General

Published 12/05/2024

Question: I must give my manager a status report every week on the status of our pending enrollment applications. Is there an easy way to get a status that I can print as proof of my status check without calling the provider contact center and getting a reference number?

Answer: If you enrolled using the Provider Enrollment Chain and Ownership System (PECOS), access the status of your application through PECOS and take a screenshot of your status. You may also use the Provider Enrollment Status Lookup self-service tool on the Palmetto GBA website and take a screenshot of your status inquiry results. The articles below alert providers to the CMS allowed timeframes for Medicare Contractors to process enrollment applications.

References

Question: When I called Medicare to discuss a patient’s claim specifics, I'm told information can’t be released to me even though I work for the doctor, why?

Answer: Palmetto GBA is charged with protecting the confidentiality of personally-identifiable information (PII) and protected health information (PHI) as well as provider PII in accordance with the Privacy Act of 1974 and HIPAA. To do this, any person requesting information about a specific provider and/or patient must provide details that indicate a relationship with the patient and/or provider and have a reasonable need for the desired information.

Inquirers requesting information about a provider must be able to provide the billing provider’s National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), and the last five digits of the provider’s tax ID number. Inquiries regarding a specific patient and/or claim must include the billing provider information listed above and the patient’s first and last name, Medicare Beneficiary Identifier (MBI) number, and date of birth. Other details related to the specific inquiry type should also be available upon request. Having all the necessary information available before calling Palmetto GBA will help to expedite your call time.

Question: Why in October, did I start getting claim rejections indicating that some ICD-10 codes I have been using all year, are no longer valid even though the codes are in my 2024 ICD-10 coding manual.

Answer: CMS updates ICD-10 diagnosis codes twice a year, April and October. The ICD-10 coding manual you may be referencing may not include updates post manual publication. It is possible your claim rejections are due to October 2024 ICD-10 updates. CMS provides a list of ICD-10 codes, including updates, at the link below. ICD-10 codes should be selected based on ICD-10 codes in effect for the patient encounter date. For claim rejections, review the ICD-10 codes in effect on the encounter date, then correct and resubmit the claim with a valid ICD-10 code.

Reference: ICD-10 Files. 

Question: A patient insists that they are no longer incarcerated; however, Medicare keeps denying claims saying the patient's record still shows the patient is incarcerated. How do we get this researched and corrected?

Answer: A patient that is in custody of a state or local government under the authority of a penal statute at the time the provider renders the service is considered an incarcerated beneficiary. Medicare Administrative Contractors are notified through a patient’s Common Working File (CWF) of incarceration. The Centers for Medicare & Medicaid Services (CMS) relies on data from the Social Security Administration (SSA) for Medicare enrollment and eligibility. Upon release, the Medicare eligible individual should contact SSA at 800–772–1213 (TTY users can call 800–325–0778) to inquire about enrolling, reenrolling, or other enrollment related issues following their release from incarceration. Once a patient’s CWF is updated through Social Security to reflect release and all other Medicare eligibility regulations have been met for the date of service, the claim may be billed to Medicare.

Reference: Incarcerated Medicare Beneficiaries. 

Question: My coworkers tell me that it is our practice’s responsibility to take action to determine whether a Medicare patient has insurance that needs to be billed before Medicare. I prefer to just bill Medicare and Medicare then either pays or rejects the claim telling us if the patient has other insurance. Which method is correct?

Answer: Medicare law and regulations require all entities that bill Medicare for services or items given to Medicare beneficiaries to decide whether Medicare is the primary payer for those services or items before submitting a claim to Medicare. (See Section 1862(b)(2) of the Social Security Act and regulations at 42 CFR 489.20g.) When you find another insurer as the primary payer, you must bill that insurer first. After receiving the primary payer remittance advice, bill Medicare as the secondary payer, if appropriate. The resources below outline the Medicare Secondary Payer (MSP) guidelines and offer resources to help providers when it is determined that the patient has other insurance that should be billed before Medicare. You may also use the Palmetto GBA eServices secure portal to verify if the patient has other insurance that must be billed before Medicare. Another key factor is insuring the secondary claim billed to Medicare includes all the necessary information regarding how the primary insurer handled each service on the claim to consider making secondary payment.

Resources

Last Reviewed: 12/02/2024

Question: The remittance advice shows my claim denied with Contractual Obligation, CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service. How do we know if it is because provider was not enrolled?

Answer: Speak with your credentialing team to ensure the billing provider is enrolled with Medicare for the date of service billed. Also, verify the claim was billed in the correct state where the service was performed. Visit the Palmetto GBA Provider Enrollment web page for more information on enrollment and revalidation requirements.

Resource: Provider Enrollment.

Question: Why did my claim reject due to missing/invalid rendering provider number/NPI?

Answer: Review your paper or electronic claim to verify that the correct rendering provider NPI number was entered into block 24J of the CMS-1500 claim form or in the equivalent electronic claim loop and segment. Verify that the rendering provider’s NPI was typed correctly. For additional tips on resolving this type of rejection, review the NPI: Troubleshooting Rejections article.

Resource: NPI: Troubleshooting Rejections.

Question: I got a claim denial with a Group Code CO (contractual obligation) stating medical records were requested but not received. How do I correct this? I didn’t receive a request for records and why can’t I bill the patient for the denied service?

Answer:

  • This type of claim denial is considered a contractual obligation and one you are not able to bill the patient for until the necessary information to adjudicate the claim has been received and reviewed. Palmetto GBA has a list of CPT®/HCPCs codes that require additional documentation be submitted with the claim. Claim rejections (no appeal rights listed on the remittance advice) must be refiled as new claims with the necessary documentation. If you sent documentation with your claim, review that documentation, and make sure is for the correct patient, date of service, and is complete. If the claim is a denial (appeal rights are listed on the remittance advice for the claim), you may submit a first level of appeal with the necessary documentation.
     
  • Palmetto GBA may issue an additional documentation request (ADR) as part of the review process. These letters are sent to the written correspondence address on file for the provider. Providers may also request to receive ADR letters through the Palmetto GBA eService portal. This can be especially helpful in large practices/facilities to ensure the letters reach your appropriate internal department to fulfill the record request within the noted time frame.

Resources

Question: I saw the patient for two office visits on the same day. Why was one of them denied?

Answer: Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter. For example, an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

Providers must provide enough detail to alert Palmetto GBA during the claim processing that each service represented two separate encounters meeting the above criteria. Two separate diagnosis codes listed on the claims is not sufficient to meet the criteria above. If your claim has been denied for two E/M visits on the same day, you may request an appeal and provide documentation to support the Medicare coverage for two E/M visits on the same day (listed above) has been met.

Resource: Medicare Claims Processing Manual, Section 30.6.7B (PDF).

Question: My claim denied for workers compensation (liability or no-fault), but this service had nothing to do with the workers' compensation on file.

Answer: Determining if a claim is workers compensation, liability or no fault related is driven by the diagnosis codes submitted on a claim. If the submitted diagnosis is the same or similar to what is on file for the workers compensation, the claim will deny.

Providers that believe their denial is incorrect are encouraged to review the diagnosis codes submitted on their denied claim for accuracy and make any corrections and resubmit the claim. Providers may also resubmit or appeal the claim with an explanation of benefits from the primary (workers compensation, no fault, or liability) insurer that indicates the services are not covered under their plan.

Last Reviewed: 12/02/2024

Question: Some claims deny indicating contractual obligation and some denials indicate I had an invalid code or modifier combination, or the required modifier was missing or invalid. Can I charge the patient for these denials?

Answer: Billing errors are also known as "claim submission errors" or "rejections." Rejections are not the same as denials, although providers often use the terms interchangeably. You must review rejected claims and make necessary corrections, then resubmit the claims. Once that is done, Palmetto GBA can process the claim and determine patient or provider financial responsibility.

Each claim’s rejection reason is noted on your remittance advice and includes Claim Adjustment Remark Code(s) (CARCs) that explain the reason a claim is rejected. Using those details, review your claims’ CPT®/HCPCS code and confirm the code(s) are valid codes for each date of service billed, make any necessary corrections, and resubmit the claims. If the CARC indicates the code and submitted modifier are not compatible, review the CPT® code description as well as the appended modifier’s description. Make necessary corrections and resubmit the claim. In some cases, certain services require a modifier that may have been left off a claim. Review the Palmetto GBA website resources for your type of service or provider specialty under the Topics tab at the top of the web page. Search for articles related to the specific code that you are billing. Use the Palmetto GBA Modifier Lookup tool.

Question: When and how do I go about revalidating my provider’s enrollment status?

Answer: CMS provides a Medicare Revalidation Due Date Lookup Tool. A due date listed as TBD indicates that CMS has not set the due date for revalidation yet. Do not submit enrollment revalidations if there is not a listed due date. All unsolicited revalidation applications will be returned without processing.

When required, the preferred and fastest method of revalidating an enrollment record is by using the Provider Enrollment Chain and Ownership (PECOS) system, Revalidations (Renewing Your Enrollment) Through PECOS.

Question: Why am I getting frequency denials for some services?

Answer: There are a number of reasons why a service may be denied indicating the service was provided more frequently than allowed. National Coverage Determinations and Local Coverage Determinations may have frequency limits related to a specific timeframe, indicating the limit applies to services by the same provider, the same group, or billed by any provider rendering a specific service to an individual beneficiary. Careful review of the policy will indicate how the frequency limit will be applied. Additionally, CMS uses the Medicare National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) edits to reduce improper payments. An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT® code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service. Not all HCPCS/CPT® codes have an MUE and although CMS publishes most MUE values on its website, other MUE values are confidential. Confidential MUE values are not releasable.

To understand frequency limits, review the resources below. If after reviewing documentation you feel the individual patient’s documentation supports an allowable exception to the MUE, you may exercise your individual claim appeal rights and provide the necessary supporting documentation with your appeal request.

Reference: CMS Medicare NCCI FAQ Library.

Question: What does "CO" mean on my remittance advice?

Answer: "CO" is a group code. Group codes assign financial responsibility for the unpaid portion of a claim balance e.g., CO (contractual obligation) assigns responsibility to the provider and PR (patient responsibility) assigns responsibility to the patient. Medicare beneficiaries may be billed only when group code PR is used with an adjustment. CARCs provide an overall explanation for the financial adjustment. Group codes CO or PR are used to indicate when a beneficiary may or may not be billed for the unpaid balance of the services that were performed. Your Remittance Advice will always provide the text of each reason and message code at the end of the notice. CaRCs are provided to assist in explaining denial, rejection or adjustment reasons that apply to your claim. The definition of each is provided at the bottom of your Remittance Advice. Help understanding many of the most common CARCs associated with a contractual obligation may be found on the Palmetto GBA web site by searching for the CARC.

Reference: Health Care Payment and Remittance Advice.

Question: Who do I contact with questions?

Answer: CMS requires the providers utilize the Provider Contact Center as the first point of contact for most questions. The green “Contact Us” link in the upper-right corner of Palmetto GBA’s website provides contact information for Palmetto GBA. The Palmetto GBA website contains the answers to most of your inquiries. The Palmetto GBA eServices portal should be used to verify eligibility or claim status, including information about other applicable insurance that may be primary to Medicare. 

The following telephone, email, and written inquiries are examples of answers to questions often misdirected to Palmetto GBA.

  • Medicare Advantage Plan’s coverage, billing, or claim determinations must be directed to the individual Medicare Advantage plan
  • Railroad Medicare questions must be directed to the Railroad Medicare contact center at 888–355–9165 (Railroad Providers — Contact Railroad Medicare)
  • How a primary insurer handled a claim must be directed to the applicable primary insurance plan
  • Questions regarding letters received, must be directed to the entity that sent the letter or as directed within the letter. Not all letters referencing Medicare are from Palmetto GBA. 

Question: I have contracted with a third-party contractor to handle my claims and claim follow up. Can I ask the contracted entity to call Palmetto GBA on every claim and get a tracking or reference number to prove that they followed up on each of my claim?

Answer: While a provider’s contract terms with a third party are not dictated by Palmetto GBA or CMS, Palmetto GBA discourages provider from requiring that a third-party contractor simply call Palmetto GBA to get a reference or tracking number to prove to you that they are meeting the terms of your third-party contract. In most instances, inquiries for claim or appeal status are unnecessary and needlessly tie up our Provider Contact Center lines. Claim and appeal status are available through the Palmetto GBA eServices portal. Additionally, third party contractors should have access to your Medicare remittance advice and correspondence regarding claims and appeals and used as a resource before calling Palmetto GBA.

Palmetto GBA tracks inquiry volume by provider. Unnecessary calls from a provider’s third-party contractor will reflect as though the inquiry was from the provider they represent and whose NPI is used when passing privacy during a call. You are encouraged to consider these items when contracting with a third party to help reduce unnecessary calls to the provider contact center.

Last Reviewed: 12/02/2024

Question: What are my options for verifying claim status?

Answer: Claim status can be verified through the Palmetto GBA eServices portal or through the Palmetto GBA Interactive Voice Response (IVR) system. We encourage you to verify the date your claim was initially submitted and understand that the date you send a claim to a billing company or clearinghouse may not be the same day that your claim was forwarded to and received by Palmetto GBA for consideration. Once received and processed, Palmetto GBA must apply a payment floor. The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. The payment floor represents the earliest date contractors may release payment for a completed clean claim. You should not expect Medicare payment for a claim until after the waiting period ends.

eServices: Once logged in you will have to have permission to access the Claims tab. Once you open the Claims tab, the claims status screen will appear. The few required fields are marked as required. Other fields are optional. Reference: eServices User Manual (Section 4.0).

Sign up or log in for Welcome to Palmetto GBA eServices.

IVR: Call your jurisdiction’s Provider Contact System and answer the survey prompt then select Option 3 for the IVR. Use the Part B IVR User Guide to walk you through the steps to verify claim status using the IVR.

References

Question: Why when I check the claim status in eServices, through the IVR or with a customer service representative, might I get the response that my claim is not on file?

Answer: There are several reasons.

Question: When Medicare rejects my claim, why does my Remittance Advice (RA) show a CO group code and the entire submitted charge listed as a contractual obligation indicating I can’t bill the patient for the service?

Answer: CMS expects providers to submit claims with accurate and complete information so that the claim can be processed. When a claim is rejected because required information is missing, incomplete or invalid, the entire submitted charge for that service is identified as a contractual obligation and the provider is not afforded appeal rights. The remittance advice will indicate what information is missing, incomplete or invalid using Claim Adjustment Remark Codes. The provider must correct the claim, provide the necessary information, and resubmit the claim. Once the claim has all the necessary information, Palmetto GBA will adjudicate the claim and the dollar amount in the contractual obligation field could likely change based on the claim determination.

Question: I want to opt-out of Medicare, not have to submit claims to Medicare, and have Medicare patients pay out of their pocket for my services. How do I do this?

Answer: You must first be an eligible type of provider to opt-out of Medicare. Only certain types of providers may opt-out of Medicare. Manage Your Enrollment | CMS An eligible provider that wishes to opt-out must submit an opt-out affidavit to Medicare and enter into a private contractor with each of your Medicare patients before most services are provided. Information on what it means to opt-out of Medicare and the process for opting-out can be found at the resources below. Reference: Manage Your Enrollment.

Question: Isn’t there a faster easier way to request a first level appeal other than mailing or faxing the redetermination request?

Answer: The simplest and most efficient way to submit a redetermination is through Palmetto GBA’s eServices portal. Palmetto GBA also offer an eDelivery option for receiving your redetermination decision letters electronically. You can get your Medicare redetermination notices (MRNs) the same day that they are issued, delivered directly to your computer. You can even choose to get an email to let you know that the letter is waiting for you. The eServices User Manual provides instructions on the submission process.

  • If a paper claim, the claim may not have been delivered to Palmetto GBA, or if the claim was received through the U. S. mail, the claim may not yet have been entered into the claim processing system
  • Your billing company or clearinghouse may not have forwarded the claim to Palmetto GBA
  • Your electronic claim may have been stopped by billing software and additional action may be required to move the claim to transmit to Medicare

Last Reviewed: 12/02/2024


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