Medicare Part B 2001 New Provider Training II - Palmetto GBA

“Building a Relationship with Medicare”
New Provider Training
September 18, 2008 (Part II)

Agenda – Day 2
• Corrected Claims
• Faxed Attachments
• Remittance Notice
• Comprehensive Error Rate Testing
(CERT)
• Advance Beneficiary Notice (ABN)
• Provider Contact Center
• Palmetto GBA Publications &
Resources
• Appeals
• Medicare Overpayments
• Fraud & Abuse
• Question & Answer Session

Corrected Claims
If a claim does not pay – denied,
rejected, otherwise unprocessable –
It must be corrected and submitted
as a new claim.
Examples of denied claims:
• Medical necessity
• Unprocessable (CO-16) due to
missing information
• Procedure code being bundled
into other services (Add the
appropriate modifier.)

Corrected Claims
We don’t adjust “corrected claims.” (you
should correct and resubmit them.)
If payment has been made, but the claim
was submitted with incorrect information,
an appeal should be requested.
Examples of Appeals:
• Incorrect number of units
• Incorrect date of service
• Incorrect diagnosis or
procedure code

Coding Resources
Helpful coding resources:
ICD-9-CM
• Guidelines
• Truncated Diagnosis
Coding
CPT
HCPCS

Fax Claim Attachments
• Palmetto GBA offers the
option of faxing your
documentation with electronic
claim submission
• Fax the information same day
or up to two days prior to the
electronic claim submission
• www.PalmettoGBA.com/bsc
• Resources
• Forms – “FAX Cover Sheet: Part
B Electronic Claims ”

Fax Attachments
Please do not use the Fax
Attachment Coversheet for:
• Responding to Additional
Development Request
(ADR) Letters
• Appeal Request
• Medicare Secondary Claims

“What we give to you in the relationship”
How to Interpret the
Remittance Advice

Remittance Advice
• The Medicare Remittance
Advice helps provide an
explanation of how your
claim processed and why.
• Standardized reason
codes and text messages
for all statuses
• Uniform appearance and
content

Remittance Advice
Header
Claims
Glossary

Header
A
B
C
• A) Medicare Contractor
• B) Provider
• C) NPI, Page #, Date, Check/EFT #

Claims Detail
A
A
A
A
B
• A) Claims
• B) Totals

Glossary
A
B
• A) Codes: Group, Reason, Remark
• B) Code descriptions

Claims Detail
A B C
• (a) NAME The Medicare beneficiary’s name
• (b) HIC The beneficiary’s Health Insurance Claim
Number (Medicare number)
• (c) ACNT The patient’s account number submitted
on the claim

Claims Detail
D E F
• (d) ICN The internal control number assigned to the claim
as they reach the Medicare office.
• (e) ASG The assignment indictor. Y = assigned claim; N =
non-assigned claim
• (f) MOA The Medicare Outpatient Adjudication codes are
used to convey appeal information and other claim-specific
information that does not involve a financial adjustment.

Claims Detail
G
I
H
• (g) PREF PROV The provider Identification
Number (PIN) does not display on this remittance.
• (h) SERV DATE The dates of the services for
which a claim was submitted.
• (i) POS The place of service indicator.

Claims Detail
J
L
K
• (j) NOS The number of services indicator
• (k) PROC The CPT or HCPCS code billed
• (l) MODS The modifiers submitted

Claims Detail
M
P
N
O
• (m) BILLED The amount billed on the claim for the service.
• (n) ALLOWED The amount Medicare allowed for the
service.
• (o) DEDUCT The amount applied to the patient’s annual
deductible.
• (p) COINS The amount applied to the 20 percent
coinsurance

Claims Detail
Q
R
• (q) RC-AMT The adjustment reason code indicates
adjustments made other than deductible and
coinsurance. If more than one, additional codes
appear on the next line.
• (r) PROV PD The amount the provider is paid for
this service.

Claims Detail
T
• (t) PT RESP The amount considered to be patient’s or
patient’s supplemental insurance responsibility.
• (u) CLAIM TOTALS The totals of the billed, allowed,
deductible, coinsurance, and total paid to the provider.
• (v) NET The net amount the provider is being paid. This
total includes interest if applicable.
U
V

Claims Detail
W X Y
For adjusted claims (example above is pasted in just for show)
• (w) PREV PD Includes amounts previously paid for the services.
• (x) INT Total interest accumulated for this patient and date of service.
• (y) LATE FILING CHARGE Displays the late filing charge.

Claims Detail & Totals
A
A
A
A
B
• A) Claims
• B) Totals

Claims totals
A B C D E F G H I
• Grand totals for all claims combined
• A) # OF CLAIMS - Number of Claims
• B) Billed AMT - Billed Amount
• C) ALLOWED AMT – Allowed Amount
• D) DEDUCT AMT – Deductible Amount
• E) COINS AMT – Coinsurance Amount
• F) TOTAL RC-AMT – Total Reason Code Amount
• G) PROV PD AMT – Provider Paid Amount
• H) PROV ADJ AMT – Provider Adjustment Amount
• I) CHECK AMT – Check Amount

Glossary
A
B
• A) Codes: Group codes, Reason, Remark
• B) Code descriptions

Glossary Codes
Group Codes - Financially Responsible Party
CO
PR
Contractual Obligation
Patient Responsibility
Reason Codes – Why Claim Paid Differently Than Billed
4 Procedure inconsistent with modifier
5 Procedure inconsistent with place of service
Remark Codes – Additional Explanation
M31
M76
Claim lacks the radiology report
Incomplete/invalid diagnosis

MREP
• Medicare Remit Easy Print
Software
• Easy navigation
• Print your ERA
• Search Capabilities
• Print and export ERA’s
• Archive, Restore and
Delete ERA’s

CERT
• Comprehensive Error Rate
Testing
• AdvanceMed was awarded a
contract by CMS to determine
the paid claim error rates at
the:
• national,
• contractor specific,
• benefit category, and
• provider type
• Livanta, (CERT Documentation
Contractor).

Responding to Requests
Helpful Tips.
• Respond within 75 days.
• Attach medical records to original
request.
• Do not staple.
• Do not submit photocopy of the
cover sheet.
• Do not punch holes in medical
records as this may obscure
valuable information.
• If responding to multiple request
on the same patient for various
dates of service, respond to each
request separately.
• Include the bar coded cover sheet.

Where to Mail Records
• Where should you mail CERT
records
• Records should be sent to the
following address:
LIVANTA
CERT Documentation Contractor
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701
or
or FAX to (240) 568-6222

ABN
• Advance Beneficiary
Notice (ABN)
• Applicable to medical
necessity denials
• ABN must be in writing
• Patient must be notified
before service is rendered
• “Blanket” notices are not
valid
• Use GA modifier to
indicate ABN on file

ABN
• ABNs cannot be copied.
• For replicable copies, visit CMS’s Web site at:
http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp
• Also at: www.PalmettoGBA.com/bsc, “Forms”

Provider Contact Center
• Call (888) 828-2092 for
service Monday
through Friday from
8:30 a.m. – 4:30 p.m.
• Have your NPI provider
number ready

IVR Options
• Interactive Voice
Response (IVR) Unit
• Call 1-866-238-9654
• Payment Floor
• Claim Information
• Order a Duplicate
Remittance
• Beneficiary Entitlement
• Beneficiary Part B
Deductible

Education Department
Provider Outreach and Education
• Are you having a problem with
filing your claims
• Do you have a new person in
your office
• If you would like an Ombudsman
to visit your office or to speak at
a meeting:
o Call 866-238-9654 and
choose Option 8
or
o Complete the Provider
Outreach and Education
Request Form.

Education Outreach
Formal workshops
(Face-to-Face Workshops)
On-line workshops
(Interactive classroom setting)
Web-Based Training Modules
(Self-paced learning)

Online Knowledge Center
WWW.PalmettoGBA.com/bsc

Online Knowledge Center
The Knowledge Center, Welcome Page

Catalog

Medicare Advisory
• Subscriptions are
available.
• Medicare Advisories
are $100 for a yearly
subscription.
• They can be sent to
any address.
• They can be
downloaded from the
Web site for free.

Register for the listserv
• Access the web at
www.PalmettoGBA.com/bsc
• Register your practice, and
you’ll be notified by e-mail
when new or important
information related to your
specialty is added to our
Web site.
• You can update your profile
at any time!

Medicare Part B Appeals
Medicare law provides a
system for appealing Part B
claims when the charges on
those claims were not
processed to your
satisfaction.

Medicare Part B Appeals
Reopenings
Not a level of the appeals
process
Correction of minor errors
or omissions
Telephone reopening line:
1-866-815-7891

Medicare Part B Appeals
Federal Court Review
Department of Appeals Board (DAB) Review
Administrative Law Judge (ALJ) Hearing
Reconsideration – “NEW” Level
Redetermination
Five Levels of the Appeals Process

Medicare Part B Appeals
Appeal Level Timeliness Monetary
Threshold
Redetermination 120 days of initial claim None
Reconsideration
180 days of
Redetermination
None
ALJ Hearing 60 days of Reconsideration $120
DAB Review 60 days of ALJ Hearing None
Federal Court
Review
60 days of DAB Review $1180

Overpayments/Refund
• A provider must refund
to Medicare any
overpayments or
duplicate payments
made to them.
• Medicare will request a
refund for any
overpayment equaling
$10 or more.

Overpayments/Refunds
If an overpayment is detected it may be
handled one of two ways:
1. If you are unsure of the amount to be refunded you
should send a letter of explanation to the Medicare
Provider Contact Center and ask that we request a
refund.
• Refund requests usually take from 4 to 6 weeks

Overpayments/Refunds
2. If the exact amount of
overpayment is known send a check
with a copy of the Medicare
remittance and the Overpayment
Refund Form to:
Medicare B Overpayments
Department
AG-245
Palmetto GBA
PO Box 100190
Columbia SC 29202-3190

Fraud or Abuse
• Fraud - an intentional deception
that could result in unauthorized
benefits
• Example: A claim submitted for
payment for services that were
not provided
• Abuse - a practice, which
although not considered a
fraudulent act, may cause
financial loss to the Medicare
program
• Example: Medically unnecessary
services or excessive charges

Second Level Screening Team
• Detect, prevent Medicare
fraud and abuse
• Receive complaints
• Research allegations
• Take action
• Recoup money
• Appropriate education
• Just call the PCC

TriCenturion
TriCenturion is a Program
Safeguard Contractor
(PSC) under contract
with CMS to perform
selected Medicare
program integrity tasks.

TriCenturion
TriCenturion
specializes in datadriven
fraud and
abuse investigation
• Fraud case development
• Law enforcement review
• Medical Review to
support Fraud and abuse
• Fraud prevention
education
• Fraud complaint
processing

TriCenturion
Contacting TriCenturion
By mail:
P.O. Box 100282, ZA-191
Columbia, S.C. 29202-3282
By Telephone:
(803) 264-7700
Internet address:
www.TriCenturion.com

Any questions
Q&A Session

Thank You!
The information provided in this workshop was current as
of 9/17/08. Any changes or new information superceding
the information in this workshop will be provided in
articles and publication and publication dates after
9/17/08 posted at www.PalmettoGBA.com under
Providers/Part B Carrier/South Carolina.