Palmetto GBA is publishing the following Frequently Asked Questions (FAQs) based upon data analytics identifying topics generating a high volume of telephone inquiries between September 1, 2018, through December 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).

JMA Highest Inquiry Categories: September 1, 2018, through December 31, 2018

  • RTP/Unprocessable Claim 2,838
  • Financial 1,096
  • Claim Denials 6,719
  • Appeals 2,014
  • General 3,058
  • Claim Status 3,259

JJA Highest Inquiry Categories: September 1, 2018, through December 31, 2018

  • RTP/Status 2,915
  • Financial 1,512
  • Denials 9,171
  • Appeals 1,739
  • General 3,870
  • Claim Status 4,346

FAQs Related to Highest Inquiry Categories:
Q. 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?

A. 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 seven 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.

Q. Does Medicare preauthorize services?
A.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 Advanced Beneficiary Notice (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 HCPCS modifier.

Q. How can I verify if a patient went to another facility upon discharge?
A. Providers needing to verify if a patient was admitted inpatient to another facility upon discharge may obtain this information through the Interactive Voice Response (IVR). Once applicable information is given to the IVR, the IVR will provide the starting date and type of facility of the following claim.

Q. Are late entries acceptable in a patient's chart? Is it acceptable to add a late entry after the patient is discharged?
A. This is addressed in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section These entries must be clearly signed or initialed, dated, and identified as a late entry. If the person making the entry can legitimately confirm that the entry happened and has direct memory of that occurrence, a clearly labeled late entry is reasonable. An entry should not be made if this cannot be supported. As the time between the event and the time it is documented increases, fewer details are generally correctly remembered.

Q. How should a provider submit a reopening request for a claim that is beyond the claim filing timeframe?
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 (PDF, 84 KB) or CMS MLN Special Edition SE1426 (PDF, 1.01 MB) for further guidance.

Q. Who is liable when a beneficiary enrolls or disenrolls from a Medicare Advantage (MA) Plan during a period of service?
A. 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:

  1. Whether a provider is included in an inpatient hospital or home health PPS
  2. The date of enrollment

If the patient changes Medicare Advantage status during an inpatient stay in 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.

Q. Must a Skilled Nursing Facility (SNF) list all consolidated billing (CB)– included services it renders to a beneficiary on the Medicare claim?
A. Yes, an SNF must list all CB-included services even though the SNF is not reimbursed for each specific service, but paid Prospective Payment System (PPS). Otherwise, the provider is out of compliance with Medicare’s rules for consolidated billing. A lapse could result in the recoupment of any identified overpayments.

Q. Are all outpatient services the SNF Part A beneficiary receives are separately billable to Part B?
A. If an SNF Part A beneficiary goes anywhere other than a hospital outpatient department to receive a category I service, the SNF must account for the item on the consolidated bill and pay for it out of the resulting PPS rate lump sum.

Q. Are claims for category I services provided to a beneficiary in the midst of a Part A SNF stay excluded if the hospital that provides them owns the free­standing clinic?
A. A clinic that bills Medicare using the hospital’s provider number is considered a hospital outpatient department and will therefore have to bill separately for the service it rendered during the Part A SNF stay. However, if the clinic uses a different Medicare provider number than the hospital, it is considered a freestanding clinic, and the service must therefore be included in the SNF’s consolidated bill.

Q. Are EPO and Aranesp always excluded from consolidated billing for a SNF Part A beneficiary?
A. EPO and Aranesp are excluded from Part A consolidated billing only when provided in conjunction with dialysis to end-stage renal disease (ESRD) beneficiaries and billed by an approved renal dialysis facility or outside dialysis supplier. However, these drugs are included in consolidated billing whenever they are given to either:

  • An ESRD beneficiary directly by the SNF
  • A non-ESRD beneficiary

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department

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