Jurisdictions J and M Part B Frequently Asked Questions: July 2021

Question: My claim denied for a non-covered diagnosis code. How do I know what diagnosis code is acceptable?

Answer: Medicare considers services for payment based on medical necessity; therefore, the diagnosis used would need to be relevant to the service being performed. The Palmetto GBA website offers Local Coverage Determinations (LCDs) and coverage articles for some services that may be used as a reference in understanding when a service might be considered medically necessary. Not all services have policies. You may also use the search function on the Palmetto GBA website. There may be additional articles related to the procedure you are performing that could provide some billing guidance. 


Question: What happens to my claim if a beneficiary’s Medicare is no longer in effect?

Answer: If it is determined that a beneficiary’s effective date ended prior to a date of service, the claim will deny. As the provider, you are responsible for reaching out to the beneficiary to determine if they have another insurance that should be billed instead of Medicare. 

Question: The patient states they were not receiving home health at the time they saw me for services, but my claim denied indicating the patient was under a home health episode of care. What should I do?

Answer: A home health agency can bill Medicare in advance for a thirty-day episode of care. When those dates are reflected on a patient’s record, the claims processing system uses the dates on file to determine if there is an overlap in care. If the patient was released from the agency prior to the thirty days, the agency is responsible for making sure the actual dates are reported correctly to Medicare. The Provider Contact Center can assist you with determining the name of the home health agency if you would like to reach out to them concerning an update that may be needed on your patient’s behalf.

Question: Where and how do I enter the suffix for a patient’s name (e.g., Jr. Sr.) on a claim?

Answer: If you are submitting a CMS-1500 standard paper claim form, the suffix information goes in box two. Enter the patient’s last name, first name, middle initial and suffix as the name is shown on the patient’s Medicare card. 

If you are required to submit an electronic claim, patient suffix information is required in Loop 2010BA, NM1/IL, 07 segment. The Palmetto GBA website has an interactive CMS-1500 Claim form housed under Tools for future reference.

Reference: Palmetto GBA CMS-1500 Interactive Claim Form.

Question: I called and was informed that Palmetto GBA was not the Medicare Administrative Contractor (MAC) for my provider. How do I determine the MAC for my provider?

Answer: Palmetto GBA is the MAC for Medicare services provided in Alabama, Georgia, North Carolina, South Carolina, Tennessee, Virginia and West Virginia. If your practice location/facility is not located in one of these states and providing Medicare Part B services in one of these states, your Part B claims should not be billed to Palmetto GBA. To find out who your Medicare contractor is, see Who are the MACs?

Question: When I check the status of a claim through eServices, the Interactive Voice Response System (IVR) or with a provider contact center representative, and it is determined the claim in question is not on file, what is my next action?

Answer: You should verify the patient’s MBI number and date of service on the patient’s card as it compares to the information that you submitted on the claim and are asking about. If you use a clearing house, vendor, or billing company, verify that the claim in question was submitted to Medicare by that entity and that there is confirmation (when billing electronically) that the claim was accepted and not rejected by Palmetto GBA. If the claim was never filed, or was rejected and required corrective action, the claim must be corrected and then resubmitted. Providers have one calendar year from the date of service to submit a claim. A claim that has not been submitted has no appeal rights.

Question: How do I begin to receive electronic payments instead of a paper check?

Answer: You must complete and submit the Electronic Funds Transfer (EFT) Authorization Form (CMS-588) to request electronic funds transfer. 

Reference: Electronic Funds Transfer (EFT) Authorization Agreement (PDF, 84 KB).

Question: How do I use the patient account number I was given regarding a withholding?

Answer: The patient account number is associated with the provider’s office and is optional for claim submission. If you are provided with a patient account number, that number was submitted by your office on the claim in question. You should be able to locate patient-specific information by researching your accounting system. 

Question: Why are my lab service claims denying or rejecting?

Answer: Laboratory services have specific billing requirements depending on the laboratory service billed. There are several things to consider when billing for lab services. First, services must be medically necessary for the individual patient or if a Medicare covered preventive service, must meet the CMS preventive service criteria. The claim adjustment reason and remark codes listed on your remittance advice will provide you with information regarding why the lab service was denied or rejected. Here are several important reminders regarding laboratory services:  

  • Submit your claim with a valid and effective CLIA certificate number or CLIA waiver number 
  • Make sure that your CLIA certification/waiver match the services performed
  • Include any modifier that may be required 
  • Report the name and NPI of the ordering or referring provider
  • Verify that any medical necessity requirements for the specific lab services as outlined in national and local coverage determinations, have been met
  •  Verify if there is a Medically Unlikely Edit (MUE) for a specific lab service


Question: Why doesn’t Medicare perform prior authorizations?

Answer: When legislated and instructed to do so, Medicare Administrative Contractors (MAC) may require prior authorization for certain services. Currently, there are two prior authorization initiatives for providers in all or part of Palmetto GBA’s jurisdictions. 

  1. Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
  2. Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport

For prior authorization regarding oral medication, contact the beneficiary to determine the name of their drug plan and then reach out to the drug plan for assistance with a formulary of covered medicines under their plan.

Question: Why am I unable to change the number of units of service that I have billed on a claim through the telephone reopening process if I have done this before on another claim?

Answer: Telephone Reopening can assist with changing units if it falls within the Medically Unlikely Edits (MUE). If you wish your claim to be reopened to bill more units than allowed by a MUE for a given day, additional documentation must be submitted via an appeal.

Last Updated: 07/23/2021