Palmetto GBA is publishing the following Frequently Asked Questions (FAQ) based upon data analytics identifying topics generating a high volume of telephone inquiries between October 1, 2022, through December 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 home health agency (HHA) billed for beneficiaries that were in a skilled nursing facility (SNF) receiving home health services. Why are they rejecting as an overlap?
Answer: Beneficiaries cannot be institutionalized and receive home health care simultaneously. Therefore, claims for institutional inpatient services (inpatient hospital, SNF and swing bed claims), have priority in Medicare claims editing over claims for home health services.
If an HH claim is received, and CWF finds line-item visits on the HH claim that falls within the dates of an inpatient, SNF or swing bed claim (not including the dates of admission and discharge and the dates of any leave of absence), Medicare will reject the HH claim. This also works in reverse: if an inpatient, SNF or swing bed claim is received and it falls within line-item visits submitted on a processed HH claim, the HH claim will be reopened, adjusted and rejected.
With the above rejections, the HHA may submit a new claim removing any dates of service within the inpatient stay that were billed in error.
Reference: IOM Publication 100-04, Chapter 10 (PDF), Section 30.9 — Coordination of HH PPS Claims Episodes With Inpatient Claim Types.
2. Question: What is the Provider Enrollment Revalidation process for Medicare?
Answer: Every five years, the Centers for Medicare and Medicaid Services (CMS) requires providers to revalidate their Medicare enrollment record. Failure to respond to our notice to revalidate will result in a hold on Medicare payments and possible deactivation of Medicare enrollment. Palmetto GBA returns informational claims messaging for providers that are due to revalidate. The following informational message will be provided on claims that have been adjudicated if a revalidation is due.
While the five-year mark is standard, providers should continue to report normal changes as needed. Examples include changes in ownership or changes in authorized official(s) or delegated official(s). These circumstances must be reported to the MAC on the Medicare enrollment application within 30 calendar days of the change. All other changes to the enrollment application must be reported within 90 days.
3. Question: What is the criteria to receive Service Intensity Add-on (SIA) Payment for hospice?
Answer: A hospice claim will be eligible for a SIA payment if the following criteria are met:
- The day is a Routine Home Care (RHC) level of care day
- The day occurs during the last seven days of life (and the beneficiary is discharged deceased)
- Service is provided by a Registered Nurse (RN) or social worker
- The SIA payment is provided for visits of a minimum of 15 minutes and a maximum of four hours per day, i.e., from 1 unit to a maximum of 16 units combined for both nursing visit time and/or social worker visit time per day
- The service is not provided by a social worker via telephone
Reference: IOM, Publication 100-04, Chapter 11 (PDF), Section 30.2.2 — Medicare Claims Processing Manual.
4. Question: What penalties could agencies face for not filing a cost report in a timely manner?
Answer: The penalty for not filing the cost report timely is that 100 percent of any payments will be withheld. In addition, providers will be assessed interest at the prevailing rate at the time the cost report is due. Furthermore, if the cost report cannot be submitted by the due date, providers may request a reduced payment suspension rate of 50 percent during a grace period of 60 days. The request should be submitted before the due date of the cost report.
On the 61st day, if the cost report has not been filed, the rate of suspension will change to 100 percent. If a provider fails to request a reduction in the suspension rate, or if the MAC does not concur with the request for a reduced suspension rate, then 100 percent of the provider’s payments will be suspended. Terminated providers will immediately have 100 percent of their payments suspended for failure to file a cost report.
The payment hold will be released after the cost report has been received, reviewed and accepted. In peak periods (such as the month of June), it may take 30 days to accept the report. Please file timely (or early) to prevent being placed on payment hold!
Note: Remittance Advices (RAs) will be issued as normal during a payment hold. When the hold is released, the RAs will not be reissued. Providers will need to use the previously issued RAs for their accounting requirements.
- The Provider Reimbursement Manual, Part 2-15-2, Section 104
- IOM Publication 100-06, Chapter 8 (PDF), Section 10.2 — Medicare Financial Management Manual
5. Question: What are the requirements for a beneficiary to be transferred to another hospice agency?
Answer: The beneficiary is allowed to change the designation of the hospice they receive care from only once in each election (benefit) period. The change of hospice is not considered a hospice revocation. The beneficiary must file a signed statement with the hospice they have received care from and the newly designated hospice. The statement must include:
- The name of the hospice the patient was receiving care from;
- The name of the hospice that patient plans to receive care from; and
- The date the change is effective
The date of transfer is billable and reimbursable to both the discharging and admitting agency. The transfer process is the only option for both agencies to be reimbursed on the same day because when a new hospice admission occurs after a hospice revocation or discharge that resulted in termination of the hospice benefit, the new admission date cannot be the same as the revocation or discharge date of the previous benefit period.
When one hospice transfers a patient to another hospice with any gap following the date of transfer, this is deemed a gap in care and, therefore, wouldn’t be considered a continuous hospice election. In an effort to prevent gap billing from occurring during a hospice transfer, CR 12619 created a new CWF edit that no longer allows gaps of care to occur during a transfer. The CWF edit will reject the hospice transfer if the transfer doesn’t occur immediately and there’s a gap in the number of billing days between one hospice and the next.
Transfers aren’t allowed from the same provider. Hospices must not send an 8XC if the CMS Certification Number (CCN) is the same. In this case, the patient isn’t transferred to another hospice, they’re transferred to another location of the same hospice.
Note: The Change of Provider/Transfer Notice (Type of Bill 8XC) does not get submitted until after the other provider has finalized their billing.
- IOM Publication 100-02, Chapter 9 (PDF), Section 20.2 — Medicare Benefit Policy Manual
- IOM Publication 100-04, Chapter 11 (PDF), Section 20.1.3 — Change of Provider/Transfer Notice
- JM HHH — Hospice_Discharges_and_Revocations Chart (PDF)
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.
- Responding to a Hospice Additional Documentation Request
- Responding to a Home Health Additional Documentation Request (ADR)
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
- 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:
- Participating Plans
- Billing & Payment
- Eligibility Check
- Directions for Submitting Claims
- Outreach & Education
- Publications —Hospice Benefit Component Technical and Operational Guidance
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
- 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.
- Introduction — Publication 100 (PDF)
- Coverage Information: Medicare Benefit Policy Manual — Publication 100-02
- Billing Information: Medicare Claims Processing Manual — Publication 100-04
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