Provider Contact Center (PCC) Frequently Asked Questions (FAQ): January 1, 2020 - March 31, 2020

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, 2020, through March 31, 2020. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

JJ Part A Highest Inquiry Categories

  • RTP/Status: 5,880
  • Financial: 1,392
  • Denial/Reject Explained: 7,934
  • Appeals: 1,419
  • General: 5,117
  • Billing: 1,131


 

JM Part A Highest Inquiry Categories

  • RTP/Status: 4,234
  • Financial: 895
  • Denial/Reject Explained: 6,989
  • Appeals: 872
  • General: 10,965
  • Billing: 1,137

 

Home Health and Hospice Highest Inquiry Categories

  • RTP/Status: 3,870
  • Financial: 1,433
  • Denial/ Reject Explained: 4,836
  • Appeals: 247
  • General: 6,329
  • Billing: 8,920

JJ and JM Part A FAQs Related to Highest Inquiry Categories

Why are my claims rejected as duplicates? What can I do to avoid this happening in the future?
The system has edits in place that will identify information such as duplicate services, multiple claims for the same provider on a date(s) of service, as well of same date of service for different providers. The edits are programmed to review paid, finalized and pending claims. If similar services are detected the claim system will reject the newest claim submission as a duplicate.

There are a variety of ways that providers can avoid receiving a duplication rejection on claims. Methods include:

  • Adding distinct modifiers (if applicable) to services that will trigger the claims system to determine the charge is not a duplicate
  • Ensure that once a claim is submitted that processing (claim is in a B9997 status location) is completed prior to sending in any type of adjustment for the dates of service if an error is detected in how it was billed
  • If a third-party biller is responsible for submitting claims on your behalf, as a best practice give instruction to ensure that software only submits the claim(s) once and perform quality control checks to ensure there are no glitches causing claims to be submitted multiple times in error

My claims are editing for an add-on code. What is it and why is it needed for my claim?
According to the CMS National Correct Coding Initiative Edits (NCCI) web page Add-on Code Edits, an add-on code is a HCPCS/CPT code that describes a service that, with one exception (see Change Request 7501 for details), is always performed in conjunction with another primary service. An add-on code (with one exception) is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner. An add-on code (with one exception) is never eligible for payment if it is the only procedure reported by a practitioner.

Add-on codes are divided into three groups to determine appropriate payment:

  • Type One: The add-on code has a limited number of primary codes that are acceptable for payment
  • Type Two: The add-on code does not have a specific list of primary procedure codes
  • Type Three: The add- on code has some specific primary codes identified but is not an all exclusive list

Add-on list codes are updated on an annual basis, on or by January of each year, and any updates are posted as necessary on a quarterly basis. It is important that add-on codes are added to claims to ensure proper payment. The most recent complete add-on code file can be found at April 1, 2020 Complete Add-on code edits.

My claim has a discharge status code of 20 because the beneficiary is deceased, but my claim is rejecting. How do I correct?
The most common reason for a claim rejection with a discharge code of 20 is because the “from” or “through” date on the claim is after the beneficiary’s reported date of death in the Common Working File (CWF). There are several reason other reasons why a claim may reject with the discharge status code of 20:

  • The date of death on CWF is incorrect
  • Occurrence code 55 (date of death) contains a date that is after the reported date in CWF
  • A previously processed claim with patient discharge status of 20 was billed incorrectly

A provider can correct this issue by:

  • Verifying the date of death for the beneficiary is correct in CWF. If it is found that the date is not correct the Social Security Administration (SSA) will need to be contacted.
  • If a previously billed claim was processed with the incorrect date of death the claim will need to be adjusted

My claim is rejecting for an Office of Inspector General (OIG) audit. How do I need to handle this claim?
When a provider receives a rejection for an OIG audit, the information concerning the specific audit can be found in the remarks section of the claim for the specific OIG Project Number.

Once the OIG Project Number is obtained the provider can determine the specifics of the audit by visiting the OIG Homepage and entering the OIG number into the search bar. Once project number is entered in the search bar there will be information concerning the OIG audit which includes:

  • Why the OIG audit was completed
  • Methods use to complete the review
  • OIG findings
  • Recommendations and CMS comments concerning the audit

There are options to obtain the complete report concerning the OIG audit or a brief overview of information concerning the OIG audit.

The beneficiary has a Medicare Advantage (MA) plan. Is there a method to identify the name of the MA plan online?
Yes, there is a directory that contains the listed of current MA plans on the CMS website. The directory for reporting period April 2020 can now be found on the website using the following the MA Plan Directory Reporting Period April 2020 and downloading the file listed.

HHH FAQs Related to Highest Inquiry Categories

What are the Rural add-on categories for CY 2020?
The Federal Register Document 11 08 2019, Section 50208(a)(1)(D) of the BBA of 2018, lists the rural add-on categories as the following:

  • High Utilization: Rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under Part A of Medicare, or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare
  • Low Population Density: Rural counties and equivalent areas with a population density of six or fewer individuals per square mile of land area and are not included in the “High utilization” category
  • All other: Rural counties and equivalent areas not in either the “High utilization” or “Low population density” categories

Why are my claims rejected as duplicates? What can I do to avoid this happening in the future?
The system has edits in place that will identify information such as duplicate services, multiple claims for the same provider on a date(s) of service, as well of same date of service for different providers. The edits are programmed to review paid, finalized and pending claims. If similar services are detected the claim system will reject the newest claim submission as a duplicate.

There are a variety of ways that providers can avoid receiving a duplication rejection on claims. Methods include:

  • Adding distinct modifiers (if applicable) to services that will trigger the claims system to determine the charge is not a duplicate
  • Ensure that once a claim is submitted, that processing (claim is in a B9997 status location) is completed prior to sending in any type of adjustment for the dates of service if an error is detected in how it was billed
  • If a third-party biller is responsible for submitting claims on your behalf, as a best practice give instruction to ensure that software only submits the claim(s) once and perform quality control checks to ensure there are no glitches causing claims to be submitted multiple times in error

My hospice claim has a patient discharge status code of either 40, 41 or 42 because the beneficiary is deceased, but my claim is rejecting. How do I correct?
The most common reason for a claim rejection with a patient discharge code of 40, 41 or 42 is because the “Through” date on the claim is after the beneficiary’s reported date of death in the Common Working File (CWF). There are several reason other reasons why a claim may reject with the discharge status code of 40, 41 or 42:

  • The date of death on CWF is incorrect
  • Occurrence code 55 (date of death) contains a date that is after the reported date in CWF
  • A previously processed claim with patient discharge status of 40, 41 or 42 was billed incorrectly

My claim is rejecting for an Office of Inspector General (OIG) audit. How do I need to handle this claim?
When a provider receives a rejection for an OIG audit, the information concerning the specific audit can be found in the remarks section of the claim for the specific OIG Project Number.

Once the OIG Project Number is obtained, the provider can determine the specifics of the audit by visiting the OIG Homepage and entering the OIG number into the search bar. Once project number is entered in the search bar there will be information concerning the OIG audit which includes:

  • Why the OIG audit was completed
  • Methods use to complete the review
  • OIG findings
  • Recommendations and CMS comments concerning the audit

There are options to obtain the complete report concerning the OIG audit or a brief overview of information concerning the OIG audit.

What is the FY 2020 Hospice aggregate cap?
According to CMS transmittal R4363CP entitled “Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Hospice Pricer for FY 2020,” the hospice cap amount for the 2020 cap year is equal to the 2019 cap amount ($29,205.44), updated by the FY 2020 hospice payment update percentage of 2.6 percent. As such, the 2020 cap amount is $29,964.78.

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Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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