Published 01/13/2023

Palmetto GBA is publishing the following Frequently Asked Questions (FAQ) based upon data analytics identifying topics generating a high volume of telephone inquiries between January 1, 2022, through March 31, 2022. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

1. Question: My agency has a numerous number of claims that are in a suspended status on FISS. Is there a problem with all of my claims that are in suspended locations? Is there anything that can be done to make my suspended claims process quicker?

Answer: All Medicare billing transactions will temporarily suspend (“S”) in different status and locations (S/LOCs) as they process through FISS. Once a claim is submitted to Medicare, assuming that it has no errors and meets medical necessity requirements, it will remain in a suspended status until it is ready to be paid. The Medicare Claims Processing Manual Publication 100-04 Chapter 1 Section 80.2.1 (PDF) states that Medicare contractors have 30 days to process clean claims. While the typical timeframe to process claims is less than this, contractors have the full 30 days from the receipt date of a clean claim to process it. There is no provider action needed during this timeframe unless otherwise notified.

Claims may also suspend due to system issues that prevent Medicare billing transactions from processing appropriately. Billing transactions impacted by these issues may be suspended for more than 30 days. The first course of action for the provider should be to check the Claims Payment Issues Log on the Palmetto GBA website.

Claims that are suspended in ST/LOC’s SB6001 can be in the location up to 45 days awaiting the return of documentation that has been requested from the provider as part of the Additional Documentation Request (ADR) process.

Additional information regarding ADR process can be found using the links below.

2. Question: I have many beneficiaries that our hospice agency bills for that have elected to enroll in Medicare Advantage Organizations (MAO) that are involved in the Value-Based Insurance Design Model (VBID) and we are seeing issues that were not occurring with billing claims to Palmetto GBA prior to Calendar year (CY 2021) what changed?

Answer: For Medicare beneficiaries who are MAO enrollees and elect hospice prior to January 1, 2021, the Medicare Administrative Contractor (MAC), was responsible for processing claims of the hospice services. However, for Medicare beneficiaries who are MAO enrollees and have elected hospice on or after January 1, 2021, and prior to January 1, 2025, and the MAO plan is participating under the hospice benefit component of the VBID Model, all of his or her Medicare benefits will be covered by the MAO plan.

Key Policies and Requirements for CY 2022 (continued from CY 2021)

  • Participating MAOs must continue to cover hospice care for enrollees who choose to elect hospice through an in-network or out-of-network hospice provider
  • Participating MAOs continue to be prohibited from applying any prior authorization to hospice care related to the enrollee’s terminal condition
  • Participating MAOs must continue to pay for out-of-network hospice care at 100% of Original Medicare rates, including physician services and the service intensity add-on (SIA) payments
  • Participating MAOs must continue to pay for any unrelated services and/or post-hospice live discharge costs, as long as they are deemed to be appropriate and medically necessary
Billing and Claims Under the Hospice Benefit
  • For questions about enrollment, billing, claims, and contracting related to enrollees of participating plans, hospice providers should contact the participating MAO.
  • Hospice providers must continue (as they have in CY 2021) to send all notices and claims to both the participating MAO and the relevant Medicare Administrative Contractor (MAC) on a timely basis
  • The MAO will process payment, and the MAC will process the claims for informational and operational purposes and for CMS to monitor the Model
  • If you contract to provide hospice services with the plan, be sure to confirm billing and processing steps before the calendar year begins, as they may be different.

Note: Beneficiaries enrolled in the hospice benefit component of the VBID Model, will remain enrolled in the MA plan after a discharge or revocation.

Resource: CMS VBID Model Hospice Benefit Component Overview Homepage. This page provides links to VBID:

  • Coverage
  • Participating Plans
  • Billing & Payment
    • Eligibility Check
    • Directions for Submitting Claims
  • Outreach & Education
    • Publications —Hospice Benefit Component Technical and Operational Guidance
    • Mailings
    • Events
  • FAQ

3. Question: How does a facility determine whether it is going through a change of ownership versus a reorganization? Answer: The CMS Regional Office (RO) makes the determination of whether a particular circumstance constitutes, for Medicare purposes, a change of ownership or a reorganization. Prior to submitting the CMS-855A, contact your CMS RO. CMS has made the Contacts Database available to providers to assist in determining who should be contacted. To utilize the database please follow the steps below:

  • Select Organization Type
    • CMS RO — Center for Medicare & Medicaid Services Regional Office
  • Select Contact Type
    • Any
  • Select a Region or State Territory
    • Select appropriate region or state
  • Select Show Contacts to display the list of regional offices based on your selection
  • Select See Details to obtain necessary details to complete search

4. Question: Our agency’s claims continue to reject for Reason Code C5460, what can be done to avoid getting this error?

Answer: Reason Code C5460 is designed to look for an affirmed Unique Tracking Number (UTN) on claims subject to Review Choice Demonstration (RCD). If the UTN submitted is incorrect or was determined to be non-affirmed the reason code will edit on the claim. To avoid this reason code please ensure that the UTN being used on claims are correct and affirmed.

5. Question: Our agency has had to contact the Provider Contact Center (PCC) constantly regarding what has been described as known system issues what can we do to find out automatically what is causing issues?

Answer: The provider community is given the option to sign up for article update notifications via email. To sign up for email updates provider must choose the Subscribe to Email Updates link based on jurisdiction.

The CPIL is also available to the provider community. The CPIL allows facilities to see detailed information regarding identified problems which includes such information as:

  • Issue description
  • Date CPIL opened
  • Action required from the provider if applicable
  • Resolution date once resolved

Last Revised: 1/13/2023

Answer: 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: 1/13/2023

Answer: The Internet-Only Manual (IOM) System on the CMS website houses the home health and hospice manual information. Please select the following manual references for home health and hospice billing and coverage information. When viewing this information, please select the appropriate provider type to view CMS guidelines.

Last Reviewed: 1/13/2023

Answer: You can’t adjust a claim to correct a medically denied line. You must submit a Redetermination: 1st Level Appeal form along with a corrected claim.

Last Reviewed: 1/13/2023

Answer: A PTAN is the Provider Transaction Access Number, which is also known as the six-digit provider number, OSCAR number or legacy number. Providers will be asked for their PTAN when calling the provider contact center (PCC).

Last Reviewed: 1/13/2023

Shane R. Mull, M.D., MHA, FAAFP, CPC is Palmetto GBA’s Senior Medical Director accountable for all coverage policy activities at Palmetto GBA. Dr. Mull graduated from the College of Charleston in Charleston, S.C., with a B.S. in Biochemistry and a B.A. in Chemistry. He then attended the University of South Carolina School of Medicine to earn his M.D. and completed a Family Medicine Residency in Greenwood, S. C. Prior to joining Palmetto GBA he practiced in various capacities including rural health, emergency departments, urgent care and previously served as the Chief of Primary Care for a U.S. Army Hospital. He has earned an MHA from the Medical University of South Carolina and is a certified professional coder.

Miguel A. Brito, Jr., M.D., FCAP, FASCP, is part of the physician team for Palmetto GBA’s A/B MAC Jurisdictions J and M. Due to his expertise in Pathology and Laboratory Medicine, he is also part of the MolDx program. He is a graduate of the University of Miami and went on to Medical School at the University of Florida. He completed his residency in Anatomic and Clinical Pathology at the Medical College of Virginia. After residency, he was in the active private practice of Pathology for 33 years in several roles finalizing with being a partner and owner of his own group for 15 years. He has been involved in numerous hospital leadership roles from Chief of Pathology and Laboratory, Chief of Surgery and President of the Medical Staff. He was a member and Chairman of multiple hospital committees including Credentials, Infection control, Blood utilization and Medical Staff Executive Committee. He is a member and former Vice President and Executive committee member of the Florida Society of Pathologists, member and former state issues representative and current House of Delegates representative of the College of American Pathologists, member of the American Society of Clinical Pathologists and Clinical Affiliate Assistant Professor of the Florida Atlantic University College of Medicine. He is a graduate of the Physician Leadership Academy of South Florida. He holds active medical licenses in the states of Florida, Georgia, South Carolina and North Carolina. He is certified by the National Board of Medical Examiners and is board-certified by the College of American Pathologists in the specialties of Anatomic and Clinical Pathology. He is a Fellow of the College of American Pathologists and the American Society of Clinical Pathologists.

Judith K Volkar, M.D., MBA, FACOG, CNMP, serves as a Contractor Medical Director. Dr Volkar graduated from Washington and Jefferson College with a bachelor’s in biology. After attending medical school at Drexel University in Pennsylvania, she completed a residency in obstetrics and gynecology at Abington Memorial Hospital. Dr Volkar worked for the National Health Service Corps in West Virginia for four years and then spent 20 years in private practice in Johnstown, Pa., serving as Vice Chair of the Department of OB/GYN. Transitioning to academic practice, she was the quality director for Specialized Women’s Health at the Cleveland Clinic for four years and then the Quality Director for the department of OB/GYN at Magee Women’s Hospital Pittsburgh for five years. She is board-certified in obstetrics and gynecology and also serves as the ACOG advisor to the AMA CPT editorial board.

Jason D. Stroud, M.D., M.S., After graduation from Clemson University with both a bachelor’s and master’s degree in Bioengineering, Dr. Stroud attended the Medical University of South Carolina and completed a residency in Family Medicine with the Trident/MUSC Family Medicine Residency Program. Dr. Stroud has experience practicing medicine in a variety of settings including emergency room, urgent care, and private practice. Prior to joining Palmetto GBA, Dr. Stroud was in private practice in Mt. Pleasant, S.C. He currently serves as a Contractor Medical Director for A/B MAC Jurisdictions J and M. He is board-certified in Family Medicine and is a member of the American Academy of Family Physicians.

Lisa Banker, M.D., FACP, CPE, CCS, CCDS, serves as a Contractor Medical Director for Part A and Part B coverage policy for A/B MAC Jurisdictions J and M. She is a proud graduate of the University of Notre Dame and received her M.D. degree from the Medical College of Ohio. Dr. Banker is an internist by training with 14 years of practice as a primary care physician followed by several years as a hospitalist program director. Over the past several years, Dr. Banker has served as a physician administrator with a unique role encompassing hospital revenue cycle integrity, value analysis, compliance, and clinical documentation excellence work. She is a board-certified internist, a fellow of the American College of Physicians, a previous director of the American College of Physician Advisors, a certified coding specialist and a certified documentation specialist. Dr. Banker has lived in the same coastal North Carolina community for 25 years with her physician husband raising three wonderful children.

Maria Lenaz, M.D., M.S., MMM, serves as a Contractor Medical Director for Part A and B coverage policy. She is an obstetrician gynecologist by training and most recently has served as a health plan medical director. Her experience includes academia and insurers. She is a Fellow of the American College of Obstetricians and Gynecologists and a Fellow of the American Association of Physician Leadership.

Last Reviewed: 1/13/2023 

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