J11 Part A Palmetto GBA Processing Questions and Answers

1
J11 Part A Palmetto GBA Processing Questions and
Answers
2
Disclaimer

• This presentation was current at the time it was
  published or uploaded onto the Palmetto GBA Web
  site. Medicare policy changes frequently so links
  to the source documents have been provided within
  the document for your reference.
• This presentation was prepared as a tool to
  assist providers and is not intended to grant
  rights or impose obligations. Although every
  reasonable effort has been made to assure the
  accuracy of the information within these pages,
  the ultimate responsibility for the correct
  submission of claims and response to any
  remittance advice lies with the provider of
  services.
• The Centers for Medicare Medicaid Services
  (CMS) employees, agents, and staff make no
  representation, warranty, or guarantee that this
  compilation of Medicare information is error-free
  and will bear no responsibility or liability for
  the results or consequences of the use of this
  guide.
• This publication is a general summary that
  explains certain aspects of the Medicare Program,
  but is not a legal document. The official
  Medicare Program provisions are contained in the
  relevant laws, regulations, and rulings.

3
Agenda

• Medical Review/Medical Affairs Policy Questions
• Claims Processing and Edit Questions
• Appeals Questions
• RAC Notification/Demand Letter Questions
• EDI/5010 Questions
• General Questions
• Customer Service Questions

4
Medical Review/Medical Affairs Policy Questions
5
PET scans being denied inappropriately

• See the CMS PET scan NCD
• Providers are advised to review the article
  Additional Billing Clarification for Positron
  Emission Tomography (PET)

6
Claims billed according to LCDs are being denied
inappropriately

• Assure applied the LCD in effect for the dates of
  service of the claim

7
Claims Processing and Edit Questions
8
Review why all MUEs cant be published

• MLN publication ICN 006973
• CMS will not publish all MUE values because of
  fraud and abuse concerns

9
Publish and update Medicare reject code cross
walk

• Providers advised to review the article Reason
  Code Differences Between Palmetto GBA and NGS
  Virginia and West Virginia Providers
• Reason Code Resource Tool

10
When to Submit a Clerical Error Reopening Form

• Human or mechanical errors on the part of the
  party or the contractor, such as
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Computer errors
• Incorrect data items, such as provider number,
  use of a modifier or date of service

11
When to Submit a Clerical Error Reopening Form

• If there is a medically denied line item on the
  claim, the provider wants to change something
  OTHER THAN the denied line and FISS does not
  allow an adjustment, the provider should submit a
  hard copy adjustment using the Clerical Error
  Reopening Request
• A contractor shall NOT grant a reopening to add
  items or services that were not previously billed

12
Clerical Error Reopening Request Form
13
Slow processing of clerical error reopening
requests

• Allow 30 days for the processing
• Depending on the number of requests received, the
  processing time may vary

14
Too many claims go in S Suspense status and
hold there

• Some type of claims intervention is required
• Claims can require intervention for a variety of
  different reasons
• MSP development
• Adjustment requests with claim change reason
  codes D4, D8 and D9
• Claims in S status are worked daily
• Wait for the claim to move to a finalized status
  before another claim is submitted

15
Are providers required to use the GZ modifier?

• Providers should use appropriate modifiers for
  the accurate assignment of liability
• CR 7228 effective for dates of service on or
  after July 1, 2011
• The GZ modifier indicates that an ABN was NOT
  issued
• Signifies that the provider expects denial due to
  a lack of medical necessity based on an informed
  knowledge of Medicare policy.
• Medicare contractors will automatically deny
  claim line(s) submitted with a GZ modifier
• Reflect a Claim Adjustment Reason Code of 50
  (These services are non-covered services because
  this is not deemed a medical necessity by the
  payer) and
• Group Code of CO (Contractual Obligation) to show
  provider/supplier liability

16
Condition Code 44 Use

• In cases where a hospital utilization review
  committee determines
• Hospital may change the beneficiarys status from
  inpatient to outpatient
• Submit an outpatient claim (TOBs 13x, 85x) for
  medically necessary Medicare Part B services with
  Condition Code 44
• If ALL of the following conditions are met
• Change made PRIOR to discharge or release
• Hospital has NOT submitted an inpatient claim
• Physician concurs with the utilization review
  committees decision and
• Concurrence documented in the medical record

17
Condition Code 44 Use Continued

• Submits a 13x or 85x bill and report Condition
  Code 44 on the outpatient claim
• When an inpatient admission is determined not to
  be medically necessary for inpatient AFTER a
  patient was discharged, the hospital may submit
  ancillary charges on the 12X bill type after the
  original paid amount is recovered
• There should be no beneficiary responsibility for
  these instances.

18
Inappropriate claim denials for overlap

• Billing Disputes Resolution Requests
• Providers should ensure eligibility reviewed
  before patient is admitted
• If records reflect that care is or was being
  provided by another provider, and the previous
  provider has not finalized their billing, the
  receiving provider is responsible for contacting
  the existing/previous provider to request that
  they complete their billing
• Should a dispute arise, both agencies are
  required under Medicare regulations to make an
  attempt to resolve
• If the agencies are unable to resolve the
  dispute, Palmetto GBA may be contacted for
  assistance

19
MSP Billing With Value Code 44

• Provider report Value Code 44 to indicate the
  ALLOWED amount they are obligated to accept from
  primary payer
• Only use value code 44 if
• Balance due from patient and provider has
  contractual agreement with primary payer
• The amount received is less than total charges,
  or
• The amount received from the primary payer is
  less than the contracted amount.
• Note The provider should NOT report if the
  allowed amount is more than the total charges

20
Understanding D adjustment codes

• The following chart provides information on claim
  change reason condition codes.
• Only one claim change reason code can be used on
  each claim being adjusted.
• If more than one claim change reason code is
  entered, the claim will reject

21
Understanding D adjustment codes
Code Description  Code Description
D0 Changes to Service Dates  D6  Cancel only to repay a duplicate OIG payment
D1 Changes to Charges D7  Change to Make Medicare Secondary Payer
D2  Changes in Revenue Codes/HCPCS/HIPPS  D8 Change to Make Medicare Primary Payer
D3 Second or Subsequent Interim PPS Bill  D4 Changes in Grouper Codes
D5 Cancel to correct HICN or Provider ID  D9  Any Other Change
E0 (zero) Change in patient Status    Use D9 when adjusting primary payer to bill for conditional payment.This code is used if adding a modifier to change liability and there is no change to the covered charge amount.  
22
D9 Condition Code

• To reflect any other changes to be made to a
  claim that was already processed
• To report an adjustment to a claim when an
  original claim was rejected for MSP but Medicare
  is primary
• When the original claim was processed as an MSP
  or conditional claim and a change needs to be
  made to the claim such as a change in the MSP
  value code amount
• If an adjusted claim is in a Return to Provider
  (RTP) it is important to verify that the D9 code
  is being used correctly. If the D9 is the best
  code to use, the claim will need to include
  remarks indicating the reason for the adjustment.
  If remarks are not submitted, then the Medicare
  will RTP the claim using reason code 37541

23
Reminder About Adjustments on Claims with
Medically Denied Lines

• If a line item on a claim is medically denied
  (status location D B9997) and the provider has
  medical evidence that he or she thinks should
  allow the denied service to be covered by
  Medicare,
• An Appeal must be filed
• If there is a medically denied line item on the
  claim, but the provider needs to adjust the claim
  to make a change to something OTHER THAN the
  denied line item,
• The provider may key the adjustment in the system
  on the claim
• Once adjusted, the claim will go to an S
  'suspense' status and location to be reviewed by
  the claims department before processing
• Note If there is a medically denied line item on
  the claim, and FISS DOES NOT allow the provider
  to complete the adjustment electronically, 
• In this instance the provider should submit a
  hard copy adjustment using the Clerical Error
  Reopening Request form

24
Understanding why claims go to SMRADJ status

• SMRADJ is a status and location for mass
  adjustments
• Claims go into S or Suspense status when some
  type of claims intervention is required
• If providers feel a claim is in S status for a
  prolonged period of time, they may contact the
  PCC for assistance with getting the claim
  finalized
• Providers are encouraged to ask for a tracking
  number each time they contact the PCC
• Providers are advised to review the article
  Claim Status and Location Hints

25
Claims in SMTIME status are mainly credit balance
adjustments done after normal timely filing
period

• If you have a claim that needs to have timely
  filing overridden to process and pay back an
  overpayment,
• If the claim is still online you just need to
  adjust it and put in remarks the reason is to
  repay the overpayment
• If it is offline, call the PCC to request it be
  placed back online so you can then make the
  adjustment with remarks
• This will assure the claim processes and you know
  the amount to pay back.
• The only time you report it on the credit balance
  report is if the claim did not get adjusted that
  quarter

26
Extension on the time limit for claims

• For other claims that meet the CMS requirements
  to have timeliness overridden please follow the
  job aid posted on Palmetto GBAs Web site
• According to CR 7270, there are four exceptions
  where providers can request an extension on the
  time limit for claims
• 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

27
Timely Filing Job Aid
28
Hospitals are receiving RTPs with reason code
W7050 for Revenue Code 0637

• FISS narrative for reason code W7050 is,
  non-covered under any Medicare outpatient
  benefit, based on statutory exclusion
• Providers should assure they are appending the GY
  modifier to the line with Revenue Code 0637 for
  billing self administered drugs
• Providers should review the article Instruction
  on Billing for Non-covered Items/Services

29
Claims in RB7516 Status and Location

• CMS IOM Publication 100-05, Chapter 5, Section
  60.1.3.2.1, B
• Cost avoidance savings may not duplicate savings
  reported as full or partial recoveries and may
  not be shown where Medicare ultimately makes
  primary payment
• The CMS prefers cost avoidance savings only
  after 75 days have elapsed

30
Claims in RB7516 Status and Location Continued

• Claims in S/LOC R B7516 are not finalized
• Must remain in R B7516 for 75 days to become
  final
• Adjusting claims before final (R B9997 or P
  B9997) receive the 30928 reason code
• Post-pay claim can be finalized by contacting the
  PCC if and when the term date of the MSP record
  is prior to the dates of service of the claim
• The Coordination of Benefits Contractor (COBC)
  should be contacted to delete/term MSP record

31
Claims in RB7516 Status and Location Continued

• If Medicare is secondary
• Submit an adjustment
• Claim must sit 75 days
• If adjusting to make Medicare primary
• Indicate in Remarks that services are NOT related
  to an open workers comp, liability, no-fault, or
  black lung record
• Next, contact the PCC to finalize the claim
• Once the claim is finalized, the provider can
  submit the adjustment and it should process

32
Claims in RB7516 Status and Location Continued

• Reminders
• Do not attempt to adjust claims until final or
  until CWF is updated
• Request processing if CWF is updated prior to
  your 75-day hold
• If claim has been in R B7516 longer than 75 days,
  contact the PCC for assistance with processing
  the claim

33
Increase in the number of claims RTPd for
Present on Admission (POA) indicator

• Providers should refer to the job aid, Present
  on Admission (POA) Indicator Troubleshooting RTP
  Claims
• If RTPd with a reason code associated with the
  POA indicator, please verify the claim
  information against the job aid before contacting
  the PCC

34
Claims rejecting for National Drug Code (NDC)

• One NDC issue and it has been resolved
• An issue has been identified with Version 5010
  National Drug Code (revenue code 0636)
• All providers who bill DMAP drug codes for
  outpatient services need to report the NDC for
  the drugs administered
• Hospitals are required to submit the NDC for
  outpatient services only

35
Issues with billing secondary claims to Medicare

• Two MSP claims issues still pending
• A system release incorrectly affected the Release
  of Information (RI) field for the payer ID
• Medicare Secondary Payer (MSP) claims are
  returning to the provider (RTP) incorrectly with
  reason code 33981.

36
How will a provider get feedback from the COBC
regarding Condition Code 08?

• Providers have a variety of sources that can be
  used to obtain a beneficiarys other health
  insurance information.
• Direct Data Entry (DDE) system and
• Online Provider Services (OPS) portal
• Used when a beneficiary refuses to give other
  health information
• The provider should also enter information in the
  Remarks
• The claim will be submitted to Medicare as
  primary
• Condition Code 08 flags the COBC for development
  of the other insurance information
• The COBC will contact the beneficiary to
  determine whether insurance coverage exists
• Depending on the results of the inquiry, the COBC
  should
• Notify the provider of the insurance coverage or
• Bill the beneficiary

37
Clarification on the use of modifier AY

• As per Change Request (7064), the AY modifier is
  used if the services are NOT related to the
  beneficiarys ESRD dialysis treatment.
• This will allow for separate payment outside of
  the ESRD PPS
• The AY modifier should NOT be used if the service
  IS related.
• In that case, the service will be considered part
  of the bundled PPS payment

38
How can a provider resolve reason code 15202 when
we have not received a system generated request
for an outlier code?

• To resolve reason code 15202 the provider must
  enter on the claim
• Occurrence Code 47 and
• Date the outlier began
• The date the outlier began is included in the
  cost report days
• Cost report days must match accommodation days
• When cost report days and accommodation days
  match, reason code 15202 does not occur

39
Why do we have to give the date and amount of the
outlier?

• It is not the practice of Palmetto GBA to
  calculate outliers for providers
• Medicare requirements are that the provider must
  make this determination

40
Appeals Questions
41
How would we be able to follow-up on RAC appeals

• Providers can check the status of ANY first level
  redetermination/appeal by calling the PCC at
  866-830-3455

42
Determining to Appeal

• Providers can appeal a claim or claim line that
  receives a full or partial medical denial
• If a claim or line item is medically denied
  (status location D B9997) and the provider has
  medical evidence that the service should be
  covered by Medicare, an appeal may be submitted
  by using the First Request Redetermination
  Request Form.
• To access this form, go to www.PalmettoGBA.com/J11
  A and select Forms from the Top Links box on the
  left navigation

43
Redetermination Request Form
44
Appeals in relation to MUEs

• If there is a charge denial (MUE) that a
  provider is requesting an appeal on, they can
  move this item to the covered column if they are
  sending an adjustment bill.
• Most of the MUE denials are bundled services, but
  not all.  If the MUE is a bundled item, the
  review must be performed to assure that the
  provider actually orders and provided the number
  of units billed.  
• In most cases, the provider has billed more units
  than they have ordered and provided to the
  patient.  Here again, they do not need to send in
  an adjustment bill, the appeals team can review
  and adjust accordingly all types of denial.
• Providers should also refer to the MUE job aid
  for more information on MUEs

45
MUE Job Aid
46
Tips for Filing Appeals

• Do not show the items as both covered and
  non-covered on the adjustment
• Move the specific line item from the non-covered
  column to the covered column.  They should not
  move all items to the covered column
• The appeals department does not need an
  adjustment bill to adjust a claim. In fact, if
  they dont send an adjustment bill, the appeals
  team will review their requested item only 

47
Tips for Filing Appeals

• Providers are not required to submit an adjusted
  UB04 if there are no changes, it is actually
  better if they dont. 
• They must specify what they are requesting the
  appeal for.  If the provider has not requested an
  item on the reconsideration or redetermination
  appeal request, then the appeals team does not
  have authority to review the item.

48
Tips for Filing Appeals

• Please attach all documentation that you would
  like included in the redetermination.
• Examples of supporting documentation would
  include
• Medical records for the dates of service appealed
  
• Certifications/Recertifications for the
  appropriate dates of service
• Office records/progress notes
• Treatment plan/plan of care
• Physicians orders

49
What Should NOT Be Appealed?

• Requests for timely filing extensions
• Provider overlap billing disputes
• Items NOT denied due to medical necessity
• Adjustments that can be handled online
• Clerical errors
• Note Contractors shall treat the request as a
  request for reopening and transfer it to the
  reopenings unit for processing

50
Appeals are taking more than 60 days for Palmetto
to process

• Rapid escalation in workload receipts far in
  excess of historical levels or projections
• Caused a delayed in processing appeals
• Implemented processes and technology improvements
  and are preparing additional staff

51
RAC Notification/Demand Letter Questions
52
How the process works between the RAC and
Palmetto GBA

• Recovery Audit Program MAC-Issued Demand Letters
• Effective date January 1, 2012
• Implementation date January 3, 2012
• Medicares Recovery Audit Contractors (RACs) no
  longer issue demand letters

53
How the process works between the RAC and
Palmetto GBA

• Why Was This Change Made?
• To avoid any delays in demand letter issuance
• What Is The New Process?
• When a RAC finds that improper payments have been
  made to you, they will submit claim adjustments
  to your claims processing Medicare MAC, Palmetto
  GBA
• Palmetto GBA will then establish receivables and
  issue automated demand letters to you for any RAC
  identified overpayment
• We will follow the same process as is used to
  recover any other overpayment from you

54
How the process works between the RAC and
Palmetto GBA

• RAC Responsibilities
• Identify improper payments
• Submit claim adjustment to the MAC
• Respond to any audit specific questions you may
  have, such as their rationale for identifying the
  potential improper payment
• MAC Responsibilities
• Issue demand letters
• Perform the adjustments based on the RACs review
• Handle administrative concerns such as timeframes
  for payment recovery and the appeals process
• Include the name of the initiating RAC and their
  contact information in the related demand letter

55
How the process works between the RAC and
Palmetto GBA

• The RAC demands will be sent to the same address
  as any other demand letter that is sent from the
  MAC
• The address that is used to mail RAC demand
  letters is the providers physical address

56
How will we be able to identify RAC adjustments?

• When a RAC or CERT adjustment is made the type of
  bill (TOB) will show as XXH

57
Example of how RAC automated accounts will appear
on the RA

• RAC adjustments are identified by remark code N432

58
What address is the MAC using to mail the RAC
demand letters?

• RAC demand letters sent to the same address
  (physical address) that is used for any other
  demand letter
• MAC Regulations Regarding Provider Specific
  Contact Information
• A provider will NOT be able to specialize the
  address and contact person for a demand letter as
  they currently do with the RAC 
• RAC Regulations Regarding Provider Specific
  Contact Information
• A provider will still be able to specialize the
  address and contact person for development
  letters, requesting records and review results
  letters with the RAC 

59
Electronic Data Interchange (EDI)/5010 Questions
60
Late notifications of 277 CA

• An article was published on the Palmetto GBA Web
  site on 12/20/2011 in reference to 277CA issues
  that were resolved
• 277CA Issues Resolved-Two recent system
  corrections have resulted in smoother processing
  of 5010 claims
• Some submitters experienced the overlay of 277CA
  files. This issue has been corrected.
• Sporadic delivery of 277CA files has been
  resolved
• We are not aware of any other 277CA issues at
  this time
• Please contact the Palmetto GBA Technology
  Support Center (TSC) at [phone]

61
General Questions
62
Why cant Palmetto GBA work with SSA to make
eligibility updates?

• MACs are not authorized to intervene on
  eligibility issues
• The patient or their authorized representative
  must communicate with the SSA to resolve any
  eligibility issues

63
Does Palmetto GBA follow the first in first out
process?

• Yes
• All workload received is stamped with a receipt
  date and scanned into our system when it arrives
  in our mail room
• It is worked in the order in which it is received

64
IVR doesnt allow providers to verify primary
insurance for a specific date of service or
provide the HMOs name

• We do not currently offer this option in our IVR
• We are exploring adding this functionality
• We will furnish more information once a target
  date for this modification is identified

65
Customer Service Questions
66
PCC Process

• The PCC should be contacted for
• General coverage questions
• Claim denial
• System issues not on the Claims Processing Issues
  Log
• Appeals status
• Provider overlapping claim disputes
• Timely filing extension requests

67
PCCs tier/triage process

• Tier I
• Tier II
• Supervisor
• Tracking Numbers

68
Hospitals are reporting an inability to get the
Part A benefits exhaust date

• The ANSI reason codes on the Medicare RA will
  indicate if benefits have exhausted 
• CMS does not require MACs to report the date
  benefits exhausted
• IF your patient exhausts his/her benefits at your
  facility, you will have that date as well as the
  necessary denial to send to another insurer on
  your RA 
• If benefits exhausted at another facility aside
  from yours, when you submit your claim as covered
  to Medicare and if the benefits are exhausted,
  the claim will be denied with the ANSI reason
  code stating benefits are exhausted and indicate
  what the beneficiary or their supplement insurer
  owes

69
Palmetto GBA gives the provider number of the
overlapping provider, but not the provider name

• CSRs have been educating the provider on how to
  locate the name of the other provider using the
  CMS Web site.
• Effective November 14, 2011, we revised our
  practice to include furnishing the provider name
  as well

70
What can we do if a CSR does not give an accurate
response?

• If you feel you have received inaccurate
  information, please let us know by contacting us
  via email
• Go to www.PalmettoGBA.com/Medicare,
• Click on Contact Us,
• Select J11 Part A MAC,
• Scroll down to the PCC section and
• Click on the hyperlink to send us an email
• Please include the CSRs name and the tracking
  number
• Note Please do NOT include Protected Health
  Information

71
Never get a call back from the PCC

• We are addressing the process and timeliness of
  callbacks
• CMS requirement is 10 business days
• If not received, contact the PCC with the
  tracking number to inquire about the status

72
Still receiving limitations of 3 inquiries per
call

• The only time we limit the number is if we are
  experiencing an abnormally high volume of calls
• Inquire about setting up an appointment or
  receiving a call back

73
Questions?