Description
Dates of service billed are within a beneficiary Medicare Advantage (MA) plan enrollment period; therefore, no Medicare payment can be made.

Resolution

  • Upon admission for Medicare-covered services, review all insurance (including Medicare Part D) cards the beneficiary has and verify the information on the card is valid
  • Upon admission and prior to billing, verify whether an MA plan will impact the dates of service by checking the beneficiary's eligibility file. This information is available in the eServices Plan Coverage tab.
  • Since MA plan election records are updated the first part of each month, providers whose dates of service span two consecutive months or extend beyond 30 calendar days are encouraged to check MA plan information for the beneficiary monthly
  • Review the "Bill Code" field on the eServices Plan Coverage tab

    • If the OPT code or bill code is a “C,” the MA plan is responsible for processing the claim
    • According to the Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 11, §30.4 (PDF, 493.55 KB), "While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS." In addition, "the duration of payment responsibility by fee-for-service contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiaries. MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked."
    • If the OPT or bill code is a “1,” services may be submitted to Palmetto GBA for processing
    • The eServices Plan Coverage tab will display the MA Plan’s name, identifier, and contact information. If the plan name and contact information is not available in eServices, access the MA Claims Processing Contacts directory, which contains a list of all active Medicare contracts and their corresponding plan type.
    • If the MA plan election is posted to the beneficiary's eligibility file in error, the MA plan will need to correct this information. Providers should contact the MA plan directly to update the beneficiary's record.
    • Providers should be aware that until the beneficiary's eligibility file is updated, any claims submitted to Palmetto GBA will be impacted by the incorrect MA plan information; therefore, providers should not submit Medicare claims until the MA plan information is corrected
    • If the MA plan election was correctly posted to the beneficiary's file and impacts your dates of service, you must look to the MA plan for reimbursement of services. Do not submit billing transactions to Palmetto GBA for payment, unless the eligibility file indicates the fee-for-service (FFS) contractor is responsible for processing the beneficiary's Medicare claims or there is a hospice election that impacts the MA plan enrollment period and your services are unrelated to the hospice election.

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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