RESOLVED: High Volume of Pending Claims Requiring Medical Review

Current Status
12/6/2018: Resolved Jurisdiction J and M medical review workloads have been reduced to within the normal workload ranges.

Issue Identified: On Going

Issue: Palmetto GBA is experiencing a high volume of pending workload for claims that require clinical review.

The list below includes examples of claim types that may be affected; however, the list is not all inclusive.

  • Unclassified Procedure Codes that need an operative report
  • Claims requiring a coverage decision
  • Claims that need additional documentation 

Provider Action: No provider action is necessary at this time and there is no need to contact the Provider Contact Center. Palmetto GBA has implemented a plan and is currently working to reduce the pending claims volume for these claims. The CPIL will be updated as new information is available. 

Financial Hardship: Providers that have more than 100 claims pending that meet the criteria listed above and the delay is creating a financial hardship may call the Provider Contact Center with the internal control numbers (ICNs) of the affected claim and request the claims be expedited. Providers should not include any claims that have been pending after claim submission for less than 30 days and requests must meet the 100 claim minimum and/or financial hardship.

Status

12/6/2018 Resolved: Jurisdiction J and M medical review workloads have been reduced to within the normal workload ranges.

10/26/2018: Palmetto GBA continues to work through the pending workload requiring medical review. Requests representing a provider financial hardship and meeting the criteria for the expedited requests outlined in this CPIL are completed in the order they are received.

9/20/2018: Palmetto GBA continues to reduce the pending workload and expedite those inquiries that are brought forward representing a provider financial hardship and meeting the other criteria for expedited requests outlined in this CPIL.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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