General


Question: Why does my claim deny as a duplicate?

Answer: Claims will be denied as a duplicate if Medicare has already processed a claim from the provider for the same patient, same date of service and same procedure or service. Providers should always check the status of their previously submitted claim prior to submitting the claim again. The preferred method of checking claim status is by using the eServices portal.

While your clearinghouse or billing company may allow you to correct a claim and simply resubmit the claim, if the claim has already been medically reviewed or processed with a payment or denial being issued on your remittance advice, you should consider requesting a simple claim reopening or a first level appeal through eServices for necessary corrections. Below are additional resources to help providers understand and handle duplicate denials or billing for multiple, identical services provided to the same patient on the same day.

Resources

Question: How do I know which secondary insurance plans Medicare will automatically send my claims to after Medicare has processed a patient’s claim?

Answer: CMS developed a model national contract, called the Coordination of Benefits Agreement (COBA), which standardizes the way that eligibility and Medicare claims payment information within a claim’s crossover context is exchanged. A list of the Automatic Crossover Trading Partners (insurers) in production along with a list of contacts for each of the trading partners, is located on the CMS website (PDF, 1.76 MB).

Question: When my claim is rejected and not afforded appeal rights why does the Medicare Remittance Advice show the entire submitted charge as a CO or Contractual Obligation meaning I cannot bill the patient?

Answer: When a claim is rejected, Claim Adjustment Reason and Remark Codes are included on the remittance advice (RA) to inform the provider why the claim was rejected. A rejected claim means that information included on the claim was incorrect, incomplete, or required information was missing. Rejected claims have no appeal rights and the claims must be corrected and resubmitted. Claim Adjustment Group Code CO means the dollar amount listed on the RA is a Contractual Obligation and includes any amounts for which the provider is financially liable. The patient may not be billed for these amounts and must correct and resubmit the claim so that Medicare can make a claim payment determination to allow or deny the service/procedure in question.

Question: When a patient has Medicare and another insurance, how do I determine if Medicare is the primary or secondary insurer?

Answer: Palmetto GBA provides an MSP Lookup tool that asks a series of questions that must be answered to help a provider determine if Medicare is the primary or secondary insurer. Additionally, verify if Medicare is primary or secondary for specific patients through the Palmetto GBA eServices portal or Interactive Voice Response (IVR) Unit. If Medicare records do not match the MSP Lookup Tool outcome, refer the patient to the Coordination of Benefits Contractor to have his or her records corrected.

Resources

Question: Can a patient have Part A Medicare benefits and not Part B Medicare benefits?

Answer: Yes. Part B of the Medicare program is medical insurance and typically Medicare beneficiaries must enroll in Part B Medicare and must make premium payments for Part B coverage. Some patients may opt not to enroll in Part B. The patient’s Medicare card should indicate an effective date if the patient has Part B Medicare insurance.

Question: I saw a patient in my office and provided and evaluation and management service and a chest X-ray (with no modifier). Medicare paid for the visit but denied the chest X-ray. I was told it was because the patient was in a Skilled Nursing Facility (SNF) and the SNF is responsible for the chest X-ray. Why is the SNF responsible when I was the doctor that took and read the chest X-ray in my office?

Answer: In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the Part A Medicare Administrative Contractor (MAC) to the SNF. These bundled services had to be billed by the SNF to the Part A MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. This is referred to as SNF Consolidated Billing (SNF CB). When a Part B service is denied as bundled by SNF CB, the Part B provider must look to the SNF for compensation for any bundled service that was provided. SNF Consolidated Billing

For Medicare beneficiaries in a covered Part A stay, these separately payable Part B services include:

  • Physician's professional services
  • Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;
  • Certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services
  • Erythropoietin for certain dialysis patients
  • Certain chemotherapy drugs
  • Certain chemotherapy administration services
  • Radioisotope services and
  • Customized prosthetic devices

There are a number of services that are excluded from SNF CB and are still billed separately to Part B Medicare. In your example, the technical component of a chest X-ray is bundled by SNF CB. The professional component (interpretation and report) of the chest X-ray is excluded from SNF CB and you may bill Part B Medicare for that service. Because you billed the X-ray with no modifier, the entire chest X-ray was denied. You must rebill Medicare on a new claim for the chest X-ray interpretation and report (represented by appending the CPT modifier 26). You would look to the SNF for reimbursement for the SNF CB portion of the chest X-ray representing the technical component (TC HCPCS modifier).

For a full listing of excluded services (those that can be billed to Medicare Part B) visit the CMS SNF CB webpage. File 1 and 2 under the “Downloads” section at the bottom of the page.

Last Reviewed: 11/5/2021

Question: Why can't my patient contact the Provider Contact Center for claims information?

Answer: The Provider Contact Center and associated Interactive Voice Response System (IVR) are specifically for Medicare provider inquiries. The Centers for Medicare & Medicaid Services (CMS) has dedicated resources to assist Medicare patients with inquiries. Patients should be referred to the Beneficiary Contact Center at 1–800–MEDICARE (800–633–4227) or to medicare.gov.

Why did the claim I submitted for procedure code G0438 get denied for eligibility?

The HCPCS code G0438 is an initial annual wellness visit (first AWV) which is not payable during the patient’s first 12 months of initial Medicare eligibility. If this service is billed during the initial 12 months of the patient’s initial Medicare eligibility or Medicare has already paid another provider for an initial annual wellness visit, the visit will be denied. More details about Medicare covered Wellness Visits is available in the reference below.

Resource: Medicare Wellness Visits — ICN MLN6775421 February 2021.

Question: Why did my claim deny stating the patient was enrolled in a Medicare Advantage when the patient states that they no longer have that plan?

Answer: Palmetto GBA will deny a claim if, at the time the claim is processed, Medicare records indicate the patient was still enrolled in a Medicare Advantage (MA) plan. If the patient disenrolled from the MA plan, the disenrollment is effective at the end the month of disenrollment, not the day the patient initiated the enrollment change. The MA plan would need to report the disenrollment information to the Benefits Coordination & Recovery Center (BCRC) so that Medicare records can be properly updated. 

Providers may contact the patient or use the Palmetto GBA interactive voice response system to access the patient’s eligibility information and obtaining the MA plan identification (ID) number. Once the MA plan ID number is obtained, you may obtain contact information for the MA plan by using the MA Plan Directory on the CMS website. 

Resources 

Question: Why didn’t my patient’s claim cross over to the patient’s secondary insurer after Medicare processed the claim? When I called Medicare, I was told there was not crossover information on file.

Answer: Not all secondary plans agree to receive crossover claims from Medicare. If a patient has a supplemental or secondary insurance plan that would like to have claims crossed over after Medicare has processed them, the plan will need to have a Centers for Medicare & Medicaid Services Coordination of Benefits Agreement (COBA) on file with the Benefits Coordination & Recovery Center (BCRC). In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurer he or she may have. This may require the beneficiary to submit copies of their paid Medicare claims or copies of their Eligibility of Benefits (EOBs) to their secondary or supplemental insurer.

Medicaid is the only insurer that Medicare will automatically submit cross over claims to without a crossover agreement. 

Resource: Coordination of Benefits Agreement.

Question: Why hasn’t the appeal I submitted two weeks ago been completed?

Answer: The first level appeal may take up to 60 days from the date of receipt to process. You can use the Palmetto GBA Appeal Status Tool to check the status of your first level appeal. If you submitted your first level appeal through eServices, you could check the status of your appeal through eServices. Upon completion of your appeal, if the decision is favorable, you will receive a payment. If the review decision is unfavorable, you will receive a letter providing you with the reason for the denial of your appeal and any next steps available.

Resources

Question: Why can’t I obtain the next eligibility date for a procedure code on the IVR?

Answer: Not all services have a next eligible date available on the eService portal. You will need to contact the Provider Contact Center and speak to a representative if the information cannot be found on the Interactive Voice Response (IVR) or via eServices. 

Resources

Question: Can I bill the patient for the annual deductible before submitting a Medicare claim?

Answer: The Medicare Part B deductible for 2021 is $203.00. The patient and/or any secondary/supplemental insurance is responsible for the first $203 of covered Medicare services in 2021 before Medicare can make a payment for a service that is not exempt from deductible. 

To prevent collecting deductible from a patient that may have already met all or part of their deductible, providers are encouraged to wait until receipt of the Medicare remittance advice for their service to determine if any amount was applied to the patient’s deductible. Another provider may have submitted a Part B claim prior to you which was applied to the patient’s deductible, even if you believe you are the first provider to see a patient in a calendar year. The deductible may have already been fully or partially met making it inappropriate for you to collect the deductible from the patient. 

Palmetto GBA’s Interactive Voice Response (IVR) and eService portal can help you determine how much of the annual Part B deductible a patient has met but will not include any amount applied to the deductible for any claim that is still being processed at the time you check the IVR or eService portal. 

Resources

Question: My claims are denying because a required certification has expired. How do I update my certification information with Medicare?

Answer: A copy of any required new or renewed certification must be submitted to Palmetto GBA’s Provider Enrollment department. This can be done by mailing the information to Palmetto GBA according to your jurisdiction.

Palmetto GBA (JJ)
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306    

Palmetto GBA (JM)
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190 

Question: Why did Medicare offset my remittance advice even though I had already submitted the refund?

Answer: Medicare will begin offsetting your payments when an overpayment has been demanded and the refund is not received within the timeframe specified in your overpayment demand letter. If you submitted a payment, we could locate the date we received the refund to confirm that it was received after your refund deadline and/or if the payment was applied to any other outstanding overpayments due. The finance department will issue you a refund if you are entitled. 

Question: What is the status of my Provider Enrollment application?

Answer: The Provider Enrollment Application Status Lookup allows you to enter your PTAN, NPI or the Document Control Number (DCN) in the tool to find the status of your enrollment application. If you do not receive status information using the number you entered, please call the Palmetto GBA Provider Contact Center. We will research the status of your enrollment application. We ask that you allow 24 hours after each transaction for status information to be updated.

Resources

Question: Why can’t I receive payment on a service that requires Outpatient Department prior authorization when I will be performing one of the services in my office?

Answer: Medicare prior authorization is only required when specific services are performed in a hospital outpatient setting. When it is safe and appropriate to render one of those services in your office and your office is not considered a hospital outpatient facility, no prior authorization is required. If a prior authorization is submitted for one of these services and you indicated that you are performing the service in your office and not in a hospital outpatient facility, the prior authorization will be returned to you as prior authorization is not needed. 

Last Reviewed: 10/22/2021

Question: Why is my claim being reduced because another surgery was done on the same day?

Answer: This can happen when multiple surgical procedures are performed by a single physician or physicians in the same group practice, on the same patient, at the same operative session or on the same day for which separate payment may be allowed. 

Multiple surgery adjustments are made in order to arrive at the final fee schedule amount. Details regarding multiple surgeries, how to determine if surgeries are applicable to the multiple surgery payment rule, payment information and important reminders are outlined in the Palmetto GBA Multiple Surgeries on the Same Day article. 

Resources

Question: How do I know if my surgical CPT® code requires prior authorization?

Answer: The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services.

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

A full list of codes requiring OPD PA (PDF, 119 KB) is available on the CMS website.

Question: How can I obtain my PTAN (provider transaction account number) in PECOS (Provider Enrollment, Chain and Ownership System)?

Answer: The Provider Enrollment, Chain and Ownership System (PECOS) is the most efficient way to find a PTAN. Follow these steps to find PTANs in PECOS.

  • Log into Internet-based PECOS
  • Select "My Associates" on PECOS home page
  • Select "View Enrollments" by applicable individual or organizational enrollment
  • Click on "View Medicare ID Report"
  • PTAN or PTANs are listed in the Medicare ID column

Question: What is a Medically Unlikely Edit (MUE)?

Answer: A Medically Unlikely Edit (MUE) for a specific HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE and CMS does not publish all MUEs. Nonpublished MUEs are not releasable by CMS or the Medicare Administrative Contractor. MUEs are adjudicated as claim line edits or date of service edits. The type of MUE edit is noted on the published MUE file.

See Medically Unlikely Edits on the CMS website.

Question: What are the therapy caps for 2021?

Answer: Therapy thresholds, formerly referred to as therapy cap amounts, are thresholds above which outpatient physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one threshold amount for PT and SLP services combined and a separate threshold amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI).

For CY 2021, the KX modifier threshold amounts are: 

  • $2,110 for PT and (SLP) services combined; and
  • $2,110 for OT services

Resource: MLN Article 12014 “2021 Annual Update of Per-Beneficiary Threshold Amounts” (PDF, 147 KB).

Question: My claim denied due to timely filing. Can I file an appeal for my claim?

Answer: If an appeal request is filed late, the time period may be extended for filing a redetermination if good cause can be shown. These extensions are not routinely granted. It is important to provide detailed supporting documentation if requesting an extension of this time limit.

There are only four exceptions that may be considered when a redetermination is submitted past the time limit for filing the appeal.

  • Administrative error
  • Retroactive Medicare entitlement
  • Retractive Medicare entitlement involving a state Medicare agency
  • Retroactive disenrollment from a Medicare Advantage plan or PACE provider organization

If your claim does not fall within one of the above categories, or you do not provide the necessary supporting documentation, filing an appeal for timely filing will not change the outcome of the timely filing decision, although you have the right to file an appeal of the timely filing decision if you disagree..

Question: Why am I unable to get the status of a second level appeal, (reconsideration) when I call the Provider Contact Center?

Answer:  Reconsiderations are conducted by a qualified independent contractor (QIC). Generally, the QIC will send their decision to all parties within 60 days of receipt of the request for reconsideration. If a provider has not received any correspondences regarding their reconsideration (second level appeal), you must contact the QIC, C2C Innovative Solutions at (904) 224–2613 for details. Palmetto GBA does not have access to the status of the QIC’s reconsideration determinations.

Last Reviewed: 10/22/2021

Question: I have several claims that denied with a message stating that I am not certified or eligible to perform this procedure. What can I do prior to submitting my claim to ensure this does not happen?

Answer:
There are a few things that you should consider prior to submitting your claim:

  • Be sure that you are submitting your claim with the correct rendering and/or billing provider information (the PTAN/NPI should not be deactivated)
  • If your license or certification information has expired, make sure that information is submitted via fax to Provider Enrollment:
    • JJ: (803) 870–0157
    • JM: (803) 699–2438)
  • Make sure you are billing only for services that are within your provider’s state scope of practice
  • If you have more than one NPI, check to ensure that the correct PTAN/NPI combination is used for the corresponding date of service
  • Is your provider enrollment file up to date and have you responded to any requests regarding your PTAN/NPI enrollment?
  • Do not bill a paper claim if you are required to bill electronically

Question: Why was I asked to call back when I was not able to provider my PTAN/NPI/TIN? I am a new provider and did not have that information at the time of my call.

Answer: Providers who call into the Provider Contact Center are required to authenticate prior to speaking to a representative about claim specific or beneficiary eligibility information. If you do not have this information, the CSA is only able to assist you with general information. General information is considered information that can be provided without going into a beneficiary’s record (e.g., information found on the website, referrals, addresses and telephone numbers, etc.).

Question: What does it mean when a claim denies for overlap of service?

Answer:
An overlap in service means that a submitted claim is denying because another provider (SNF, home health, hospice or outpatient hospital) has provided information stating the beneficiary was receiving services, usually within a facility, at the time of your service.

If it is determined that the patient was not in fact in a facility at the time of your service, you may exercise your appeal rights as long as it is within 120 days of the initial determination, otherwise you would have to file a Late Submission Redetermination and prove good cause.

Good cause may be found when the record clearly shows, or the provider, physician or other supplier alleges, that the delay in filing was due to one of the following:

  • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the MACs or the Social Security Administration) to the provider, physician or supplier; or
  • Unavoidable circumstances that prevented the provider, physician or other supplier from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the provider, physician or supplier’s control, such as major floods, fires, tornados and other natural catastrophes.

You may also want to contact the facility and ask them to have any records that remain open, closed, so claims can properly process.

Question: I filed an appeal but have not received a notification. What do I do?

Answer: To find the status of your request for redetermination, providers can use the JJ and JM Part B Redetermination Status tool found on the website. This can be done by entering the Internal Control Number (ICN) of the claim in question and click “Search Now.” The ICN is found on the right side of your remittance notice on the same line as the patient’s name.

A duplicate copy of an affirmation letter can be obtained by speaking with a Customer Service Advocate (CSA). The letter will be mailed to the address shown in the heading of the letter. However, if the appeal was overturned, it results in a payment on a remit.

Question: Why did my claim deny for Medicare Secondary Payer (MSP)? I checked my patient’s eligibility prior to submitting my claim.

Answer: If you checked your patient’s information and it stated that Medicare was primary, the following could have occurred:

  • There could have been a recent update from the Benefits Coordination and Recovery Center and Medicare records are now reflecting current information
  • You may have submitted your claim with a diagnosis related to a Workers’ Compensation, No-Fault, or Liability open record
    • If it is determined that the diagnosis is related to an open record, the claim denied accordingly, and you would need to submit the claim to the proper insurer
    • If you are stating that the services you rendered are not related to any open case or diagnosis that’s on file, you have the right to file an appeal as long as it’s within 120 days of the initial determination, otherwise, you will need to submit a Late Submission Redetermination and prove good cause

Good cause may be found when the record clearly shows, or the provider, physician or other supplier alleges, that the delay in filing was due to one of the following:

  • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the MACs or the Social Security Administration) to the provider, physician or supplier; or
  • Unavoidable circumstances that prevented the provider, physician or other supplier from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the provider, physician or supplier’s control, such as major floods, fires, tornados and other natural catastrophes.

Question: Why didn’t Medicare pay my Medicare Secondary Payer (MSP) claim proper?

Answer:
Palmetto GBA has the Medicare Secondary Payer tool that can be used to determine the claim payment calculations when Medicare is the secondary payer for services. The calculations are done by detail line item. If the calculation does not provide a paid amount, it is because the provider has contracted with the primary insurance company and is obligated to accept their allowed amount for the service.

The Medicare Secondary Payer tool can be used to determine the claim payment calculations when Medicare is the secondary payer for services.

Question: Why am I told by Customer Service Advocates (CSAs) that they cannot tell me how to bill when I ask them for the modifier?

Answer: Palmetto GBA CSAs are not able to inform providers what procedure codes, modifiers or claim-specific information to submit because they are not billers or coders and are not familiar with the services that were rendered. What they can do is:

  • Point you to specific education or reference material for additional information
  • Offer guidance for correction or proper claim submission
  • Explain how to appeal with proper documentation (if this is the proper course of action)
  • Transfer your call to Provider Enrollment if related or send your questions to another department for additional research

Question: Why didn’t Medicare pay my claim at 80 percent?

Answer:
When determining if you were paid correctly for a service, consider who rendered the service.

Nonphysician Practitioners Pricing
Provider Specialty
Pricing Information
Certified Nurse-Midwife (CNM-42) Services
Reimbursement is made at 80% of lesser of actual charge or 100% of Medicare Physician Fee Schedule (MPFS) for same service performed by a physician — Medicare Claims Processing Manual; Publication 100-04, Chapter 12, Section 130.1.
Licensed Clinical Social Worker (LCSW-80) Services
Allowed at 75% of MPFS — Medicare Claims Processing Manual; Publication 100-04, Chapter 12, Section 150.
Nurse Practitioner (NP-50) and Clinical Nurse Specialist (CNS-89) Services
Allowed at 85% of MPFS — Medicare Claims Processing Manual; Publication 100-04, Chapter 12, Section 120.
Nutrition Professional/Registered Dietician Services (71)
Allowed at 85% of MPFS — Medicare Claims Processing Manual; Publication 100-04, Chapter 12, Section 300.4.
Physician Assistant (PA-97) Services
Reimbursement equals 80% of actual charge or 85% of MPFS, whichever is less — Medicare Claims Processing Manual; Publication 100-04, Chapter 12, Section 110.

Last Reviewed: 10/22/2021

Question: Why are my claims denied as duplicates? What can I do to avoid this happening in the future?

Answer: The system has edits in place that will identify information such as duplicate services, multiple claims for the same provider on a date (s) of service, as well of same date of service for different providers. The edits are programmed to review paid, finalized and pending claims. If similar services are detected the claim system will reject the newest claim submission as a duplicate.

There are a variety of ways that providers can avoid receiving a duplication rejection on claims.

Methods include:

  • Adding distinct modifiers (if applicable) to services that will trigger the claims system to determine the charge is not a duplicate. In some instances, a note may be required in the claim narrative field to indicate the time that each service was performed to prevent duplicate denials.
  • Check the status of a submitted claim to ensure that that the submitted services have not already processed and paid
  • If a claim has denied as a duplicate and should be a service that is considered for payment, file an appeal with documentation to support the medical necessity of the repeat service
  • If a third-party biller is responsible for submitting claims on your behalf, as a best practice, give instruction to ensure that software only submits the claim(s) once and perform quality control checks to ensure there are no glitches causing claims to be submitted multiple times in error

Question: The beneficiary has a Medicare Advantage (MA) plan. Is there a method to identify the name of the MA plan online?

Answer:
Yes, by choosing the correct options, the Interactive Voice Response (IVR) will give the MA Plan ID number. There is a directory that contains the list of current MA plans on the CMS website. The directory for reporting period June 2020 can now be found on the CMS website and may be downloaded. MA Plan Directory as of June 2020 (ZIP).

Question: My claim is denying stating the patient was enrolled in a Skilled Nursing Facility (SNF). Is there a way to identify the name or NPI of the facility?

Answer:
Yes. Once the provider can verify specific information regarding the patient, denied services and billing provider, the provider contact center is able to release the SNF name, address and telephone number as it relates to the date(s) of service in question.

Question: My claim has rejected for name formatting. How can I ensure this does not continue to happen?

Answer:
Claims should be submitted according to the information on the beneficiary’s Medicare Beneficiary Identifier (MBI) card; the card should include the patient’s MBI as well as any hyphenated names. The beneficiary’s name submitted on a claim should match the information exactly as it is on the MVI card or the claim will reject.

Question: I have submitted a claim for rhinoplasty for a beneficiary with Gender Dysphoria (GD). Can you tell me why it was denied?

Answer:
Services that are considered cosmetic for the treatment of gender dysphoria are not covered. For a list of covered criteria and services considered as cosmetic, refer to Local Coverage Article A53793, Billing and Coding: Gender Reassignment Services for Gender Dysphoria.

Question: Has my patient satisfied the deductible for 2020? How can I determine if my patient has met their 2020 deductible without speaking to a representative?

Answer:
Deductible information can be found by using patient information using the IVR or Palmetto GBA's eServices.

Question: Is a Prior Authorization needed for Botox injections?

Answer:
Each outpatient department Botox injection provided on or after July 1, 2020, requires prior authorization as part of Medicare’s Outpatient Department Prior Authorization program. Below is a list of services that are part of the Medicare Outpatient Prior Authorization program.

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Last Reviewed: 10/22/2021

Appeals FAQ

Question
: Will I receive a letter once my appeal is finalized?

Answer: For any redetermination that results in an unfavorable decision, the provider will receive a letter by mail or through eServices via eDelivery. For providers enrolled in eDelivery, a secure inbox message will be sent with a link to the letter. To receive eDelivery of your Medicare redetermination letters, providers must be signed up for eServices and select eDelivery.

Question: When will a Remittance Advice (RA) be received for a favorable decision?

Answer: When a fully favorable decision is rendered, the claim is adjusted to allow for payment. When processing of the adjustment has been completed, the adjustment will appear on the Remittance Advice and you typically receive your RA within 30 days of the claim adjustment date. Access the claim details on the Claim Status Inquiry screen on Palmetto GBA’s eServices portal.

Claim Status FAQ

Question:
Why can’t I find my claim through the IVR?

Answer: If you are unable to locate a claim through the IVR, verify the provider and beneficiary information entered for the query, confirm the claim was submitted by you or your billing company, or, if an electronic claim, the claim may have been rejected at the point of submission and did not enter the claim processing system. Review your 277CA electronic claim submission acknowledgement report to determine if the claim was rejected and must be corrected and resubmitted.  

If the IVR does not locate a claim on file, the CSA will not be able to locate the claim (considering all information entered/provided regarding patient and provider are correct)

Claim Denials FAQ

Question: My claim denied due to a date of death on file, but the beneficiary is not deceased. How does the patient’s date of death get corrected?

Answer: The beneficiary will need to contact the Social Security Administration (SSA) to have the date of death removed from their record. Once the date of death has been removed from the beneficiary’s record, the claim should be resubmitted for processing. If the claim is resubmitted after timely filing (more than one year from the date of service), the claim cannot be appealed by the provider.

General Information FAQ

Question:
Does Medicare cover prescription medication?

Answer: Palmetto GBA is unable to address drug plan coverage and criteria.
Medicare prescription drug coverage is an optional benefit offered under Medicare Part D. To determine if a prescription medication is covered, contact the beneficiary for the name of their chosen drug plan and contact the drug plan.

HIPAA FAQ

Question:
I can’t find my patient’s new Medicare Beneficiary Identifier (MBI). How can I submit claims?

Answer: Patients should present their Medicare card that identifies the patient’s MBI number. When patients do not present their Medicare card, you may use the MBI Lookup tool in the Palmetto GBA eServices online portal to obtain a patient’s MBI number. Identifying a patient MBI number through eServices requires a user to be logged in. Once logged in, click on the MBI Lookup tab located in the header of the portal. All required (*) fields must be complete: Beneficiary’s Last Name, First Name, Date of Birth, and Social Security Number.

Eligibility/Entitlement FAQ

Question:
Is the eligibility date for Medicare Part A and B the same?

Answer: No. Some beneficiaries are automatically enrolled in Medicare Part A and others sign up when they’re first eligible. Certain people may choose to delay Medicare Part B enrollment, giving the patient different effective dates for Part A and Part B coverage.

Provider Eligibility FAQ

Question:
Why did my claim reject or deny for missing incomplete NPI number?

Answer: The claim rejected due to the NPI submitted on the claim. The NPI may have been incorrectly entered, no longer effective, or the NPI was not linked to the billing provider.

Last Reviewed: 10/22/2021

A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on April 15, 2021.

Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A webpage.

Last Reviewed: 10/22/2021

Each bank may be unique in how they create their statements but typically a Palmetto GBA Part B Jurisdiction J EFT payment will appear as an EFT from MAC-PTB ALGATN.

Last Reviewed: 10/22/2021





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