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Printed Date: 9/22/2015
Palmetto GBA is publishing the following Frequently Asked Questions (FAQs) based upon data analytics identifying topics generating a high volume of telephone inquiries between May 1, 2018, through August 31, 2018. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).
FAQs Related to Highest Inquiry Categories:
Q1. How should a provider submit a Reopening request for a claim that is beyond the claim filing timeframe?
A1. A. Providers should submit a Reopening request on type of bill (TOB) XXQ to identify them as a Reopening. This TOB should only be used when the submission falls outside the period to submit an adjustment bill. Also, submit the appropriate R1-R9 reopening condition code and adjustment condition code, adjustment reason code (Direct Data Entry (DDE) users only) and good cause remarks in the proper format. Claims determined to not have good cause will be Returned to Provider (RTP'd). See CMS MLN Matters MM8581 or CMS MLN Special Edition SE1426 for further guidance.
Q2. How can I verify if a patient went to another facility upon discharge?
A2. Providers needing to verify if a patient was admitted inpatient to another facility upon discharge, may obtain this information through the IVR. Once applicable information is given to the IVR, the IVR will provide the starting date and type of facility of the following claim.
Q3. Does Medicare preauthorize services?
A3. Under Medicare law, payment for services and supplies is based upon the reasonableness and necessity of the services performed and supplied, and is determined on a case-by-case basis. Medicare is unable to preauthorize coverage of an anticipated service or supply. If a provider is in doubt as to whether Medicare will cover a service or supply for a specific patient, he/she may safeguard themselves by having the beneficiary sign a waiver of liability ABN prior to having the service performed. A waiver holds the beneficiary liable for the service should it be denied for medical necessity reasons. If an ABN is obtained, the service must be appended with a GA modifier.
Q4. When a Customer Service Representative (CSR) tells me that they will do a callback to research the claim or situation further, when should I expect a call back?
A4. Per CMS regulations, Palmetto GBA does have up to 10 business days to call providers back with an update or an answer; however, we do our best to make the contact within 7 business days. It is required for the CSR to make three attempts to reach a provider and/or leave a message to request a return call. If the provider does not respond after three callbacks, the CSR will close the callback. In this case, providers may call in for the answer.
Q5. If a primary payer retroactively recoups their payment years later, we send a claim to Medicare for primary payment. Medicare denied the claim for timely filing. We appealed the timely filing denial and provided documentation showing the other payer had recouped their payment. Why was my timely filing appeal denied?
A5. The CMS IOM 100-4 Medicare Claims Processing Manual, Chapter 1, Section 70.7.1 (PDF, 4.24MB), contains what conditions contractors will allow for exceptions to and extensions of timely filing requirements.
The exceptions include:
The CMS MSP Manual (Pub. 100-05), Chapter 3, Section 10.5 (PDF, 252 KB) also addresses this situation:
"In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen." You may refer to:
Q6. What laboratory services are covered under the rural health clinic (RHC) benefit?
A6. A RHC is required to furnish certain laboratory services onsite, although only certain components of these services are covered under the RHC benefit. An RHC may also offer other special services, such as chronic care management, telehealth, and home health services. Coverage and billing restrictions may apply to these services.
An RHC must be able to furnish the following laboratory services onsite for the immediate diagnosis and treatment of its patients:
You may refer to the MLN Rural Health Clinic Fact Sheet (PDF, 187 KB).
Q7. Who is liable when a beneficiary enrolls or disenrolls from a Medicare Advantage (MA) Plan during a period of service?
A7. When a patient enrolls or disenrolls in a Medicare Advantage organization during a period of service, two factors determine whether the Medicare Advantage (MA) organization is liable for the payment:
If the patient changes Medicare Advantage status during the inpatient stay for an inpatient institution, the patient's status at admission or start of care determines liability. If the hospital inpatient was not a Medicare Advantage enrollee upon admission but enrolls before the discharge, the MA organization is not responsible for payment.
If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.
Further information is available in the CMS Medicare Claims Processing Manual (Publication 100-04), Chapter 1, Section 90 (PDF, 4.24M B).
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Last Updated: 04/17/2019