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Medicare Part B 2001 New Provider Training II - Palmetto GBA

Medicare Part B 2001 New Provider Training II - Palmetto GBA

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“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.

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