Transcript Slide 1

J11 Part A Palmetto GBA
Processing Questions and
Answers
1
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.
2
Agenda
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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
3
Medical Review/Medical
Affairs Policy Questions
4
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)”
5
Claims billed according to LCDs
are being denied inappropriately

Assure applied the LCD in effect for the
dates of service of the claim
6
Claims Processing and Edit
Questions
7
Review why all MUEs can’t
be published

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MLN publication ICN 006973
CMS will not publish all MUE values because
of fraud and abuse concerns
8
Publish and update Medicare
reject code cross walk
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Providers advised to review the article
“Reason Code Differences Between
Palmetto GBA and NGS: Virginia and
West Virginia Providers”
Reason Code Resource Tool
9
When to Submit a Clerical
Error Reopening Form

Human or mechanical errors on the part of the party
or the contractor, such as:

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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
10
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
11
Clerical Error Reopening
Request Form
12
Slow processing of clerical
error reopening requests
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Allow 30 days for the processing
Depending on the number of requests
received, the processing time may vary
13
Too many claims go in ‘S’
Suspense status and hold there
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Some type of claims intervention is required
Claims can require intervention for a variety of
different reasons:
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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
14
Are providers required to use
the GZ modifier?
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Providers should use appropriate modifiers for the accurate
assignment of liability
CR 7228 effective for dates of service on or after July 1,
2011:
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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
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Reflect a Claim Adjustment Reason Code of 50 (These services are noncovered services because this is not deemed a “medical necessity” by
the payer) and
Group Code of CO (Contractual Obligation) to show provider/supplier
liability
15
Condition Code 44 Use

In cases where a hospital utilization review committee
determines:
 Hospital may change the beneficiary’s 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:
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Change made PRIOR to discharge or release
Hospital has NOT submitted an inpatient claim;
Physician concurs with the utilization review committee’s
decision; and
Concurrence documented in the medical record
16
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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.
Inappropriate claim denials for
overlap
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Billing Disputes Resolution Requests
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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
18
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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:
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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
19
Understanding “D” adjustment
codes
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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
20
Understanding “D” adjustment
codes
Code
Description
Code
Description
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.
D0
***This code is used if adding a
modifier to change liability and
there is no change to the
covered charge amount.
21
D9 Condition Code
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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
22
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,
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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,
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An Appeal must be filed
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
23
Understanding why claims go
to SMRADJ status
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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
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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”
24
Claims in SMTIME status are mainly
credit balance adjustments done after
normal timely filing period
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If you have a claim that needs to have timely filing
overridden to process and pay back an overpayment,
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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
25
Extension on the time limit for
claims
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For other claims that meet the CMS requirements to have
timeliness overridden please follow the job aid posted on
Palmetto GBA’s Web site
According to CR 7270, there are four exceptions where
providers can request an extension on the time limit for
claims
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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
26
Timely Filing Job Aid
27
Hospitals are receiving RTPs with
reason code W7050 for Revenue
Code 0637
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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”
28
Claims in RB7516 Status and
Location
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CMS IOM Publication 100-05, Chapter 5,
Section 60.1.3.2.1, B
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“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”
29
Claims in RB7516 Status and
Location Continued
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Claims in S/LOC “R B7516” are not finalized
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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
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Claims in RB7516 Status and
Location Continued
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If Medicare is secondary
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Submit an adjustment
Claim must sit 75 days
If adjusting to make Medicare primary
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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
31
Claims in RB7516 Status and
Location Continued

Reminders:
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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
32
Increase in the number of claims
RTP’d for Present on Admission
(POA) indicator
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Providers should refer to the job aid, “Present on
Admission (POA) Indicator: Troubleshooting
RTP Claims”
If RTP’d with a reason code associated with the
POA indicator, please verify the claim information
against the job aid before contacting the PCC
33
Claims rejecting for
National Drug Code (NDC)
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One NDC issue and it has been resolved
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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
34
Issues with billing secondary
claims to Medicare

Two MSP claims issues still pending:
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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.
35
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
beneficiary’s other health insurance information.
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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
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The COBC will contact the beneficiary to determine whether insurance
coverage exists
Depending on the results of the inquiry, the COBC should:

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Notify the provider of the insurance coverage or
Bill the beneficiary
36
Clarification on the use of
modifier AY
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As per Change Request (7064), the AY modifier is
used if the services are NOT related to the
beneficiary’s 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
37
How can a provider resolve reason code
15202 when we have not received a system
generated request for an outlier code?
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To resolve reason code 15202 the provider must
enter on the claim:
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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
38
Why do we have to give the
date and amount of the outlier?
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It is not the practice of Palmetto GBA to
calculate outliers for providers
Medicare requirements are that the provider
must make this determination
39
Appeals Questions
40
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
41
Determining to Appeal

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
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/J11A and select Forms
from the Top Links box on the left navigation
42
Redetermination Request
Form
43
Appeals in relation to MUEs

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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
44
MUE Job Aid
45
Tips for Filing Appeals
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Do not show the items as both covered and
non-covered on the adjustment
Move the specific line item from the noncovered 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 don’t send an adjustment bill, the appeals
team will review their requested item only
46
Tips for Filing Appeals

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Providers are not required to submit an
adjusted UB04 if there are no changes, it is
actually better if they don’t.
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.
47
Tips for Filing Appeals
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Please attach all documentation that you
would like included in the redetermination.
Examples of supporting documentation would
include:
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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
Physician’s orders
48
What Should NOT Be
Appealed?
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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
49
Appeals are taking more than 60
days for Palmetto to process

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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
50
RAC Notification/Demand Letter
Questions
51
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


Medicare’s Recovery Audit Contractors
(RACs) no longer issue demand letters
52
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?

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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
53
How the process works between
the RAC and Palmetto GBA

RAC Responsibilities

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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

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Issue demand letters
Perform the adjustments based on the RAC’s review
Handle administrative concerns such as timeframes for
payment recovery and the appeals process
Include the name of the initiating RAC and their contact
54
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 provider’s physical address
55
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
56
Example of how RAC automated
accounts will appear on the RA
•RAC adjustments are identified by remark code
N432
57
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
58
Electronic Data Interchange
(EDI)/5010 Questions
59
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 (866) 749-4301
60
General Questions
61
Why can’t 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
62
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
63
IVR doesn’t allow providers to verify
primary insurance for a specific date of
service or provide the HMO’s 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
64
Customer Service Questions
65
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
66
PCC’s tier/triage process




Tier I
Tier II
Supervisor
Tracking Numbers
67
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
68
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
69
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 CSR’s name and the tracking
number
Note: Please do NOT include Protected Health
Information
70
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
71
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
72
Questions?
73