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.
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.
- An electronic claim that rejected upon submission because of a Palmetto GBA Smart edit (Advanced Communication Engine (ACE) Smart Edit). Claims returned on a provider’s 277CA report due to a Smart edit must be reviewed and resubmitted or reviewed, corrected/updated and resubmitted before they will be entered into the claims processing system and be identifiable when checking a claim status.
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.
- eServices User Manual
- Part B IVR User Guide (PDF)
- MLN006562 – Medicare Parts A & B Appeals Process (PDF)
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.
- Jurisdiction J Part B - Provider Enrollment Email Communications
- Jurisdiction M Part B - Provider Enrollment Email Communications
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.
- 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 Frequently Asked Questions (FAQs) document.
Reference: I&A Frequently Asked Questions (FAQs) (PDF)
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.
- 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
- Jurisdiction M Part B - Provider Enrollment Application Average Processing Time
Last Reviewed 12/21/2023
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.
- 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 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?
- 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 (cms.gov) (PDF), Section 184.108.40.206. 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
- If you bill electronically, review your 277 CA report or query your claim submitter to determine if your claim may have hit a Palmetto GBA Smart Edit that requires action before the claim can be resent to Palmetto GBA for consideration
- 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. Don’t forget to check your electronic 277CA report to determine if a claim may require action after hitting a PC ACE Smart Edit.
- Jurisdiction J Part B — Smart Edits Listing and 277CA Enhancement (palmettogba.com)
- Jurisdiction M Part B — Smart Edits Listing and 277CA Enhancement (palmettogba.com)
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 (cms.gov)
- Lab National Coverage Determinations — Lab NCDs - ICD-10 | CMS
- Local Coverage Determinations and Articles — MCD Search Results (cms.gov)
- National Correct Coding Initiative Medically Unlikely Edits (not all are published) — Medicare NCCI Medically Unlikely Edits | CMS
- Medicare Preventive Services — MLN006559 – Medicare Preventive Services (cms.gov)
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. Favorable Decision Flyer — Part and Part B Appeals (palmettogba.com) (PDF)
- Jurisdiction J Part B — Detailed Confirmation of Redeterminations (palmettogba.com)
- Jurisdiction M Part B — Detailed Confirmation of Redeterminations (palmettogba.com)
Last Reviewed: 12/19/2023
Top Five Inquiries: February 1, 2023 – April 30, 2023
|Jurisdictions J and M
|Payment Explanation: Claim Status and Claim Not on File
|Misrouted Telephone or Written Inquiry: General Information
|Contractual Obligation Not Met
|Part B Entitlement/Eligibility
|Frequency/ Dollar amount Limitation: Claim Denials
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?
- Confirm your clearinghouse did not receive a Palmetto GBA Smart Edit claim rejection for the claim on the 277CA report. Claims rejected on the 277CA report require action to review, correct and resubmit or review and resubmit. Failure to work these claim rejections means the claim was never accepted into the claim processing system for adjudication.
- 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
- You find that the claim was rejected on the 277CA report and needs to be reviewed and resubmitted
- 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.
- Jurisdiction J Part B — Medically Unlikely Edits (MUEs)
- Jurisdiction M Part B — Medically Unlikely Edits (MUEs)
Last Reviewed: 12/19/2023
Top Five Inquiries: November 1, 2022 – January 31, 2023 Inquiry
|Jurisdictions J and M
|Payment Explanation: Claim Status and Claim Not on File
|Contractual Obligation Not Met
|Misrouted Telephone or Written Inquiry: General Information
|Frequency/ Dollar Amount Limitation: Claim Denials
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
- Your claim may have hit a Palmetto GBA Advanced Communication Engine (ACE) SMART edit that generated a rejection alert on the submitters 277CA report. Check with the entity that submitted your claim as claims that reject for a Palmetto GBA SMART edit will require action to review and update the claim if necessary, and then retransmit the claim to Palmetto GBA.
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.
- Jurisdiction J: Claim Rejections and Billing Errors
- Jurisdiction M: Claim Rejections and Billing Errors
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.
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.
- CMS National Coverage Determinations: National Coverage NCD Report Results (cms.gov)
- Palmetto GBA Jurisdiction J Part B Local Coverage Determinations and Articles: Jurisdiction J Part B — LCDs, NCDs, Coverage Articles (palmettogba.com)
- Palmetto GBA Jurisdiction M Part B Local Coverage Determinations and Articles: Jurisdiction M Part B — LCDs, NCDs, Coverage Articles (palmettogba.com)
Last Reviewed: 12/19/2023
Top Five Inquiries: July 1, 2022 – September 30, 2022
Question: My claim for physical therapy services denied as exceeding the Medicare threshold. What is the therapy threshold and what do I do if the patient needs more therapy then the Medicare threshold allows?
Answer: When the claim adjustment reason code PR-119 (Benefit maximum for this time period or occurrence has been met) denial appears on your remittance advice for physical or occupational therapy or speech pathology services, it is due to a Medicare therapy threshold that is in place.
On January 1, 2006, Medicare implemented financial limitations on covered therapy services (a therapy threshold). An exception to the therapy threshold may be made when a beneficiary requires continued skilled therapy services that are medically necessary as justified by appropriate documentation in the medical record. If the service qualifies as an exception and may be reimbursed over and above the threshold, submit HCPCS modifier KX with the service. Documentation in the patient's medical record must support the use of this modifier. It is important to understand the threshold, modifier, and all Medicare therapy guidelines before determining if the modifier KX is appropriate for use on an individual service.
If you believe that the denied service meets the requirements for the therapy exception, you may appeal the denial by submitting documentation to support medical necessity and request that the KX modifier be appended to the claim.
- CMS IOM Pub. 100-02, Chapter 15, Section 220.3 (PDF)
- CMS IOM Pub. 100-04, Chapter 5, Sections 10.3 and 20 (PDF)
Question: I used eServices and the IVR to check claim status and the claim was not on file. I then called the provider contact center and they told me my claim is not on file. Why would a claim I submitted not be visible or on file for the representative to see?
Answer: Only claims that have entered into the multi-carrier claim processing system can be seen by the Customer Service Advocate or accessed through the eServices portal claim status tab.
If you use a billing company or a clearinghouse, reach out and verify that the claim was submitted to Palmetto GBA and verify the date the claim was submitted. Additionally, the claim in question may have hit an Advanced Communication Engine (ACE) Smart Edit.
If you, your biller, or clearinghouse submits claims electronically, Palmetto GBA ACE Smart Edit Tool will return pre-adjudicated Part B claims information through a claim acknowledgement transaction report, which is called a Medicare 277CA report. Submitters will receive this report with ACE Smart Edits if a claim contains a potential submission error that requires the submitter's attention.
Smart Edits generate rejection alerts on the electronic 277CA report that provide submitters with granular messaging or educational awareness related to billing issues identified with their claim submission. The ACE tool affords you the opportunity to correct your billing issues prior to the claim being adjudicated in the claims processing system, allowing for more efficient and accurate claims processing. Until the claim hitting the Smart Edit is reviewed, corrected if necessary and resubmitted, the claim will not be available for a status check. Providers are encouraged to work closely with their electronic billing entity to make certain that the Smart Edits appearing on the electronic 277CA report are worked and resubmitted. For help understanding a Smart Edit that appears on the 277CA report, use the Palmetto GBA ACE Smart Edit Tool and the EDI_277CA_Smart_Edit List (PDF).
Question: My claim rejected with a Remittance Advice Remark Code MA130 (Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. Another remark code stated a required therapy modifier was not included. How do I know what services are considered therapy and require a modifier, and what are the required modifiers?
Answer: Therapy services provided by physicians, nonphysician practitioners, physical and occupational therapists, and speech language pathologists in private practice must be submitted with the appropriate modifier (HCPCS modifier GP, GN or GO) when the services are performed under a therapy plan of care.
- HCPCS modifier GP — Services delivered under an outpatient physical therapy plan of care
- HCPCS modifier GN — Services delivered under an outpatient speech-language pathology plan of care
- HCPCS modifier GO — Services delivered under an outpatient occupational therapy plan of care
A list of codes that require therapy modifiers is available on the CMS Annual Therapy Update page.
Question: My practice requires that I call on every patient that schedules an appointment and verify if the patient has Medicare, the effective dates, how much of their deductible has been met and whether Medicare is primary or secondary. Is there an easier way to get this information instead of calling each time?
Answer: Absolutely! There are two tools to assist you. The Palmetto GBA eServices portal is the easiest and fastest tool you can use to access all of the information you are trying to verify.
You must be enrolled in eServices to use the tool. Someone in your office is likely already enrolled and your office’s eServices administrator can grant you access. If no one in your office has enrolled in eServices, the instructions are available at the link below. Additionally, use section 2.0 of the eServices User Guide (PDF) to learn about registering for eServices as well as to use the various tools to access the needed information.
Palmetto GBA also offers access to the information through the Interactive Voice Response (IVR) system. Use the Palmetto GBA Part B IVR Call Flows (PDF) and Part B IVR User Guide to help you navigate the IVR system.
Question: I have submitted my provider enrollment application. Is there a way for me to check the status of that application?
Answer: If you utilized the Provider Enrollment, Chain, and Ownership System (PECOS) to submit your enrollment application, you can use the PECOS system Application Status Kiosk Tool under the “Helpful Links” section of the page to view the status of applications submitted within the last 90 days.
Paper enrollment application status may be checked using the Palmetto GBA Application Status tool for your jurisdiction.
Last Reviewed: 12/19/2023
Question: Why is my service denying as a Contractual Obligation, Group Code CO, on my remittance advice?
Answer: A dollar amount listed as Contractual Obligation (CO) assigns financial responsibility to the provider for the service and the provider is not expected to bill patients for that contractual obligation amount.
Providers should review all claim adjustment reason and remark codes (CARCs and RARCs) associated with the denied or rejected service. These CARCs and RARCs will outline the denial or rejection reason resulting in a CO denial or rejection. Providers should then review the coverage for the specific service, e.g., the service is a bundled service and not separately billable and therefore not a financial responsibility to the patient.
For a full list of the CARCs and RARCs that may appear on a claim along with the definitions, reference the CARCs and RACRs External Code Lists | X12. Additionally, use the Palmetto GBA Denial Resolution tool to find helpful information on many of the CARCs that result in CO denials. In some situations where there is a contractual obligation listed, a rejected claim may need to be corrected and resubmitted. Based on the circumstances the contractual obligation may be removed when submitted with the necessary information and all other Medicare guidelines and eligibility are met. Denied claims have appeal rights if you believe the denial was incorrect. If your appeal is favorable, you may note that the contractual obligation amount may change when the appealed claims remittance advice is received.
- Jurisdiction J Denial Resolution Tool
- Jurisdiction M Denial Resolution Tool
- Additional information regarding the Medicare remittance advice can be found in the Medicare Claims Processing Manual, (Pub.100-04), Chapter 22 (PDF) and Medicare Claims Processing Manual, (Pub.100-04), Chapter 24 (PDF)
Question: How do I know if the service I am billing (HCPCS Level II/CPT® code) is subject to a medically unlikely edit?
Answer: While the majority of Medically Unlikely Edits (MUEs) are publicly available on the CMS website, CMS will not publish all MUE values. MUEs that are published, are available in tables on the CMS Medically Unlikely web page. When an MUEs allowed units are not published in the MUE table; this does not mean that there are no allowed units. It only means that CMS does not publish the allowable units for that code. Detailed information on understanding and using the MUE table, MUE indicators, as well as how the MUE edits are used to adjudicate claims, can be found on the Palmetto GBA and CMS websites.
The lack of a published MUE does not indicate that any number/units of that code is covered by Medicare. The overarching criteria for any service is medical necessity for the individual patient. Providers may appeal a service denied due to a published or unpublished MUE and provide documentation of the medical necessity for each service billed.
A first level of appeal (Redetermination) is a redetermination of a claim by a different person then initially processed the claim. The same claim processing system and editing is used for the first level of appeal. A provider is afforded the opportunity to request a second level appeal if they still disagree with the redetermination decision. Any additional appeal rights afforded the claim are included in the redetermination decision letter.
- Jurisdiction J Part B Medically Unlikely Edits (MUE)
- Jurisdiction M Part B Medically Unlikely Edits (MUE)
- Jurisdiction J Part B Medically Unlikely Edits (MUE) Denials for Drugs
- Jurisdiction M Part B Medically Unlikely Edits (MUE) Denials for Drugs
Question: My practice is getting denials for some patient claims stating the patients are enrolled in a Medicare health plan. I am filing to Medicare, which is a health plan, what do I need to do so claims will process?
Answer: When a claim is rejected indicating the patient is enrolled in a Medicare Health Plan, this claim rejection means the patients Medicare record indicates the beneficiary is enrolled in a Medicare Advantage plan (MA plan). MA Plans are replacements to traditional/original Medicare. If a patient has a MA plan, in most cases, the claim must be submitted directly to the MA plan unless the patient is in a clinical trial, hospice stay or there is a service specifically identified as one that must be billed to original Medicare. Beneficiaries receive information regarding their MA when they enroll in the plan. The patient should have a MA Plan insurance card. Some patients may have retained their red, white, and blue traditional/original Medicare cards, however; when enrolled in a MA plan, the MA plan should be billed instead of traditional/original Medicare. The MA Plan Directory is available for providers to retrieve information regarding a particular plan such as contact information that can be used to determine beneficiary exact coverage.
If you are unaware of the MA plan the patient is enrolled in, you should reach out to the patient or their appointed representative or use the Palmetto GBA eServices tool to identify the plan and then bill that MA plan directly.
Question: Claims are being denied stating beneficiary has coverage that is primary to Medicare. My staff is verifying information through Palmetto GBAs' eServices portal, but the information is not displaying. Why would some or all of the information about the primary payer not be displayed in the MSP option under Eligibility?
Answer: The MSP tab only displays active MSP data per the date(s) requested and will not be accessible if there is no MSP data or if notification of coverage primary to Medicare has not been received by CMS. To make sure you see all of the information, enter a date range in the inquiry screen. If the patient will be seen on a future date, be certain to enter that date (or a range of dates) when conducting the MSP inquiry and not just the current calendar date.
The HETS 270/271 system we are required to access for eligibility allows date requests up to four (4) years prior to, and four (4) months in the future of, the current date. Date ranges may not exceed 12 months at a time. If the optional Date Range fields have been populated, make certain the dates include the date of service you are going to bill for. For example, entering only the current date may provide you with incorrect information if the patient is seen on a later date and their information has changed. The MSP Contractor is charged with maintaining patients' information regarding MSP information. The information provided by the MSP Contractor at the time a claim is processed is used to adjudicate Medicare claims. The MSP Contractor may have received information that required an update to the patient's MSP file after your office performed the eligibility check.
- Palmetto GBA eServices User Manual (PDF), Eligibility function and MSP sub-tab (Section 6.0 and 6.7)
- Jurisdiction J MSP web page
- Jurisdiction M MSP web page
Question: Our practice's remittance advice contains the Claim Adjustment Reason Code (CARC) 18: Exact duplicate claim/service. What are some of the reasons for these denials and how should my practice respond if a claim is not a duplicate and needs to be processed for payment?
Answer: Palmetto GBA offers the CARC 18 Denial Resolution Tool outlining common reasons for a duplicate denial and includes a section to help providers resolve these denials.
In many cases, you may find a second claim was submitted for the service before the first one completed processing or that your billing company or clearinghouse submitted the claims a second time. Using the Palmetto GBA eServices secure portal will allow you to check the status of a claim and identify the claim that is pending and being completed or has already been processed and paid. A quick review of the claims you have submitted for a patient on a given day often is also needed to help a provider identify duplicate services. When possible, Palmetto GBA always suggest a provider submit all services for date of service on the same claim to avoid duplicate denials when the same CPT® code is billed a second time on the same day. The referenced material below will assist in understanding how to bill in common situations when more than one of the same CPT®/HCPCS code must be billed.
- Jurisdiction M Claim Denial Resolution Tool: CARC 18
- Jurisdiction J Claim Denial Resolution Tool: CARC 18
Question: Why am I getting denials stating the denial is due to bilateral procedural rules?
Answer: Providers receive Remittance Advice Remark Code (RARC) N644, Reimbursement has been made according to the bilateral procedure rule, on their remittance advice (RA) for a number of reasons.
Medicare has specific rules regarding billing bilateral procedure, and they are tied to the CPT®/HCPCS code description, the code's bilateral modifier indicator as identified on the Medicare Physician Fee Schedule Data Base (MPFSDB) and how Medicare prices a service.
- Identify all the services performed and billed on a given day for that patient by your providers
- Review the CPT®/HCPCS code description paying close attention to whether the code specifies unilateral or bilateral (codes whose description indicate the code represents a bilateral service should not bill two services using the same CPT® code)
- Review and understand the MPFSDB bilateral indicator for the service. (Reference: Bilateral Surgeries and CPT® Modifier 50 to understanding those indictors is listed below.)
- Use the references below to better understand proper Medicare billing of bilateral procedures
- Jurisdiction M Modifier Lookup Tool (CPT® Modifier 50, HCPCS Modifiers RT, LT)
- Jurisdiction J Modifier Lookup Tool (CPT® Modifier 50, HCPCS Modifier RT, LT)
- Jurisdiction J Bilateral Surgeries and CPT® Modifier 50
- Jurisdiction M Bilateral Surgeries and CPT® Modifier 50
- Jurisdiction J Bilateral Procedures and Modifiers
- Jurisdiction M Bilateral Procedures and Modifiers
- Jurisdiction J Ophthalmic Biometry and A-Scans Coding Guidelines
- Jurisdiction M Ophthalmic Biometry and A-Scans Coding Guidelines
- Jurisdiction J Blepharoplasty and Blepharoptosis Repair
- Jurisdiction M Blepharoplasty and Blepharoptosis Repair
- Jurisdiction J Cataract Removal
- Jurisdiction M Cataract Removal
Question: When billing for discontinuation of services there are several different CPT® modifiers, (52, 53 and 74) that can apply. Under what circumstances are the CPT® modifiers for discontinuing services used?
Answer: There are two CPT® modifiers for discontinued service, 53 and 74 and there are specific guidelines for each. CPT® Modifier 52 is for a service where the provider is reducing their charge for a service. Careful attention should be paid to the description of each modifier along with the guidelines, instructions and documentation requirements for each modifier as outlined in the Palmetto GBA Modifier Lookup tool.
- Jurisdiction J CPT® Modifier 52 Reduced Services
- Jurisdiction M CPT® Modifier 52 Reduced Services
- Jurisdiction J CPT® Modifier 53 Discontinued Procedure
- Jurisdiction M CPT® Modifier 53 Discounted Procedure
- Jurisdictoin J CPT® Modifier 74 Discontinued outpatient hospital/ambulatory surgical center (ASC) procedure after the administration of anesthesia
- Jurisdictoin M CPT® Modifier 74 Discontinued outpatient hospital/ambulatory surgical center (ASC) procedure after the administration of anesthesia
Question: Is there one place where all preventative services timeframes are housed so that it can bookmark for my staff?
Answer: CMS offers an MLN Educational Tool Medicare Preventive Services. Once the page opens, click on any preventive service to receive details regarding any frequency guidelines for each covered preventive service. Your staff can also use the Palmetto GBA eServices portal to identify the next date the patient is eligible for many preventive service. Read more about using the Eligibility, Preventive tab in eServices in section 6.0 and subsequent sections of the Palmetto GBA eServices User Manual (PDF).
Last Reviewed: 12/19/2023
Each bank may be unique in how they create their statements but typically a Palmetto GBA Part B Jurisdiction J EFT payment will appear as an EFT from MAC-PTB ALGATN.
Last Reviewed: 12/19/2023