Jurisdictions J and M Part B Frequently Asked Questions: July 2020

Question: Why are my claims denied as duplicates? What can I do to avoid this happening in the future?

Answer: 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. In some instances, a note may be required in the claim narrative field to indicate the time that each service was performed to prevent duplicate denials.
  
• Check the status of a submitted claim to ensure that that the submitted services have not already processed and paid
  
• If a claim has denied as a duplicate and should be a service that is considered for payment, file an appeal with documentation to support the medical necessity of the repeat service
  
• 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

Question: The beneficiary has a Medicare Advantage (MA) plan. Is there a method to identify the name of the MA plan online?

Answer: Yes, by choosing the correct options, the Interactive Voice Response (IVR) will give the MA Plan ID number. There is a directory that contains the list of current MA plans on the CMS website. The directory for reporting period June 2020 can now be found on the CMS website and may be downloaded. MA Plan Directory as of June 2020 (ZIP).

Question: My claim is denying stating the patient was enrolled in a Skilled Nursing Facility (SNF). Is there a way to identify the name or NPI of the facility?

Answer: Yes. Once the provider can verify specific information regarding the patient, denied services and billing provider, the provider contact center is able to release the SNF name, address and telephone number as it relates to the date(s) of service in question.

Question: My claim has rejected for name formatting. How can I ensure this does not continue to happen?

Answer: Claims should be submitted according to the information on the beneficiary’s Medicare Beneficiary Identifier (MBI) card; the card should include the patient’s MBI as well as any hyphenated names. The beneficiary’s name submitted on a claim should match the information exactly as it is on the MVI card or the claim will reject.

Question: I have submitted a claim for rhinoplasty for a beneficiary with Gender Dysphoria (GD). Can you tell me why it was denied?

Answer: Services that are considered cosmetic for the treatment of gender dysphoria are not covered. For a list of covered criteria and services considered as cosmetic, refer to Local Coverage Article A53793, Billing and Coding: Gender Reassignment Services for Gender Dysphoria.

Question: Has my patient satisfied the deductible for 2020? How can I determine if my patient has met their 2020 deductible without speaking to a representative?

Answer: Deductible information can be found by using patient information using the IVR or Palmetto GBA's eServices.

Question: Is a Prior Authorization needed for Botox injections?

Answer: Each outpatient department Botox injection provided on or after July 1, 2020, requires prior authorization as part of Medicare’s Outpatient Department Prior Authorization program. Below is a list of services that are part of the Medicare Outpatient Prior Authorization program.

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation