR are used to indicate when a beneficiary may or may not be billed for the unpaid balance of the services that were performed. Your Remittance Advice will always provide the text of each reason and message code at the end of the notice. CaRCs are provided to assist in explaining denial, rejection or adjustment reasons that apply to your claim. The definition of each is provided at the bottom of your Remittance Advice. Help understanding many of the most common CARCs associated with a contractual obligation may be found on the Palmetto GBA web site by searching for the CARC.
References
Question: Whom do I contact with questions?
Answer: CMS requires the providers utilize the Provider Contact Center as the first point of contact for most questions. The green “Contact Us” link in the upper-right corner of Palmetto GBA’s website provides contact information for Palmetto GBA. The Palmetto GBA website contains the answers to most of your inquiries. The Palmetto GBA eServices portal should be used to verify eligibility or claim status, including information about other applicable insurance that may be primary to Medicare.
The following telephone, email, and written inquiries are examples of answers to questions often misdirected to Palmetto GBA.
- Medicare Advantage plan’s coverage, billing, or claim determinations must be directed to the individual Medicare Advantage plan
- Railroad Medicare questions must be directed to the Railroad Medicare contact center at 888–355–9165 (Railroad Providers — Contact Railroad Medicare)
- How a primary insurer handled a claim must be directed to the applicable primary insurance plan
- Questions regarding letters received, must be directed to the entity that sent the letter or as directed within the letter. Not all letters referencing Medicare are from Palmetto GBA.
Question: I have contracted with a third-party contractor to handle my claims and claim follow up. Can I ask the contracted entity to call Palmetto GBA on every claim and get a tracking or reference number to prove that they followed up on each of my claim?
Answer: While a provider’s contract terms with a third party are not dictated by Palmetto GBA or CMS, Palmetto GBA discourages provider from requiring that a third-party contractor simply call Palmetto GBA to get a reference or tracking number to prove to you that they are meeting the terms of your third-party contract. In most instances, inquiries for claim or appeal status are unnecessary and needlessly tie up our Provider Contact Center lines. Claim and appeal status are available through the Palmetto GBA eServices portal. Additionally, third party contractors should have access to your Medicare remittance advice and correspondence regarding claims and appeals and used as a resource before calling Palmetto GBA.
Palmetto GBA tracks inquiry volume by provider. Unnecessary calls from a provider’s third-party contractor will reflect as though the inquiry was from the provider they represent and whose NPI is used when passing privacy during a call. You are encouraged to consider these items when contracting with a third party to help reduce unnecessary calls to the provider contact center.
Last Reviewed: 09/18/2024
Question: What are my options for verifying claim status?
Answer: Claim status can be verified through the Palmetto GBA eServices portal or through the Palmetto GBA Interactive Voice Response (IVR) system. We encourage you to verify the date your claim was initially submitted and understand that the date you send a claim to a billing company or clearinghouse may not be the same day that your claim was forwarded to and received by Palmetto GBA for consideration. Once received and processed, Palmetto GBA must apply a payment floor. The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. The payment floor represents the earliest date contractors may release payment for a completed clean claim. You should not expect Medicare payment for a claim until after the waiting period ends.
eServices: Once logged in you will have to have permission to access the Claims tab. Once you open the Claims tab, the claims status screen will appear. The few required fields are marked as required. Other fields are optional. Reference: eServices User Manual (Section 4.0). Sign up or log in for Welcome to Palmetto GBA eServices.
IVR: Call your jurisdiction’s Provider Contact System and answer the survey prompt then select Option 3 for the IVR. Use the Part B IVR User Guide to walk you through the steps to verify claim status using the IVR.
References
Question: Why when I check the claim status in eServices, through the IVR or with a customer service representative, might I get the response that my claim is not on file?
Answer: There are several reasons.
- If a paper claim, the claim may not have been delivered to Palmetto GBA, or if the claim was received through the U. S. mail, the claim may not yet have been entered into the claim processing system
- Your billing company or clearinghouse may not have forwarded the claim to Palmetto GBA
- Your electronic claim may have been stopped by billing software and additional action may be required to move the claim to transmit to Medicare
Resource: Become a Medical Expert.
Question: When Medicare rejects my claim, why does my Remittance Advice show a CO group code and the entire submitted charge listed as a contractual obligation indicating I can’t bill the patient for the service?
Answer: CMS expects providers to submit claims with accurate and complete information so that the claim can be processed. When a claim is rejected because required information is missing, incomplete or invalid, the entire submitted charge for that service is identified as a contractual obligation and the provider is not afforded appeal rights. The remittance advice will indicate what information is missing, incomplete or invalid using Claim Adjustment Remark Codes. The provider must correct the claim, provide the necessary information, and resubmit the claim. Once the claim has all the necessary information, Palmetto GBA will adjudicate the claim and the dollar amount in the contractual obligation field could likely change based on the claim determination.
Reference: Claim Rejections and Billing Errors.
Question: I want to opt-out of Medicare, not have to submit claims to Medicare, and have Medicare patients pay out of their pocket for my services. How do I do this?
Answer: You must first be an eligible type of provider to opt-out of Medicare. Only certain types of providers may opt-out of Medicare. Manage Your Enrollment | CMS An eligible provider that wishes to opt-out must submit an opt-out affidavit to Medicare and enter into a private contractor with each of your Medicare patients before most services are provided. Information on what it means to opt-out of Medicare and the process for opting-out can be found at the resources below.
References
- Manage Your Enrollment
- Jurisdiction J Part B: Opt-Out Affidavit for Eligible Physicians/Practitioners (PDF)
Question: Isn’t there a faster easier way to request a first level appeal other than mailing or faxing the redetermination request?
Answer: The simplest and most efficient way to submit a redetermination is through Palmetto GBA’s eServices portal. Palmetto GBA also offer an eDelivery option for receiving your redetermination decision letters electronically. You can get your Medicare redetermination notices (MRNs) the same day that they are issued, delivered directly to your computer. You can even choose to get an email to let you know that the letter is waiting for you. The eServices User Manual provides instructions on the submission process.
Last Reviewed: 09/18/2024
Question: My claim denied but I don’t understand why I can’t bill the patient for certain denied services. The claim shows the dollar amount as a contractual obligation, one I am not able to bill the patient for, why?
Answer: There are several reasons your remittance notice may list a dollar amount as a contractual obligation, meaning you cannot bill the patient for that dollar amount listed. Those instances may include (not an all-inclusive list):
- When no initial determination has been made because required information is missing, invalid or incomplete, e.g., invalid CPT®, HCPCS, ICD-10 code or claims that require conditional information that is missing. You must correct the claim and resubmit as a new claim with the required information. Review your remittance advice for the Remittance Advice Remark Code (RARC) for details regarding what is missing or needed.
- Claims denied as a duplicate of a previously processed claim. If the service is not a duplicate, you may request an appeal. If the claim is a true duplicate, you may not bill the patient for that second, duplicate charge.
- Claims submitted to the wrong entity, e.g., Railroad Medicare claims, claims where a patient has a Medicare Advantage plan, Medicare is the secondary insurer, a liability claim etc. must be submitted to the correct entity and the patient should not be billed until the claim is submitted to the correct insurer.
Question: When I check the status of my claim, I get the message that the claim is not on file. What does that mean?
Answer: A status inquiry resulting in notification that the claim is not on file may be due to:
- Your clearinghouse or billing company has not yet submitted your claim to Palmetto GBA. Verify with that entity and request the date that Palmetto GBA confirmed receiving the electronic claim. Work with that entity to understand the timeliness of your claim’s submissions directly to Medicare.
- You checked the status of a claim using the wrong provider PTAN/NPI or the wrong patient information or date of service. Verify the information and check the status again. The IVR or eServices portal is looking for a claim status solely on the information you provided, and it must match what was submitted on the claim.
- A paper claim (if you are eligible to submit paper claims) that has not been received by Palmetto GBA through the postal service or other courier
References
Question: My patient has a red, white, and blue Medicare card but my claim denied indicating the patient does not have Medicare coverage, why?
Answer: A red, white, and blue Medicare card is sent to every patient when they initially enroll in original Medicare or as part of the roll out of the new Medicare Beneficiary Identifier (MBI) numbers several years ago. Since the time a patient’s card was mailed, the patient’s circumstances and eligibility may have changed, and the patient simply retained their old card. Medicare eligibility is maintained by Social Security. A Medicare beneficiary or their authorized representative may reach out to 1-800-Medicare or the Social Security office to discuss their Medicare eligibility.
Question: My claim says that something was missing, invalid, or incomplete and Medicare can’t process the claim. How do I figure out what is missing and once I figure that out, what do I need to do?
Answer: Review your remittance advice for the Remittance Advice Remark Code (RARC) for details regarding what is missing, incorrect or invalid and make necessary corrections and resubmit your claim.
Question: I submit an appeal and then must wait. What are the time frames for Medicare to process my appeal and is there a way for me to check the status of my appeal?
Answer: Medicare Administrative Contractors generally issue a decision within 60 days of the date they receive the redetermination request. When a first level appeal (redetermination) is submitted directly through the Palmetto GBA eServices portal, providers may follow the status of the individual appeal within eServices. The status of appeals submitted to Palmetto GBA by fax or mail may be checked using the Palmetto GBA Redetermination Status Tool.
References
- eServices User Manual
- Part B IVR User Guide (PDF)
- MLN006562 — Medicare Parts A & B Appeals Process (PDF)
Provider Enrollment
Question: I submitted my application and haven’t heard anything. When I call the Provider Contact Center, Palmetto GBA tells me that a request for clarification or missing enrollment application information had been sent to my practice. I never received the request. How do I find out what is needed, get a copy of that request, and respond so my application can continue process?
Answer: Let the Provider Contact Center (PCC) representative know that you did not receive the letter and would like to know what information was requested. You can also let the PCC know that you would like a copy of the letter.
References
Question: How can I find out who my provider’s provider enrollment authorized representatives are?
Answer: Providers that enrolled, revalidated, or updated a provider enrollment file through PECOS can identify their authorized representatives through PECOS. If you do not have access to PECOS, please coordinate with the person(s) within your organization that handles enrollment.
References
- Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
- I&A Frequently Asked Questions (FAQs) (PDF)
Question: The person that enrolled us through PECOS is no longer with our practice so we can’t log into PECOS. How can we get access to PECOS?
Answer: The instructions to resolve this issue can be found on the CMS website by accessing the Identity & Access (I&A) Frequently Asked Questions (FAQs) (PDF) document.
Question: My application has been pending for a long time how can I check the status of my provider enrollment application?
Answer: Providers can access the status of their provider enrollment application:
- Through PECOS Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
- By visiting the Palmetto GBA website and using the Provider Enrollment Application Status Lookup Tool. Enter your PTAN, NPI, or Document Control Number (DCN). Be certain to search using numbers that are relevant to the specific enrollment application you submitted. Status information is updated approximately 24 hours after each transaction. Information in the Provider Enrollment Application Average Processing Time educational article provides the average days you can expect for Palmetto GBA to complete the processing of enrollment applications.
Reference
- Provider Enrollment Application Status Lookup Jurisdiction J Part B
- Provider Enrollment Application Status Lookup Jurisdiction M Part B
- Jurisdiction J Part B — Provider Enrollment Application Average Processing Time
Last Reviewed: 09/18/2024
Question: My claim was rejected. The entire dollar amount of my claim was listed as Group Code, CO: contractual obligation. What do I need to do?
Answer: Use the Claim Adjustment Reason and Remittance Advice Codes on your remittance advice to determine the claim error. Until the claim is submitted with all necessary information, Palmetto GBA may not make a claim determination. You may not bill the patient until the claim is corrected and resubmitted with the necessary information.Tips
- Do not submit a rejected claim as an appeal or simple claim reopening. Correct and resubmit the claim.
- Only certain CPT/HCPCS codes require submission of additional information
- Use the PWK submission process to submit required additional documentation for electronic claims
- Electronic billers must use the appropriate electronic claim loop and segments to bill indicating how a primary insurer handled the claim
Question: I run a report every 30 days identifying Medicare claims not paid. Staff call on each claim to ask for an explanation. The Palmetto GBA representative pulls up the claim, gives the date a claim was received and tells us the claim has paid/denied/rejected or is still being processed. Sometimes the date that Palmetto GBA received the claim is not the date that we submitted the claim to our clearinghouse. Why is there a difference in dates and what can we do so that we don’t have to call on each one of these for an explanation?
Answer
- Remember when using another entity to send you claims to Medicare, that entity may have processes and protocol that may cause a claim to be delayed in being forwarded to Medicare
- The “payment floor” establishes a waiting period during which time, the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made. Medicare Claims Processing Manual (PDF), Section 80.2.1.2. Before calling the Palmetto GBA provider contact center for an explanation, be sure that staff has applied all received remittance advice to patient’s accounts.
- If your biller or clearinghouse receives your Medicare remittance advice, be certain you have verified if the claim(s) in question have already been processed and included on a remittance notice not yet sent to you from your third-party contractor
- Check the Palmetto GBA Claims Payment Issues Log to see if there is a claim processing issue that affected your claims
Question: I sometimes resubmit my claims if I haven’t gotten payment. Is this the right thing to do?
Answer: No. Resubmitting claims that have already been submitted may end up denying as a duplicate or may cause the initial claim still being processed, to deny against the new claim. Providers should use the Palmetto GBA eServices Portal or the Palmetto GBA Interactive Voice Response (IVR) system (PDF) to check the status of claims.
Question: Where does Palmetto GBA get the frequency limits that might be used when processing claims?
Answer: There are a number of Medicare coverage guidelines that may affect the frequency or number of services that a Medicare Administrative Contractor must use when adjudicating claims. Not every services has a frequency edit and not all frequency edits are published.
- National Coverage Determinations — MCD Search
- Lab National Coverage Determinations — Lab NCDs — ICD-10 | CMS
- Local Coverage Determinations and Articles — MCD Search Results
- National Correct Coding Initiative Medically Unlikely Edits (not all are published) — Medicare NCCI Medically Unlikely Edits | CMS
- Medicare Preventive Services — MLN006559 — Medicare Preventive Services
Question: I run a report every 30 days to identify any first level appeals that are still pending. Staff then call Palmetto GBA for an explanation. Is there is an easier way to check the status of our redeterminations?
Answer: Yes. The Palmetto GBA eServices Portal can be used to check the status of your first level appeals. Use the “Claims” tab and enter the claim’s ICN and a date range. Any appeal received by Palmetto GBA will populate. From there, a provider may open, view, and print any appeal determination letter issued by Palmetto GBA. Use the Palmetto GBA eServices Portal User Guide for details on accessing this information. Palmetto GBA has 60 days from the date of receipt to process your first level appeal. Be sure to build in additional time for delivery of your appeal determination letters if you receive your letters through U.S. Mail.
Providers will not receive an appeal decision letter for favorable appeals. When a first level appeal decision is favorable, the claim is adjusted, and the provider will receive a new Remittance Advice and can see the favorable decisions in the Palmetto GBA eServices Portal. Reference: Favorable Decision Flyer — Part and Part B Appeals (PDF).
Last Reviewed: 09/18/2024
Table 1. Top Five Inquiries: February 1, 2023 – April 30, 2023
| Inquiry Category | Jurisdictions J and M |
|---|---|
| Payment Explanation: Claim Status and Claim Not on File | 17,997 |
| Misrouted Telephone or Written Inquiry: General Information | 11,263 |
| Contractual Obligation Not Met | 9,439 |
| Part B Entitlement/Eligibility | 9,411 |
| Frequency/ Dollar amount Limitation: Claim Denials | 5,498 |
Question: I bill electronically through a clearinghouse. How do I know if I should call Palmetto GBA or my clearinghouse when I have not gotten paid for a claim?
Answer: Because you submit claims first to your clearinghouse and the clearinghouse then forward your claims electronically to Palmetto GBA, always start with your clearinghouse.
- Confirm you submitted your claim to your clearinghouse and that your clearinghouse received the claim
- Confirm the date that your clearinghouse submitted your claim to Palmetto GBA
- Has it been at least 14 days since the clearinghouse submitted your electronic claim?
- Check the status of your claim in the Palmetto GBA eServices portal
- Reach out to your clearinghouse if you find:
- There is a delay between when you submit your claims to your clearinghouse and when your clearinghouse submits your claim to Palmetto GBA
- You find your clearinghouse never submitted the claim to Palmetto GBA
- Other issues not meeting the contract requirements between you and your clearinghouse
Question: The patient’s Medicare Advantage plan isn’t paying claims or accepting claims the same way that Palmetto GBA does. Who do I call to have my Medicare Advantage plan questions answered?
Answer: You should reach out directly to the patient’s Medicare Advantage Plan. CMS provides oversight and direction to the Medicare Advantage Plans. Palmetto GBA is not able to address these types of Medicare Advantage Plan questions.
Question: Do I automatically have to write off any amount on the remittance advice with a group code of CO, contractual obligation?
Answer: We recommend you review the entire explanation of benefits for a claim. In some instances, the initial determination may be a contractual obligation amount because you need to submit the claim to another insurer, something is missing incomplete or invalid. In certain cases, depending on the rejection reason, you may be able to correct and resubmit a claim with invalid or missing information and the group code may then change from CO to another group code.
Question: I billed a claim using the patient’s name and MBI number that the patient gave me, but Palmetto GBA is denying my claim for eligibility, why?
Answer: Providers should obtain a copy of the patient’s Medicare card and use the MBI number and name as it appears on the patient’s Medicare card and pay close attention as to whether the patient has Railroad Medicare benefits. Providers should also query patients regarding whether they may have switched to a Medicare Advantage plan which replaced traditional Medicare. Providers may also use the Palmetto GBA eServices portal to verify eligibility before submitting a claim. Welcome to Palmetto GBA eServices.
Question: When I disagree with a Medicare Medically Unlikely Edit (MUE) how do I get Medicare to consider more services then the MUE for my individual patient?
Answer: You may exercise your appeal rights by requesting a first level appeal. Be certain to include documentation to support the medical necessity of the number of services you billed. The claim along with any documentation you submit and the CMS MUE specific information, the claim will be reviewed, and a determination made as to whether additional units of service can be allowed. If the initial claim determination is affirmed, your decision letter will include any additional appeal rights you may be afforded.
Last Reviewed: 09/18/2024
Table 2. Top Five Inquiries: November 1, 2022 – January 31, 2023 Inquiry
| Inquiry Category | Jurisdictions J and M |
|---|---|
| Payment Explanation: Claim Status and Claim Not on File | 22,505 |
| Eligibility/Entitlement | 9,589 |
| Contractual Obligation Not Met | 8,534 |
| Misrouted Telephone or Written Inquiry: General Information | 5,519 |
| Frequency/ Dollar Amount Limitation: Claim Denials | 5,192 |
Question: What are my options for verifying claim status?
Answer: Claim status can be verified through the Palmetto GBA eServices portal or through the Palmetto GBA Interactive Voice Response (IVR) system. We encourage you to verify the date your claim was initially submitted and understand that the date you send a claim to a billing company or clearinghouse may not be the same day that your claim was forwarded to and received by Palmetto GBA for consideration. Once received and processed, Palmetto GBA must apply a payment floor. The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. The payment floor represents the earliest date contractors may release payment for a completed clean claim. You should not expect Medicare payment for a claim until after the waiting period ends.
eServices: Once logged in you will have to have permission to access the Claims tab. Once you open the Claims tab, the claims status screen will appear. The few required fields are marked as required. Other fields are optional.
Reference: eServices User Manual (Section 4.0).
IVR: Call your jurisdiction’s Provider Contact System and answer the survey prompt then select Option 3 for the IVR. Use the Part B IVR User Guide to walk you through the steps to verify claim status using the IVR.
Reference: Part B IVR User Guide.
Question: Why when I check the claim status in eServices, through the IVR or with a customer service representative, might I get the response that my claim is not on file?
Answer: There are several reasons.
- If a paper claim, the claim may not have been delivered to Palmetto GBA, or if the claim was received through the U. S. mail, the claim may not yet have been entered into the claim processing system
- Your billing company or clearinghouse may not have forwarded the claim to Palmetto GBA
- Your electronic claim may have been stopped by billing software and additional action may be required to move the claim to transmit to Medicare
Question: When Medicare rejects my claim, why does my Remittance Advice (RA) show a CO group code and the entire submitted charge listed as a contractual obligation indicating I can’t bill the patient for the service?
Answer: CMS expects providers to submit claims with accurate and complete information so that the claim can be processed. When a claim is rejected because required information is missing, incomplete or invalid, the entire submitted charge for that service is identified as a contractual obligation and the provider is not afforded appeal rights. The remittance advice will indicate what information is missing, incomplete or invalid using Claim Adjustment Remark Codes. The provider must correct the claim, provide the necessary information, and resubmit the claim. Once the claim has all the necessary information, Palmetto GBA will adjudicate the claim and the dollar amount in the contractual obligation field could likely change based on the claim determination.
References
Question: Is there a way to check a patient’s Medicare eligibility online?
Answer: Absolutely. Chapter 6 of the Palmetto GBA eServices manual walks you through the steps to verify eligibility. Additionally, the Palmetto GBA User Manual can help you with verifying the next eligible date for covered preventive services and more.
Reference: eServices User Manual.
Question: What is the best way for me to know who I should call when I have a question?
Answer: The Palmetto GBA Contact Us web page includes information on contacting Palmetto GBA as well as information on when you may have to contact an entity outside of Palmetto GBA to address certain questions. A link to the Palmetto GBA Contact Us web pages are listed in the Resource section below.
All general inquiries to Palmetto GBA should be directed to the provider contact center (PCC). If assistance is needed from another area within Palmetto GBA, the PCC will utilize an internal escalation process to help in assisting you. You can use the Part B IVR User Guide (PDF) and Palmetto GBA Part B IVR Call Flows (PDF) resources to assist you in navigating the Interactive Voice Response (IVR) system.
Questions Regarding claims for patients enrolled in a Medicare Advantage plan or questions about a Medicare Advantage plan’s procedures or policies must be directed to the Medicare Advantage plan.
Resources
Question: I am getting denials indicating Medicare does not pay for as many services as I have billed why?
Answer: There could be several reasons for this type of denial. The most frequent reasons are denials based on a National or Local Coverage Determinations that include direction on the frequency/units of a service that can be billed. Another reason may be that the number of services/units you billed exceed the CMS National Correct Coding Initiative Medically Unlikely Edits (MUEs). CMS does not publish all MUEs. Links to the published MUEs and national and local coverage determinations are listed below. If you receive a claim denial, after reviewing the applicable information for the service you billed, you may exercise your appeal rights and submit documentation with your appeal to support the frequency of services billed. Some of the MUE edits may require you exercise your appeal rights beyond the first level of appeal, a reconsideration.
Resources
- CMS National Coverage Determinations: National Coverage NCD Report Results
- Palmetto GBA Jurisdiction J Part B Local Coverage Determinations and Articles
Last Reviewed: 09/18/2024