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Printed Date: 9/22/2015
Common Rejection Reasons and Helpful Hints for the Credit Balance Certification Page
1. Certification Page is missing information: Make sure to complete all fields which includes:
Common rejections issues are:
2. Certification Page is not legible: Make sure to type the necessary information in each field and try to avoid manually writing, with the exception of the signature. This will help in limiting keying errors and rejections.
3. The 'SIGN' line is a signature only. Do not print on the signature line.
4. A separate line is listed to PRINT the Name and Title of the person signing the certification page. Only an officer or administrator should sign the certification page.
5. The Date field must be completed with the date the officer or administrator signed the completed Certification Page. The date cannot be before the end of the calendar quarter being reported.
6. Check One: Please make sure to check the box that applies to you.
7. If you check the box The Credit Balance Report Detail Page(s) is attached, please double check to ensure it is completed and attached.
8. If you check the box There are no Medicare Credit Balances to report for this quarter, a detail page should NOT be attached.
9. Provide the correct Contact Person who can answer any questions regarding the Credit Balance Report submitted.
10. Ensure the correct Telephone Number of the Contact Person listed on the Contact Person line is included.
Common Rejection Reasons and Helpful Hints for the Credit Balance Detail Page
1. Spreadsheet is not legible: Make sure to type the necessary information in each field and try to avoid manually writing. This will help in limiting keying errors and rejections. You are allowed to resize the cells and rows, to make sure the information fits and is clear. Submission through eServices also helps to reduce issues with readability that result from faxing.
2. Spreadsheet is missing information: The spreadsheet should be completely and correctly filled out. There should be no missing information. Any missing information will result in a rejection.
3. Method of Payment (column 11): Please use the following only;
4. Amount Outstanding missing (column 12): Please do not put a zero amount if Medicare has not recouped the money at time of submission. We will monitor the claim adjustments that your facility has made and remove the Amount Outstanding once we have collected your payment.
5. Incorrect claims dates (columns 5/6): Please note that the Admission Date and Discharge date should be used as 'Date of Service From' and 'Date of Service To' for inpatient claims reported
Other Common Rejection Reasons and Helpful Hints
1. Check payment being submitted without 838 report: Please make sure to submit your 838 report, Certification Page, Detail page, UB04(s) and Check altogether. We will not accept a 838 report that indicates you are paying by check if the check is not attached. (You may not submit by using fax.)
2. Submit one check per provider number: Make sure to submit one check for each provider number. Please do not combined providers on one check and do not send a separate check per claim or patient.
3. Submit different provider numbers on separate 838 reports: Each provider number under your facility should have their own 838 report, Certification Page, Detail page and UB04(s) submitted to Medicare.
4. Providers are encouraged to submit an electronic xxQ type of bill (TOB) adjustment claim to pay back an overpayment to Medicare. The xxQ TOB only applies to this adjustment claims submitted electronically; it does not apply to hardcopy adjustment claims (submission of hardcopy claims requires an ASCA waiver). When the xxQ TOB adjustment claim is an untimely submission; comments need to be added in the Remarks field.
If the adjustment claim is returned to provider (RTP) for correction; you are responsible to correct any RTPs that occur or the overpayment will not process and be paid back to Medicare. Palmetto GBA will only work with the timeliness edit if you are paying back a Medicare overpayment and will not correct any other error edits that cause a RTP.
5. Credit Balance Reports cannot be submitted prior to the calendar quarter end date.
6. Please do not attempt to recreate your own version of this form or copy onto your letterhead paper. Make copies of the current form on plain paper and send the original document on or before the due dates. This is the required format by CMS; therefore, any changes made to this form will be unacceptable.
CMS Regulation References
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Last Updated: 01/04/2021