Issue Identified: May 13, 2019

Issue: The CMS third-party contractor sent a replacement file for the 2019 Merit-based Incentive Payment. The new file created claim adjustments to address changes made on that file. Palmetto GBA initially posted a Claims Payment Issue (CPI) to notify the provider community of this issue. Upward and downward adjustments resulting in under and overpayments have been completed.

Palmetto GBA has been notified that the CMS third-party vendor has performed and may perform additional adjustments to capture additional MIPS under or overpayments.

Affected claims have a date of service of January 1, 2019, or after and CARC (claim adjustment reason code) 144 (positive adjustment) or 237 (negative adjustment) on the remittance.

Provider Action: No provider action is required unless a provider receives an overpayment letter requesting incorrectly paid upward payments be refunded. Providers are encouraged to use the Palmetto GBA eServices tool to make any requested refunds.

Jurisdiction J and M Part B
Daily overpayment letters will be issued and include all overpayments identified that day (multiple claims = one demand letter)

Railroad Medicare

  • Daily overpayment letters will be issued and include all overpayments identified that day (multiple claims = one demand letter), as long as the total of all ARs together is $10 or greater
  • Claim overpayments of less than $10 will be aggregated with other claims with overpayments processed the same day, and will aggregate to a demand letter as long as the total of all ARs together is $10 or greater (multiple claims = 1 demand letter)
  • For any overpayment amounts less than $10 that cannot be aggregated to over $10, the claims are closed and written off and no demand letter is issued
    • An aggregation process runs monthly. If a provider has multiple overpayments under $10 not already included on a demand letter, the overpayments will be reviewed the following month for the previous month. If the overpayments aggregate to $10 or more, a demand letter will be sent. If the overpayments do not aggregate to $10 or more, the overpayments are closed and no demand letter will be issued.

Status 6/20/2019

MIPS adjustments resulting in under and overpayments have been completed based on the latest replacement file received from the CMS third-party contractor.

Adjusted claims appear on remittance advice. Overpayment demand letters have been issued for adjustments resulting in an overpayment. Use the financial control number (FCN) found on their remittance advice to match the adjusted claim to the overpayment request letter. Be aware that in some practices, the overpayment demand letters may be directed to a specific person or internal department. Rather than contacting the Palmetto GBA Provider Contact Center for a copy of the overpayment demand letter for overpayment details, providers should determine where their practice houses Palmetto GBA overpayment demand letters once received. 

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