Provider Contact Center (PCC) Frequently Asked Questions (FAQs): January 2018 - April 30, 2018

Palmetto GBA is publishing the following Frequently Asked Questions (FAQs) based upon data analytics identifying topics generating a high volume of telephone inquiries between January 2018, through April 30, 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

  • Appeals 3,773
    • Status 2,116
  • Claim Denials 6,462
    • Coding Errors/Modifiers 1,477
    • Claim Overlap 1,591
  • Suspended Claim Over 30 days in location 4,769
  • Payment Explanation/Calculation 2,048
  • General Information 3,163
  • RTP/Unprocessable 1,733
    • Missing/Invalid Codes 847

FAQs Related to Highest Inquiry Categories:
Q1. How do I bill Medicare if a patient has a primary insurance but the benefits have been exhausted?

A1. When benefits have been exhausted for the primary insurance, the claim is submitted to Medicare as primary with a 25 occurrence code with the date the benefits exhausted and remarks for liability, no-fault or workers' compensation situations only. Beneficiaries who are covered under a Group Health Plan (GHP) for which the benefits have exhausted should submit their claims in accordance with the MSP guidelines.

Q2. Which condition code should I use on an adjustment claim when I'm making more than one change (e.g., change to date of service and change to charges)?

A2. Use condition code D9 and indicate the changes made in the Remarks section.

Q3. We would like additional clarification on Condition Codes D9 versus D7 for MSP. We sent a claim as Medicare primary and later discovered that another payer is primary to Medicare. When we adjusted the claim to make Medicare secondary with a D7 condition code, the claim was rejected because no payment is reported from the primary.

A3. If the claim was initially processed as Medicare primary and is being adjusted to process as Medicare Secondary, and the primary payer made a payment, use the D7 condition code and verify that the correct MSP value code is reported with the amount paid by the primary payer. If no payment was made by the primary payer, or the claim was initially processed as a Medicare Secondary Payer code and being adjusted to reflect additional MSP information, use a D9 condition code. When using the D9 condition code, the adjustment reason must be entered in the Remarks field. Without remarks on the claim, the claim will be RTPd.

Q4. For conditional billing of annual and lifetime maximum, do we need to have a new denial for each claim?

A4. Conditional payment is not made for situations where the primary payer denies payment due to the lifetime maximum benefit having been met. If the patient's primary insurance is a Group Health Plan, the provider is required to submit the claim to the primary each time services are rendered to receive an EOB/RA from the primary payer. The claim is then submitted to Medicare with the appropriate Claim Adjustment Segments (CAS), and the system will automatically apply the appropriate payment calculation. If the patient's primary payer is a No-Fault, Liability, or Workers' Compensation plan, the MSP records must then be updated by the Benefits Coordination & Recovery Center (BCRC) before the claim can be submitted to Medicare.

Q5. If a primary payer retroactively recoups their payment years later, we send a claim to Medicare for primary payment. Medicare denied the claim for timely filing. We appealed the timely filing denial and provided documentation showing the other payer had recouped their payment. Why was my timely filing appeal denied?

A5. The CMS IOM 100-4 Medicare Claims Processing Manual, Chapter 1, Section 70.7.1 (PDF, 1.60 MB), contains what conditions contractors will allow for exceptions to and extensions of timely filing requirements. The exceptions include:

  • Administrative error
  • Retroactive Medicare entitlement
  • Retroactive Medicare entitlement involving State Medicaid Agencies
  • Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization.

The CMS MSP Manual (Pub. 100-05), chapter 3, section 10.5 also addresses this situation:
"In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen." You may refer to:

Q6. Some of my patients have open insurance records that they say are not valid anymore. Can you close these records so my claims will process?

A6. When insurance policies are terminated or are not valid, the Medicare patient or the Medicare provider must contact the Benefits Coordination & Recovery Center (BCRC) to have the files updated. They may be reached at 1.855.798.2627.

Q7. How often is the hospital required to complete the MSPQ for recurring outpatient services?

A7. Hospitals must collect MSP information from the beneficiary or his representative for hospital outpatients receiving recurring services. Both the initial collection of MSP information and any subsequent verification of this information must be obtained from the beneficiary or his representative.

  • Following the initial collection, the MSP information should be verified once every 90 days.
  • lf the MSP information collected by the hospital from the beneficiary or his representative is no older than 90 calendar days from the date the service was rendered, then that information may be used to bill Medicare for recurring outpatient services furnished by hospitals.

Note: This policy, however, will not be a valid defense to Medicare's right to recover when a mistaken payment situation is later found to exist. Hospitals must be able to demonstrate that they collected MSP information that is no older than 90 days from the beneficiary or his representative, when submitting bills for their Medicare patients. Acceptable documentation may be the last (dated) update of the MSP information. See: CMS Medicare Secondary Payer Manual (Pub. 100-05), chapter 3, 20.1 (PDF, 235 KB)

Q8. What laboratory services are covered under the rural health clinic (RHC) benefit?

A8. A RHC is required to furnish certain laboratory services onsite, although only certain components of these services are covered under the RHC benefit. An RHC may also offer other special services, such as chronic care management, telehealth, and home health services. Coverage and billing restrictions may apply to these services.

An RHC must be able to furnish the following laboratory services onsite for the immediate diagnosis and treatment of its patients:

  • Blood glucose
  • Chemical examination of urine by stick or tablet method or both
  • Hemoglobin or hematocrit
  • Occult blood stool examination
  • Pregnancy tests
  • Primary culturing for transmittal to a certified laboratory

Please refer to the CMS Rural Health Clinic Fact Sheet (PDF, 198 KB) 

Q9. 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?

A9. 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 7 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.

Please note: If the callback is the result of further research on a claim issue, the provider should use the self-service tools to check through DDE, eServices, or the IVR to see if there are updates to the claim.

Q10. Does Medicare preauthorize services?

A10. 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 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 modifier. 

Q11. How can I verify if a patient went to another facility upon discharge?

A11. Providers needing to verify if a patient was admitted inpatient to another facility upon discharge, may obtain this information through the IVR. Once applicable information is given to the IVR, the IVR will provide the starting date and type of facility of the following claim.

Q12. Are late entries acceptable in a patient's chart? Is it acceptable to add a late entry after the patient is discharged?

A12. This is addressed in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5. 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. The longer between the time of the event and the time it is documented, the less detail is generally correctly remembered.

Q13. How should a provider submit a Reopening request for a claim that is beyond the claim filing timeframe?

A13. 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.

Q14: How long does it take to review a probe/ADR request once Palmetto GBA receives the records? Will a denial letter be sent if it is denied?

A14. When Palmetto GBA receives requested documentation for prepayment review within 45 calendar days, we will take these steps within 30 calendar days of receiving the requested documentation:

  • Make and document the review determination and
  • Enter the decision into the Fiscal Intermediary Share System (FISS).

Note: Effective February 24, 2015, CMS Change Request (CR) 8443 (PDF, 84 KB) changes the number of days MACs have to conduct complex review from 60 days to 30 days.

We encourage you to monitor your Remittance Advice (RA) for claim determinations. A notice of the denial will come through your RA. In addition, if there is a partial or full denial, the reviewer will enter a brief comment on page 04 of the claim in DDE. Please refer to Question and Answer #15 below for information on how to view claim comments through Direct Data Entry (DDE). You may refer to CMS Medicare Program Integrity Manual (Pub. 100-08) chapter 3, section 3.3.1.1 F (PDF, 598 KB).

Q15. When medical necessity denials are issued by Palmetto GBA after review of the medical record, it is difficult to determine the details around the denial from our Remittance Advice (RA). The remit only states "medical necessity." We have attempted to contact the Provider Contact Center (PCC) for details, but are not always able to get the clarification we need.

A15. When Palmetto GBA issues a medical review denial, the denial reason code will begin with a '5' and offer a general explanation of the denial reason. The Direct Data Entry (DDE) Manual on the Palmetto GBA website also lists instructions on how to access this information from the FISS Reason Codes Inquiry Screen. Instructions begin on page 31 of the Sign-On Instructions.

For all denials, the reviewer enters a brief narrative explaining the denial on the remarks PG 04 of the claim. Instructions to locate this page are in the DDE Manual Claim Entry section on page 20. After reviewing these resources, if you have further questions related to specific medical review denials, please contact the Provider Contact Center (PCC).

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