Q. Why must providers use available self-serve tools for certain actions instead of speaking with a Palmetto GBA customer service representative?

A. CMS requires providers to use the Interactive Voice Response (IVR) system to access claim status and beneficiary eligibility information.

Providers also have the option of using the eServices portal to access claim status and beneficiary eligibility information. The Palmetto GBA eServices portal provides additional tools to assist the provider community. Review the eServices User Guide (PDF, 7.42 MB) to learn about all of the eService functions.

The process of using these tools allows Palmetto GBA to meet CMS requirements and our customer service representatives (CSRs) to assist callers with more complex inquiries which cannot be answered through the above-mentioned self-service tools.

Resources: Interactive Voice Response (IVR) Information

CMS Reference: CMS Internet Only Manual, Publication 100-09, Chapter 6, Section 50.1 (PDF, 1.31 MB), "Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR... Each MAC has the discretion to also require that providers use the Internet-based provider portal for claim status and eligibility inquiries if the portal has these functionalities."

Q. How do I know which provider enrollment application I should use?

A. The Enrollment Application Finder self-service tool provides a list of enrollment forms and tools to help you determine which form to use for your provider/group type or enrollment action. 

Q. When I submit a claim for routine foot care, where on a claim do I indicate evidence that the patient was under the care of a doctor of medicine or osteopathy during the preceding six months?

A. The NPI of this doctor and the date of the last visit to this doctor must be submitted on claims for routine foot care in the following manner:

  • Electronic claims: submit the NPI of the doctor of medicine or osteopathy in Loop 2310E or 2420D, NMI/DQ, 09 and the date of the last visit to this doctor in Loop 2300 or 2400, DTP/304, 03
  • Paper claims: submit this information in Item 19 of the CMS-1500 claim form 

Resource: Routine Foot Care General Information

Q. When do I use CPT modifier 55 and how do I submit a claim with CPT modifier 55?

A. CPT modifier 55, postoperative management only, is used to indicate that payment for the postoperative, post-discharge care is split between two or more physicians where the physicians agree on the transfer of postoperative care. Use the Palmetto GBA ‘Modifier Lookup tool’ for full details on how to bill correctly with the CPT modifier 55.

Resource: Modifier Lookup Tool - CPT Modifier 55

Q. Where can I find information on Medicare’s coverage of the Medicare Diabetes Prevention Program (MDPP) Expanded Model and information on appropriate billing for the Medicare diabetes prevention program?

A. Visit the CMS Medicare Diabetes Prevention Program (MDPP) Expanded Model webpage for guidance, fact sheets and other resources. 

Q. My claim is rejecting indicating information on the claim is incomplete and/or invalid and I need to correct and resubmit the claim. How can I find out what is wrong with the claim without having to call the provider contact center each time?

A. A claim that is rejected as unprocessable because required information is missing or is invalid and/or incomplete is not afforded appeal rights. The tips below will help you determine what needs to be corrected on your claim before resubmitting the claim as a new claim with required and valid information.

  • Claims that reject as unprocessable are considered billing errors. The claim will contain remittance advice remark codes (usually remark code MA130).
  • Claims rejected with remark code MA130 will include additional remark codes to further detail the error. Look for and review all remark codes to find the specific error. If no additional remark codes are listed in addition to remark code MA130 contact your vendor or billing company to make certain they are providing you with all remark codes provided by Palmetto GBA on the Palmetto GBA remittance advice.  
  • Unprocessable claims cannot be sent in for reopening or redetermination (first level appeal).

Use Web tools to help identify and correct billing errors, such as the Denial Resolution, Modifier Look-up and specialty Web articles.

Q: As a Jurisdiction J (JJ) provider, what fax coversheet do I use when I am required to send additional documentation with an electronic claim?

A. Jurisdiction J providers should use the PWK fax coversheet and be sure to complete the necessary PWK data elements on your electronic claim to alert Palmetto GBA that you have faxed in necessary documentation. View the Submitting Additional Documentation article for full details and a link to the PWK fax coversheet.

Did you know Part B eServcie users can skip having to fax additional documentation and can send required additional documentation though the Palmetto GBA  eServices portal. We pre-populated the eServices form with the information we know from your registration record. This will save you several steps. Access the form in eServices by accessing the Additional Documentation Form sub-tab located under the Claims tab. If the sub-tab is not displaying, ask your eService administrator to grant you access to this function. Learn more about this eService feature in section 4.8 of the eServices User Manual (PDF, 7.42 MB).

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

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