General

Published 04/18/2023

Top Five Inquiries: July 1, 2022 – September 30, 2022

Inquiry Category

Jurisdiction J

Jurisdiction M

Total

Claim Denials

22,263

20,909

43,172

Claim Status

14,450

13,458

27,908

RTP/Unprocessable Claim

6,460

6,231

12,691

Eligibility/Entitlement

5,877

5,143

11,020

Provider Enrollment

4,299

5,067

9,366

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. 

References

  • CMS Pub. 100-02, Chapter 15, Section 220.3 (PDF)
  • CMS 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: 4/18/2023

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.

References

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.

References

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 patientÔÇÖs 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.

References

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.

References

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.

Tips

  • 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

References

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.

References

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: 4/18/2023

Question: How do I determine the reason my service was denied as not medically necessary?

Answer: Palmetto GBA's article, CARC 50 outlines the claim adjustment reason code 50. (These services are non-covered services because they are not deemed a medical necessity by the payer.) Additionally, the associated claim adjustment reason codes that may also be used in conjunction with CARC 50 are included as well as helpful tips in understanding and resolving this type of denial/rejection.

References

Question: How can I check the status of my claim and get details on claim payment or claim rejection if the claim has already been processed?

Answer: Palmetto GBA offers, and the Centers for Medicare & Medicaid Serices (CMS) requires, providers use self-service tools to obtain claim status/claim details. Most providers prefer to use the Palmetto GBA eServices portal because it allows a provider to check claim status and view associated remittance advice (RA) for a paid, denied or rejected claim. The RA provides details regarding how the claim was handled and allows for simple reopening or appeal requests to be completed through the Palmetto GBA eServices portal. Providers also have the option of using the Palmetto GBA Interactive Voice Response (IVR) system to check claim status. The article listed below can assist providers in using the IVR.

References

Question: How do you find a local coverage determination (LCD) or National Coverage Determination (NCD)?

Answer: LCDs, Palmetto GBA coverage articles and NCDs are housed on the searchable CMS Coverage Database. Palmetto GBA also provides an article to help providers identify if a service has an LCDs or coverage article. If a policy is available, this Palmetto GBA article links you to the information on the CMS Coverage Database.

References

Question: How do I know how much Medicare allows for certain services?

Answer: Palmetto GBA offers a Medicare Physician Fee Schedule lookup tool for services paid under the Physician Fee Schedule. Links to the Clinical Laboratory Fee Schedule, DMEPOS Fee Schedule, Ambulatory Surgical Center Fee Schedule, Ambulance Fee Schedule, and Drugs and Biologicals Fee Schedule are also available on the Palmetto GBA website.

References

Question: How do I know what services require prior authorization?

Answer: Certain hospital outpatient department (OPD) services require prior authorization for the Part A outpatient claim. Palmetto GBA has a web page dedicated to OPD prior authorization including the services with a prior authorization requirement for the hospital outpatient services.

Repetitive scheduled non-emergent ambulance transports (RSNAT) also have a prior authorization process. Details on the RSNAT prior authorization process are outlined on the Palmetto GBA Ambulance Prior Authorization web page.

References: OPD

Question: How long does it take for a claim to process?

Answer: From the date Palmetto GBA receives a claim, payment for clean claims may be released by Palmetto GBA as soon as the CMS timeframe requirements for claims payment have been satisfied. The payment floor (minimum amount of time, required by law, for which all Medicare carriers must hold payment) is 14 days for electronic claims, and 29 days for paper claims.

References

Question: How can I check full eligibility for a patient, including if they are enrolled in a Medicare Advantage plan if the patient is enrolled in a hospice or home health episode of care?

Answer: Using the Palmetto GBA eServices portal is the fastest way to check all of these items. Information on how to register for eServices and how to access these elements of the patient's eligibility is located in Section 6 of the Palmetto GBA eServices User Manual, which begins on page 59.

Question: How do I notify Medicare that my group's address has changed?

Answer: Information regarding when and how Palmetto GBA must be notified of provider enrollment file changes is available on the Palmetto GBA website.

References

Question: How do I know when I need to revalidate my provider's enrollment?

Answer: Palmetto GBA sends revalidation notifications electronically through eServices for eServices users and by U.S. mail for non-eServices users. Providers and suppliers can also utilize the CMS Revalidation List Lookup Tool to determine if their revalidation date has been set. The list will include all enrolled providers and suppliers. CMS sets every provider's revalidation due date at the end of a month and posts the revalidation due date six to seven months in advance. A due date of ÔÇ£TBDÔÇØ means that CMS has not set the due date yet.

  • The information at the bottom of the tool will indicate a date the data in the tool was last refreshed and the date the next data refresh is tentatively scheduled
  • 'Adjusted' revalidation due dates for May and June 2022 have been added
  • All providers are identified on the downloadable file in a new column called 'Enrollment Type' and are identified as follows:
    • 1-PartA
    • 2-DME
    • 3-PartB (Non-DME)

Resources

Question: What is the status of my appeal and when should I expect a response to my appeal request?

Answer: The first level appeal may take up to 60 days, from the date of receipt to process. Use the First Level Appeal Redetermination Status Tool available on the Palmetto GBA website to verify your appeal has been received, is pending, or completed. When a first level of appeal is submitted through eServices, a provider may also track the status of that appeal request through eServices.

References

Question: I have a WO on my remit. Can you tell me what it is for?

Answer: If a refund owed Medicare is not received within 30 days, we will begin recoupment procedures from future payments for your Tax ID number. When an offset/withhold occurs, toward the end of your remittance advice (RA), you will find a Withholding (WO) reason code, followed by the financial control number (FCN) or invoice number(s) associated with the overpayment(s) recoupment. The FCN number on the RA can be matched to the invoice/FCN number on the overpayment demand letter you were sent to notify you of the overpayment. Use the Palmetto GBA eServices portal to access overpayment letters using the FCN number listed on the remittance advice.

References

Question: My remit has a levy on it. How should I handle this?

Answer: When and adjustment code LE appears on a remittance advice it indicates that a federal agency is utilizing the Federal Payment Levy Program (FPLP) to withhold available Medicare funds to satisfy federal agency debt. Palmetto GBA does not have any details concerning this withholding. Any information concerning the debt collection is only available by calling the Treasury Offset program at the number listed on your remittance advice.

When the adjustment code IR appears on your remittance advice it indicates that Medicare funds are being withheld due to an IRS tax levy. Palmetto GBA has no details regarding this withhold and providers should contact the IRS.

Last Reviewed: 4/18/2023

Claim Denials

Question: I have to call the Provider Contact Center every time I get a denial. How can I figure out why the claim was denied without calling the provider contact center?

Answer: After Medicare processes a claim, an electronic or standard paper remittance advice (RA) is sent with final claim adjudication and payment information. Itemized information is reported within that RA for each claim and/or line to enable you to identify payments, denials or rejections. All Medicare Administrative Contractors (MACs) use a standard set of claim adjustment reason and remark codes (CARCs and RARCs) to explain how a claim was handled. If you receive a version of a paper or electronic remittance advice from someone other than Palmetto GBA, that entity decides what information from the official Palmetto GBA RA they include on their version of the RA. Speak with that entity if you are not seeing the CARCs and RARCs associated with Palmetto GBA's claim decisions.

Palmetto GBA also has a Denial Resolution Tool that outlines the reasons and provider actions for some of the most common CARCs and RARCs.

Resources

Claim Status

Question: I am a third-party biller and I do not get the Medicare Remittance Advice. How can I check the status of claims?

Answer: As a third-party biller, you should be communicating with your client to make arrangements for them to provide you with copies of remittance advice or grant you access to their claim information through the Palmetto GBA eServices portal. Third-party billers should not use the provider contact center (PCC) to obtain information that is readily available and provided to the billing provider. Nor should a third-party biller contact the PCC to verify patient demographics or check claim status. The CMS requires all providers, including third-party billers, use the Palmetto GBA eServices portal or the Interactive voice response (IVR) to verify eligibility and claim status.

Resources

Return to Payer (RTP)/Unprocessable

Question: My claim did not pay but it also did not deny. The message is telling me I have to correct and resubmit the claim. How do I know what is missing or wrong with my claim?

Answer: CMS requires Medicare Administrative Contractors (MACs) to reject a claim when required information is missing, invalid or incomplete. When this happens, the claim is referred to as rejected or unprocessable. Without the required information being submitted on a claim, MACs are unable to make a claim determination to pay or deny the claim. A rejected or unprocessable claim must be corrected and resubmitted as a new claim and no appeal rights are afforded the rejected claim. The provider's remittance advice will include claim adjustment remark codes that detail the incomplete, invalid, or missing information.

Resource: Claim Rejections and Billing Errors.

General Info

Question: Does Medicare cover prescription drugs?

Answer: Medicare prescription drug benefits are handled by a patient's Medicare Advantage plan or through a separate Medicare Part C drug plan. Providers should query patients or their authorized representative regarding the patient's Medicare drug plan and contact the drug plan directly for questions about prescription drug plan coverage as it may vary by plan. As the Medicare Administrative Contractor for original/traditional Medicare Administrative Contractor, Palmetto GBA is not able to assist providers with questions or concerns regarding a patientÔÇÖs Medicare prescription drug coverage.

Question: How can I find a list of contacts for Palmetto GBA?

Answer: You may use the Palmetto GBA Contact Us link on the top-right corner of your jurisdiction's home page.

Resource: Contact Us web page.

Question: Why hasn't my appeal been processed when I submitted it three weeks ago?

Answer: To meet standards set by the CMS, Medicare Administrative Contractors (MACs) must complete first-level appeals (redeterminations) within 60 days from the date of receipt.

The following practices complicate and slowdown the completion of first level appeal requests:

  • Submitting duplicate appeal requests using different submission methods (eServices, fax, or mail), or automatically resubmit an appeal at 30 and/or 60-day intervals. Palmetto GBA must match the duplicate requests with the original request.
  • Faxing a second request because a provider is unsure if the first fax was successfully transmitted. View your fax machine's fax confirmation page to confirm the fax was successfully sent and compare the number of pages you intended to fax to the number of pages transmitted.

Resource: Shorten Appeals Decision Times by Avoiding Duplicate Appeals Requests. 

Question: What other ways can I check the status of my appeal?

Answer: Track your appeal requests. The time frame for Palmetto GBA to complete a redetermination requests begins once the appeal is received by Palmetto GBA. If you are mailing your appeal, you must allow for additional time for the appeal to reach Palmetto GBA.

  • Submitting your first level appeal requests (redeterminations) through the Palmetto GBA eServices portal allows you to check the status of that appeal in the eServices tool without having to call the provider contact center or use the IVR
  • Use the Palmetto GBA Redetermination Status tool available on the Palmetto GBA website
     

Question: Will I receive a letter once my appeal is finalized?

Answer: You will not receive an appeal decision letter for fully favorable appeal determinations. Once Palmetto GBA adjusts the affected claim, you will receive payment and notification of the adjusted claim on your remittance advice.

If the decision is unfavorable or partially unfavorable, you will receive an appeal decision letter sent through U.S. mail or you can sign up to receive eDelivery of your Medicare redetermination notices (MRNs) through eServices.

Resources

Eligibility/Entitlement

Question: How can I tell if my patient has traditional Medicare, a Medicare Advantage or Railroad Medicare benefits?

Answer: Review the following educational article for your jurisdiction: New Year: Identify Beneficiary Insurance Changes For 2022.

Last Reviewed: 4/18/2023

Question: Why does my claim deny as a duplicate?

Answer: Claims will be denied as a duplicate if Medicare has already processed a claim from the provider for the same patient, same date of service and same procedure or service. Providers should always check the status of their previously submitted claim prior to submitting the claim again. The preferred method of checking claim status is by using the eServices portal.

While your clearinghouse or billing company may allow you to correct a claim and simply resubmit the claim, if the claim has already been medically reviewed or processed with a payment or denial being issued on your remittance advice, you should consider requesting a simple claim reopening or a first level appeal through eServices for necessary corrections. Below are additional resources to help providers understand and handle duplicate denials or billing for multiple, identical services provided to the same patient on the same day.

Resources

Question: How do I know which secondary insurance plans Medicare will automatically send my claims to after Medicare has processed a patient's claim?

Answer: CMS developed a model national contract, called the Coordination of Benefits Agreement (COBA), which standardizes the way that eligibility and Medicare claims payment information within a claim's crossover context is exchanged. A list of the Automatic Crossover Trading Partners (insurers) in production along with a list of contacts for each of the trading partners, is located on the CMS website (PDF).

Question: When my claim is rejected and not afforded appeal rights why does the Medicare Remittance Advice show the entire submitted charge as a CO or contractual obligation meaning I cannot bill the patient?

Answer: When a claim is rejected, Claim Adjustment Reason and Remark Codes are included on the remittance advice (RA) to inform the provider why the claim was rejected. A rejected claim means that information included on the claim was incorrect, incomplete, or required information was missing. Rejected claims have no appeal rights and the claims must be corrected and resubmitted. Claim Adjustment Group Code CO means the dollar amount listed on the RA is a Contractual Obligation and includes any amounts for which the provider is financially liable. The patient may not be billed for these amounts and must correct and resubmit the claim so that Medicare can make a claim payment determination to allow or deny the service/procedure in question.

Question: When a patient has Medicare and another insurance, how do I determine if Medicare is the primary or secondary insurer?

Answer: Palmetto GBA provides an MSP Lookup tool that asks a series of questions that must be answered to help a provider determine if Medicare is the primary or secondary insurer. Additionally, verify if Medicare is primary or secondary for specific patients through the Palmetto GBA eServices portal or Interactive Voice Response (IVR) unit. If Medicare records do not match the MSP Lookup Tool outcome, refer the patient to the MSP Contractor to have his or her records corrected.

Resources

Question: Can a patient have Part A Medicare benefits and not Part B Medicare benefits?

Answer: Yes. Part B of the Medicare program is medical insurance and typically Medicare beneficiaries must enroll in Part B Medicare and must make premium payments for Part B coverage. Some patients may opt not to enroll in Part B. The patient's Medicare card should indicate an effective date if the patient has Part B Medicare insurance.

Question: I saw a patient in my office and provided and evaluation and management service and a chest X-ray (with no modifier). Medicare paid for the visit but denied the chest X-ray. I was told it was because the patient was in a Skilled Nursing Facility (SNF) and the SNF is responsible for the chest X-ray. Why is the SNF responsible when I was the doctor that took and read the chest X-ray in my office?

Answer: In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. This is referred to as SNF Consolidated Billing (SNF CB). When a Part B service is denied as bundled by SNF CB, the Part B provider must look to the SNF for compensation for any bundled service that was provided. SNF Consolidated Billing.

For Medicare beneficiaries in a covered Part A stay, these separately payable Part B services include:

  • Physician's professional services;
  • Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
  • Certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;
  • Erythropoietin for certain dialysis patients;
  • Certain chemotherapy drugs;
  • Certain chemotherapy administration services;
  • Radioisotope services; and
  • Customized prosthetic devices

There are a number of services that are excluded from SNF CB and are still billed separately to Part B Medicare. In your example, the technical component of a chest X-ray is bundled by SNF CB. The professional component (interpretation and report) of the chest X-ray is excluded from SNF CB and you may bill Part B Medicare for that service. Because you billed the X-ray with no modifier, the entire chest X-ray was denied. You must rebill Medicare on a new claim for the chest X-ray interpretation and report (represented by appending the CPT® modifier 26). You would look to the SNF for reimbursement for the SNF CB portion of the chest X-ray representing the technical component (TC HCPCS modifier).

For a full listing of excluded services (those that can be billed to Medicare Part B) visit the CMS SNF CB web page. File 1 and 2 under the 'Downloads' section at the bottom of the page.

Last Reviewed: 4/18/2023

A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on July 15, 2022.

Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A web page.

Last Reviewed: 4/18/2023

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: 4/18/2023


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