General

1. Question: What is an Accountable Care Organization (ACO)?

Answer: An ACO is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. Participating in an ACO is purely voluntary for providers. If you have claims that are subject to the ACO and being reduced providers need to verify within their facility who authorized participation in the program.

2. Question: Where can I find information about ACOs?

Answer: Although there are other types of ACO models that can be found on the CMS website, the most recent is referred to as Next Generation ACO. CMS maintains a site dedicated to the latest information on the Next Generation ACO Model program on its website that includes financial and quality results, benefit enhancements, beneficiary information, evaluations, toolkits, case studies, and an interactive map.

3. Question: Who should I contact with my questions relating to the Next Generation ACO model?

Answer: If you have specific questions relating to the Next Generation ACO model, please send them to NextGenerationACOModel@cms.hhs.gov.
Palmetto GBA will not be able to answer any questions you have relating to your enrollment in an ACO.

Question: How does a provider identify ACO processed claims?

Answer: In Direct Data Entry (DDE) on page 1, providers will see the following value codes that are populated on ACO claims:

• Q0 — Accountable Care Organization Reduction
• Q1 — ACO Payment Reduction

These value code amounts will appear as the amount in which payment has been reduced based on agreements the provider has with their designated ACO.

5. Question: Why does the IVR ask for the NPI, PTAN, and TIN before transferring me to a representative?

Answer: In order to check provider or beneficiary specific information, a provider must first be authenticated using the NPI, PTAN and TIN. When callers give this information to the IVR, the representative that gets the call is able to see the authenticated information. When the provider is authenticated by the IVR, the caller and representative can discuss issues immediately without going through the provider authentication process. This is required due to CMS Internet Only Manual (IOM) Publication 100-09, Chapter 6 (PDF)

6. Question: When a provider has a National Provider Identifier (NPI) for a facility, how can they find out which facility it belongs to without calling the Provider Contact Center?

Answer: Providers can look up the NPI for a facility on the National Plan and Provider Enumeration System (NPPES) website. Once on the site, click on NPI Registry, and then click on Organizational Provider. This will bring you to the NPI Registry Search page where you can enter the facility's NPI and the security image and click Search. In most cases, the search results will display the facility's name, address, phone number, and fax number.

7. Question: What happens if someone ignores a demand letter request from Noridian regarding a Part A Overpayment?

Answer: If there is no response after 30 days, one 30-day period of interest is accrued and a second demand letter is sent out. If there is no response to the second demand letter, a third demand letter will be sent with current interest calculations. The third demand letter will also include the intent to refer debt to the Department of Treasury's Debt Collection Center for cross servicing and offset of Federal payments and certain eligible State payments information. If there is no response on day 61, the matter will be referred to the Department of the Treasury Debt Collection Center. The provider will also remain on payment withholding at the contractor level. The Debt Collection Center will use various tools to collect the debt, including offset, demand letters, phone calls, referral to a private collection agency and referral to the Department of the Justice for litigation. Other collection tools available, which may be used, include Federal salary offset, administrative wage garnishment and the offset of income tax returns through the Internal Revenue Service. If the debt is discharged, it may be reported to the IRS as potential taxable income. During the collection process, interest will continue to accrue on the debt and the provider will remain legally responsible for any amount not satisfied through the collection efforts. 

8. Question: Where are the Claim Adjustment Reason Codes (CARC) located?

Answer: The CARC list is available at: https://x12.org/codes/claim-adjustment-reason-codes.

9. Question: How can I verify if a patient went to another facility upon discharge?

Answer: Providers needing to verify if a patient was admitted inpatient to another facility upon discharge, may obtain this information through the IVR. Once applicable information is given to the IVR, the IVR will provide the starting date and type of facility of the following claim. 

10. Question: How would a provider obtain pre-authorization for prescription drugs for a beneficiary?

Answer: Prescription drugs are covered under Medicare Part D. A beneficiary has many Medicare Part D drug plans available to choose from. Please refer to the back of the Medicare Part D card for contact information to obtain a pre-authorization. This information is not available through the Provider Contact Center.

11. Question: Where can a provider find out who the patient has elected for their Part D drug coverage?

Answer: The Provider Contact Center (PCC) customer service representatives (CSRs) do not have access to a beneficiary's Part D coverage information. Physician or suppliers must contact the beneficiary to confirm who they have elected for coverage. If they are unaware of who they have elected, the beneficiary must contact the Beneficiary Call Center.

Last Reviewed: 12/19/2024

1. Question: My facility has received notification that provider revalidation is due. What are the processing timeframes for the revalidation to be completed once it has been submitted?

Answer:  The average processing timeframes for revalidations once they have been received is listed below:

Application Type and Submission Method	Average Processing Days to Complete
Paper Application — Accurate at Submission — No Missing Information	14
Paper Application — Incomplete at Submission — Missing Information/Signatures	35
Internet PECOS Submitted Application — Accurate at Submission — No Missing Information	7
Internet PECOS Submitted Application — Incomplete at Submission — Missing Information/Signatures	35

2. Question: My claims are receiving a rejection due to a “risk GHO period.” Please explain the term and why it is affecting claims payments.

Answer: When claims are receiving a rejection regarding a risk GHO period it is stating that the Common Working File (CWF) has received information that the beneficiary is enrolled in a Medicare Advantage (MA) plan on the beginning date of service and the claim must be billed to that plan and not Original Medicare.

Another situation in which rejections for a risk GHO period can occur is if the claim contains condition code (CC) 04 which indicates that the claim is being submitted to Original Medicare for “informational only” purposes, but the dates of service(s) listed on the claims do not fall within the dates listed in CWF as the active timeframe for the MA plan. Additional information regarding how MA plans can affect processing can be located using the following resources:

• IOM Publication 100-04 Chapter 1 Section 90 Medicare Claims Processing Manual (PDF)
• IOM Publication 100-04 Chapter 3 Section 90 Medicare Claims Processing Manual (PDF)
   

3. Question: We are a skilled nursing facility that has a large number of beneficiaries recently that leave our facility and return the hospital the day of discharge (same day). This is causing claims rejections. Why?

Answer: Skilled Nursing Facilities (SNF) can be paid for the date of admission from the hospital as it counts as a utilization day, but the day of discharge is not if the beneficiary returns to the hospital from the SNF. This situation is called a Same Day Transfer. In this situation no payment is made to the originating facility which in this case would be the SNF. The hospital however can be paid because the day would count as the first utilization day due to the admission. Additional information regarding same day transfers can be found in IOM Publication 100-04,Chapter 6 Section 40.3.3 Medicare Claims Processing Manual (PDF) .

4. Question: Why does my claim keep returning stating that I need to add Occurrence Code 47 to the claim?

Answer: When claims edit for Occurrence Code (OC) 47 it means that the cost outlier threshold amount has been exceeded. The OC 47 is the first day the inpatient cost outlier threshold is reached. A beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. OC 47 cannot be equal to or during the dates of occurrence span code (OSC) 74 (noncovered level of care) or OSC 76 (patient liability).

Many providers refer to the OC 47 date as the day after the Diagnosis Related Grouping (DRG) cutoff day. This day is the "To" date or "End" date of the inlier period. Once the PPS threshold amount is known add the daily covered charges incurred by the patient until determining the day that covered charges reach the cost outlier threshold amount. Exclude days and charges during noncovered spans.

For more information, please refer to IOM Publication 100-04 Chapter 3 Section 20.7.4 Medicare Claims Processing Manual (PDF).

5. Question: Our influenza claims are rejecting as duplicates for billing to the same MAC . How do we avoid this rejection?

Based on information located in IOM Publication 100-04 Chapter 18 Section 10.4.1 Medicare Claims Processing Manual (PDF), the following of the following has occurred to receive the rejection:

• If CWF receives a claim with either HCPCS codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90687, 90688, 90694 or 90756 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and any one of those HCPCS codes, the second claim submitted to CWF rejects.
• If CWF receives a claim with HCPCS codes 90670, 90671, 90677 or 90732 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and the same HCPCS code, the second claim submitted to CWF rejects when all four items match.
• If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with the same MBI number, same MAC (Part A) number, same date of service, and same procedure code, CWF rejects the second claim submitted when all four items match

To avoid this rejection please verify the beneficiary vaccination history prior to claim submission.

6. Question: My facility is a psychiatric hospital/unit and therefore exempt from Perspective Payment System (PPS) payments. How do we handle claims for beneficiaries that enroll in a Medicare Advantage (MA) Plan in the middle of an inpatient stay?

Answer: For providers that are exempt from PPS, they must split bill the appropriate coverage portion of the beneficiary’s inpatient stay with Medicare and an MA plan. Providers must bill Medicare for the timeframe prior to MA enrollment and bill the appropriate MA plan for the remaining dates of service with supporting documentation. The provider must also submit a no-pay claim to Medicare for the dates the MA plan was in effect so that the beneficiary’s inpatient utilization days are reported. For more information regarding billing please refer to IOM Publication 100-04 Chapter 1 Section 90 Medicare Claims Processing Manual (PDF).

7. What penalties could facilities face for not filing a cost report in a timely manner?

Answer: The penalty for not filing the cost report timely is that 100 percent of any payments will be withheld. In addition, providers will be assessed interest at the prevailing rate at the time the cost report is due. Furthermore, if the cost report cannot be submitted by the due date, providers may request a reduced payment suspension rate of 50 percent during a grace period of 60 days. The request should be submitted before the due date of the cost report. On the 61st day, if the cost report has not been filed, the rate of suspension will change to 100 percent. If a provider fails to request a reduction in the suspension rate or if the MAC does not concur with the request for a reduced suspension rate, then 100 percent of the provider’s payments will be suspended if the cost report is not filed timely. Terminated providers will immediately have 100 percent of their payments suspended for failure to file a cost report.

Additional Resources regarding Cost Reports can be found in The Provider Reimbursement Manual — Part 2-15-2 Section 104 IOM Publication 100-06 Chapter 8 Section 10.2 Medicare Financial Management Manual (PDF).

8. Question: My facility has been receiving overpayment notifications and after reviewing our financial status determined that there is no way that all funds can be repaid within the timeframe on the demand letters. What option is available to us?

Answer: If the total overpayment amount cannot be repaid within 30 days after receiving the first demand letter, providers should request an extended repayment schedule (ERS). This request must be submitted per specific overpayment and must include in detail:

• The number of months the ERS is being requested
• The monthly payment amount being requested
• The first payment
• Must provide detailed explanation with documentation supporting the need and continue to make the monthly payments that was proposed in the ERS while it is being considered.

Additional Information

• Jurisdiction M Part A — Requesting an Extended Repayment Schedule (ERS) 
• Jurisdiction J Part A — Requesting an Extended Repayment Schedule (ERS) 
   

9. Question: My facility submitted an IRF-PAI and received payment, but it was reduced. What would cause a payment reduction?

Answer: Under the prospective payment system for inpatient rehabilitation facilities (IRF), the Centers for Medicare & Medicaid Services (CMS) establishes a prospective payment rate for each of 92 distinct case-mix groups. IRFs must electronically transmit a patient assessment instrument (PAI) for each IRF stay to the National Assessment Collection Database If an IRF transmits the PAI more than 27 calendar days from (and including) the beneficiary's discharge date, the IRF's payment rate for the applicable case-mix group incurs a 25 percent late-assessment penalty. For more information, please review IOM Publication 100-04 Chapter 3 Section 140.3.4 Medicare Claims Processing Manual (PDF).

10. Question: What is the Provider Enrollment Revalidation process for Medicare?

Answer: Every five years, the Centers for Medicare and Medicaid Services requires providers to revalidate their Medicare enrollment record. Failure to respond to our notice to revalidate will result in a hold on Medicare payments and possible deactivation of Medicare enrollment. Palmetto GBA returns informational claims messaging for providers that are due to revalidate. The following informational message will be provided on claims that have been adjudicated if a revalidation is due. While the five-year mark is standard providers should continue to report normal changes as needed. Examples of such changes are changes in ownership or changes in authorized official(s) or delegated official(s). These circumstances must be reported to the MAC on the Medicare enrollment application within 30 calendar days of the change. All other changes to the enrollment application must be reported within 90 days.

Additional Information 

• Jurisdiction M Part A — Revalidation 
• Jurisdiction J Part A — Revalidation

Last Reviewed: 12/19/2024

1. Question: My facility is seeing an increasing number of claims rejecting with indication of having an ongoing responsibility to medicals (ORM) where can I find information regarding this topic?

Answer: ORM reporting is a mandatory requirement for liability insurers, no-fault insurers, and workers’ compensation plans and insurers due to the implementation of Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). These entities are often identified as Responsible Reporting Entities (RREs). ORM information is reported so that claims for the same incident or injury are checked and not paid primary by Medicare if there is other insurance that should pay first. Once ORM is indicated on a beneficiary’s record it will always remain unless proof is submitted to indicate an error has occurred. RRE’s are required to report that an ORM period has ended however, which will assign a termination date but will not remove that there is an ORM record. If the beneficiary’s record contains a termination date any future claims after termination date will not be affected. If no termination date has been indicated claims will continue to be checked for potential same incident or injury information to determine if payment should be processed or rejected. It is important to note that ORM indication on a beneficiary record does not automatically mean that payments for medicals have been made. The ORM means that the RRE has made a determination that they are assuming responsibility. For more information on ORM please see the resources below:

• Mandatory Insurer Reporting (NGHP)
• Ongoing Responsibility for Medicals (ORM)

2. Question: My claims are returning stating the procedure codes being used are invalid based on the date of service billed. Where can lists be found that has the timeframe where codes are valid?

Answer: It is imperative that information billed on claims are accurate for the dates of service(s) to ensure claims are processed accurately. CMS has created a webpage that has the codes listed by effective date ranges. This list is updated annually.

Access the code information at List of CPT/HCPCS Codes. 

3. Question: My facility is struggling with the SNF Interrupted Stay Policy. How can it be explained in simple terms?

Answer: The SNF interrupted stay policy exists to ensure that beneficiaries are not being frequently discharged and readmitted a facility to obtain a new discharge payment.

PDPM includes an interrupted stay policy, which combines multiple SNF stays into a single stay when the patient’s discharge and readmission occurs within a prescribed window.

If a patient is discharged from a SNF and readmitted to the same SNF no more than three (3) consecutive calendar days after discharge, then the subsequent stay is considered a continuation of the previous stay. If patient is discharged from SNF and readmitted more than three (3) consecutive calendar days after discharge, or admitted to a different SNF, then the subsequent stay is considered a new stay.

4. Question: Why are my SNF claims being rejected with a benefits exhaust reason code if they were submitted with the condition code DR as instructed?

Answer: CMS utilized its authority under section 1812(f) of the Social Security Act to waive certain Medicare requirements under the SNF PPS due to the COVID-19 pandemic. Specifically, for patients who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. This waiver applies only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances. If those conditions are not applicable claims will be rejected. This also applies if the beneficiary has already utilized the additional days granted under the waiver.

5. Question: When value codes Q0 and Q1 are on my remittance advice what does that indicate?

Answer: If the remittance advice information for a particular claim contains value code Q0 and/or Q1 it indicates Accountable Care Organization (ACO) involvement. The value code Q0 indicates Accountable Care Organization reduction. The value code Q1 indicates an Accountable Care Organization Payment Reduction. These value codes indicate the amount in which payment has been reduced based on provider’s agreement with an ACO. CMS has detailed information regarding ACO’s at Accountable Care Organizations (ACOs).

6. Question: My facility receives beneficiaries from SNFs where they receive occupational therapy (OT). We are not receiving payment from Medicare for those services. Please advise why?

Answer: Therapies such as OT, physical therapy (PT), and speech-language pathology (SLP) must be billed by the SNF in which the beneficiary is located. These services are included in SNF consolidated billing. As a part of SNF consolidated billing the service must be billed by the SNF for beneficiaries that are in a Medicare-certified bed. The facility has to have an agreement with the SNF. According to Medicare regulations, the SNF must pay the rendering provider for services included in consolidated billing.

More information on SNF Consolidated Billing can be found at SNF Consolidated Billing.

7. Question: My claims are editing for ESRD Consolidated Billing Services. What services are included under that policy?

Answer: Under the ESRD Prospective Payment System (ESRD PPS) certain laboratory services, drugs and biologicals, equipment, and supplies are subject to consolidated billing and are not separately payable when provided to ESRD beneficiaries by providers other than the ESRD facility. Under consolidated billing, ESRD facilities are expected to furnish services, either directly, or under an arrangement with an outside supplier.

The items and services subject to ESRD Consolidated billing are updated yearly and can be found at ESRD PPS Consolidated Billing.

8. Question: The number of claim rejections are increasing for my facility related to preventive services being provided by the facility for frequency. Is there a tool that can be used to prevent this from continuing?

Answer: CMS has developed a Preventive Services Chart (PDF) to assist facilities with information such as frequency requirements for related services. The information is listed by service type.

Last Reviewed: 12/19/2024

Palmetto GBA is publishing the following FAQ based upon data analytics identifying topics generating a high volume of telephone inquiries between April 1, 2022, through June 30, 2022. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

1. Question: My facility is seeing an increasing number of claims rejecting with indication of having an ongoing responsibility to medicals (ORM). Where can I find information regarding this topic?

Answer: ORM reporting is a mandatory requirement for liability insurers, no-fault insurers, and workers’ compensation plans and insurers due to the implementation of Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). These entities are often identified as Responsible Reporting Entities (RREs). ORM information is reported so that claims for the same incident or injury are checked and not paid primary by Medicare if there is other insurance that should pay first.

Once ORM is indicated on a beneficiary’s record it will always remain unless proof is submitted to indicate an error has occurred. RRE’s are required to report that an ORM period has ended however, which will assign a termination date but will not remove that there is an ORM record.

If the beneficiary’s record contains a termination date any future claims after termination date will not be affected. If no termination date has been indicated claims will continue to be checked for potential same incident or injury information to determine if payment should be processed or rejected.

It is important to note that ORM indication on a beneficiary record does not automatically mean that payments for medicals have been made. The ORM means that the RRE has made a determination that they are assuming responsibility. For more information on ORM please see the resources below:

• Mandatory Insurer Reporting (NGHP) 
• Ongoing Responsibility for Medicals (ORM) 
   

2. Question: My claims are returning stating the procedure codes being used are invalid based on the date of service billed. Where can lists be found that has the timeframe where codes are valid?

Answer: It is imperative that information billed on claims are accurate for the dates of service(s) to ensure claims are processed accurately. CMS has created a webpage that has the codes listed by effective date ranges. This list is updated annually. Please use the link below to access the code information: List of CPT/HCPCS Codes.

3. Question: My facility is struggling with the SNF Interrupted Stay Policy. How can it be explained in simple terms?

Answer: The SNF interrupted stay policy exists to ensure that beneficiaries are not being frequently discharged and readmitted a facility to obtain a new discharge payment.

PDPM includes an interrupted stay policy, which combines multiple SNF stays into a single stay when the patient’s discharge and readmission occurs within a prescribed window.

If a patient is discharged from a SNF and readmitted to the same SNF no more than three (3) consecutive calendar days after discharge, then the subsequent stay is considered a continuation of the previous stay.

If patient is discharged from SNF and readmitted more than three (3) consecutive calendar days after discharge, or admitted to a different SNF, then the subsequent stay is considered a new stay.

4. Question: Why are my SNF claims being rejected with a benefits exhaust reason code if they were submitted with the condition code DR as instructed?

Answer: CMS utilized its authority under section 1812(f) of the Social Security Act to waive certain Medicare requirements under the SNF PPS due to the COVID-19 pandemic. Specifically, for patients who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period. This waiver applies only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances. If those conditions are not applicable claims will be rejected. This also applies if the beneficiary has already utilized the additional days granted under the waiver.

5. Question: When value codes Q0 and Q1 are on my remittance advice, what does that indicate?

Answer: If the remittance advice information for a particular claim contains value code Q0 and/or Q1 it indicates Accountable Care Organization (ACO) involvement. The value code Q0 indicates Accountable Care Organization reduction. The value code Q1 indicates an Accountable Care Organization Payment Reduction. These value codes indicate the amount in which payment has been reduced based on provider’s agreement with an ACO. CMS has detailed information regarding ACO’s using the following link: Accountable Care Organizations (ACOs). 

6. Question: My facility receives beneficiaries from skilled nursing facilities (SNF) where they receive occupational therapy (OT). We are not receiving payment from Medicare for those services. Please advise why?

Answer: Therapies such as occupational therapy (OT), physical therapy (PT), and speech-language pathology (SLP) must be billed by the SNF in which the beneficiary is located. These services are included in SNF Consolidated billing. As a part of SNF Consolidated billing the service must be billed by the SNF for beneficiaries that are in a Medicare-certified bed. The facility has to have an agreement with the SNF. According to Medicare regulations he Skilled Nursing Facility (SNF) must pay the rendering provider for services included in consolidated billing. More information on SNF Consolidated Billing can be found using the following link: SNF Consolidated Billing. 

7. Question: My claims are editing for ESRD Consolidated Billing Services. What services are included under that policy?

Answer: Under the ESRD Prospective Payment System (ESRD PPS) certain laboratory services, drugs and biologicals, equipment, and supplies are subject to consolidated billing and are not separately payable when provided to ESRD beneficiaries by providers other than the ESRD facility. Under consolidated billing, ESRD facilities are expected to furnish services, either directly, or under an arrangement with an outside supplier. The items and services subject to ESRD Consolidated billing are updated yearly and can be found using the following link: ESRD PPS Consolidated Billing 

8. Question: The number of claim rejections are increasing for my facility related to preventive services being provided by the facility for frequency. Is there a tool that can be used to prevent this from continuing?

Answer: CMS has developed a preventive services chart to assist facilities with information such as frequency requirements for related services. The information is listed by service type and can be found using the following link: Preventive Services Chart.

9. Question: My claims are editing for procedure-to-procedure edits. How do I find those?

Answer: CMS has developed a Medicare NCCI FAQ library that contains the links to important information such as the Medicare NCCI Procedure to Procedure (PTP) Edits Medicare NCCI FAQ Library The information is updated quarterly and contains addition and deletion information.

10. Question: Where can I locate the most recent list of changes to the Inpatient Only List for device codes?

Answer: The January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS) implemented January 3, 2022, contains the most recent information regarding device codes. This notification contains information regarding the inpatient only device codes. Please refer to the information link before for additional information and attachments: January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS).

Last Reviewed: 12/19/2024

Palmetto GBA is publishing the following FAQ based upon data analytics identifying topics generating a high volume of telephone inquiries between January 1, 2022, through March 31, 2022. We hope the answers to the questions below help you maximize your time by reducing your need to contact the Provider Contact Center (PCC).

1. Question: Why are my previously processed 131 claims being adjusted with a 13G claim and rejecting with Reason code C7252?

Answer: Outpatient claims (13X/85X) receive edit C7252 when services reported are within the admission and discharge dates of a SNF inpatient Part A claim for non-therapy services.

Skilled Nursing Facility (SNF) Consolidated Billing (CB) requires the SNF to bill all services for Part A residents receiving skilled care with the exception of excluded services.

Prior to billing the claim, verify whether the patient is in a covered Part A SNF stay. If so, then you must determine if the services are subject to SNF CB.

Instructions for SNF CB

• Go to the CMS SNF CB website
• Click on the Part A MAC update for the year in question
• Scroll to downloads, then click on the annual SNF consolidated billing HCPCS updates
• You will get a question to open or save the file; click "open"
• Then double click to open the excel (xlsx) file
• Once you open the excel file, you can perform a search for the service provided by either the CPT®/HCPCS code or description of the service
• If the service appears on the annual SNF consolidated billing HCPCS updates file, it is excluded from SNF CB (unless the word "inclusion" appears in the "Major Category" column) and may be billed separately on the 13X or 85X claim
• If the service does not appear on the annual SNF consolidated billing HCPCS updates file, it is included in SNF CB and must be included on the SNF inpatient Part A claim. Contact the SNF to discuss services under arrangement
• When outpatient Part B claims include services subject to SNF CB, the Common Working File (CWF) rejects the claim with reason code C7252. This edit reads only the first line of the claim. If that service is part of SNF CB, the entire claim rejects even if other services on the claim are not part of SNF CB.
• As a result, you must split your claim. Submit a claim for services not subject to SNF CB first. Once that claim processes, submit a no-pay claim for services subject to SNF CB.

2. Question: I have researched the Palmetto GBA website searching for the 2022 Wage Index information and cannot locate any current information. Where is this information located?

Answer: Fiscal Year(FY) 2022 Wage Index information can be located on the CMS website under the FY 2022 Wage Index Home Page. Frequently calls to the Provider Contact Center (PCC) includes questions regarding Core-Based Statistical Areas (CBSA). The latest information regarding that topic as well as many other wage indices related topics can be found utilizing this invaluable resource.

3. Question: My claims are returning to provider (RTP) with Reason Code 15202? What can I do to avoid receiving this error?

Answer: 
Description
On inpatient hospital or inpatient SNF bills with covered days greater than zero, the accommodation days shown with revenue codes 10x–21x must be equal to the cost report days. Outpatient claims should not be billed with covered days.

Resolution
**Always verify patients’ available benefits before filing claims. **

• Verify the dates of service and patient status
• Verify the number of covered (Value Code (VC) 80) and non-covered days (VC 81)
  • Note reviewing the patient status is crucial in this step to ensure accuracy of day count (example: If the patient status is a 30 the day is included in the day count)
• Verify the number of units shown with the accommodation revenue codes (010X–021X) Verify the dates shown with occurrence span codes
• When billing condition code 04 and 69 charges should be submitted as covered
• When billing occurrence span code 77 charges should be submitted as covered
• If your claim is an adjustment; please ensure all lines are covered when resubmitting your claim
• If billing SNF and occurrence code 22 is present, you may bill covered up to the occurrence code 22. Then you should bill 210 until discharge.
  • Note when billing occurrence span code 74 it must be billed with rev code 180 and there should be no money associated with this line on your claim.
• Condition code 04 is informational only and should always be billed with covered charges, units and days
• When billing occurrence code M1 claim days and units should be non-covered
• When billing condition code 21 days and units should be submitted as non-covered

Resource: CMS Internet Only Manual (IOM), Publication 100-4 Chapter 3 Section 40.2, Medicare Claims Processing Manual.

4. Question: What could cause my financial account to be put on a hold?

Answer: There are a few reasons why the financial holds could have been put in place. The two most common reasons are late/unfiled credit balance and cost reports. The resources below are helpful tools that can provide resolutions related to the two most common reasons as well as other situations.

JJ Part A Resources

• Credit Balance Reporting (CMS-838) 
• Submitting the Credit Balance (838) Report and Due Dates
• Using Medicare's Online Credit Balance Report Lookup Tool 
• Credit Balance Report 
• Cost Report Filing
• Cost Report Status Tool
• How to Change Your Cost Reporting Period

CMS Resources

• Medicare Financial Management Manual, IOM 100-06, Chapter 12 (PDF)
• Contractor Desk Review and Audit, IOM 100-06, Chapter 9, PS&R (PDF) (PDF) 
• Medicare Financial Management Manual, IOM 100-06, Chapter 5, Section 240 (PDF)
   

5. Question: My staff has issues with getting claims that contain a device-intensive procedure code to process. What is the best method of handling these types of claims?

Answer: Device-intensive procedure codes billed without at least one device code required for the procedure on the same claim with the same date of service or a device code billed without the device-intensive procedure code that is necessary for the device to have therapeutic benefit to the patient on the same claim with the same date of service will not complete processing.

To avoid this from occurring the provider must verify the following:

• Ensure that the procedure and device code(s) reported on the claim are correct
• Ensure that the procedure/device code(s) are submitted on the same claim with the same date of service

Once the information is verified and everything is correct , providers must check the codes in the I/OCE Quarterly Release Files relevant to the date of service on the claim to determine if a code is applicable. 

If the Device-intensive procedure was discontinued Medicare Claims Processing Manual Publication 100-04 Chapter 4 Section 61.2 (PDF) states that the following modifiers can be reported with the procedure codes:

• 52 (Reduced services)
• 73 (Discontinued outpatient procedure prior to anesthesia administration)
• 74 (Discontinued outpatient procedure after anesthesia administration)

If there is no applicable HCPCS code for the device the provider may report HCPCS Code C1889.

For certain device-intensive procedures, providers may bypass the device edit requiring at least one device HCPCS code for the procedure. For situations where no device was performed with certain device-intensive procedures, providers may bypass the edit by reporting modifier CG per information found in Medicare Claims Processing Manual Publication 100-04 Chapter 4 Section 61.3.5 (PDF).

6. Question: My facility has a numerous claim that are in a suspended status on FISS. Is there a problem with my claims that are in suspended locations? Is there anything that can be done to make my suspended claims process quicker?

Answer: All Medicare billing transactions will temporarily suspend (“S”) in different status and locations (S/LOCs) as they process through FISS. Once a claim is submitted to Medicare, assuming that it has no errors and meets medical necessity requirements, it will remain in a suspended status until it is ready to be paid. The Medicare Claims Processing Manual Publication 100-04 Chapter 1 Section 80.2.1 (PDF) states that Medicare contractors have 30 days to process clean claims. While the typical timeframe to process claims is less than this, contractors have the full 30 days from the receipt date of a clean claim to process it. There is no provider action needed during this timeframe unless otherwise notified.

Claims may also suspend due to system issues that prevent Medicare billing transactions from processing appropriately. Billing transactions impacted by these issues may be suspended for more than 30 days. The first course of action for the provider should be to check the Claims Payment Issues Log (CPIL) on the Palmetto GBA website based on the jurisdiction.

Select Claims Payment Issues Log to view the current and resolved CPILs.

Claims that are suspended in ST/LOC’s SB6001 can be in the location up to 45 days awaiting the return of documentation that has been requested from the provider as part of the Additional Documentation Request process (ADR).

Please review the Medical Review Part A Fact Sheet for additional information regarding ADR process.

7. Question: How does a facility determine whether its is going through a change of ownership versus a reorganization?

Answer: The CMS Regional Office (RO) makes the determination of whether a particular circumstance constitutes, for Medicare purposes, a change of ownership or a reorganization. Prior to submitting the CMS-855A, contact your CMS RO. CMS has made the Contacts Database available to providers to assist in determining who should be contacted. To utilize the database please follow the steps below:

• Select Organization Type
  • CMS RO — Center for Medicare & Medicaid Services Regional Office
• Select Contact Type
  • Any
• Select a Region or State Territory
  • Select appropriate region or state
• Select Show Contacts to display the list of regional offices based on your selection
• Select See Details to obtain necessary details to complete search
   

8. Question: Our facility has had to contact the Provider Contact Center (PCC) constantly regarding what has been described as known system issues what can we do to find out automatically what is causing issues?

Answer: The provider community is given the option to sign up for article update notifications via email. To sign up for email updates provider must choose the Subscribe to Email Updates link based on jurisdiction.

The Claims Payment Issues Log is also available to the provider community. The CPIL allows facilities to see detailed information regarding identified problems which includes such information as:

• Issue description
• Date CPIL opened
• Action required from the provider if applicable
• Resolution date once resolved
   

9. Question: I am a new Skilled Nursing Facility(SNF) and am questioning whether my facility needed to participate in the SNF Value-Based Purchasing Program (SNF VBP). Does my facility have to?

Answer: The SNF VBP Program is not optional. All SNFs paid under Medicare’s SNF Perspective Payment System (PPS) are required to participate in the SNF VBP Program. The types of SNFs paid under the SNF PPS include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities. Participation in the SNF VBP Program does not require any action on the part of SNFs to enroll, nor does it require any additional data collection burden.

CMS has developed the Skilled Nursing Facility Value-Based Purchasing Program: Frequently Asked Questions (PDF) to assist providers with questions surrounding SNF VBP.

Last Reviewed: 12/19/2024

More Background to Question
A PIP hospital provider received a demand letter requesting payment on a RAC DRG change that resulted in an overpayment. The provider agrees with the findings and will not appeal. Because the provider receives no monetary payments on inpatient claims individually (bi-weekly PIP payments occur), it is the providers belief that any adjustments to inpatient claims result in updating the Provider Statistical and Reimbursement (PS&R) and then the overpayment will be accounted for at the time of cost report settlement. If the provider issues a check to Palmetto GBA and the claim is also adjusted in the FISS system, will we not be repaying the amount twice, both in the check issued and then upon cost report settlement?

Answer
According to Change Request (CR) 7601, the PS&R is supposed to segregate and exclude RAC-initiated adjustments to PIP claims. Therefore, the provider may send in payment for the demanded overpayment. They will not get hit twice when the cost report is settled, since it will be excluded from the settlement calculation. If the provider does not want to send in a check, an accounts receivable (AR) will be created and Palmetto GBA will send a demand letter for RAC adjustments. In this case, we would offset against the PIP payment to collect the debt. Providers need to be aware that if the offset collection isn’t enough to fully collect the debt, interest could accrue.

There is also the option of requesting an immediate offset on all future ARs or specific ARs. If providers select this option, they will still receive the demand letter to let them know a debt has been incurred; Palmetto GBA will then offset the debt from future PIP payments.

Last Reviewed: 12/19/2024

Answer: Yes, you may use the therapist intervention notes to help support your codes. You are allowed to do that for Medicare purposes. Make sure that the physician is informed on the therapist activities and you will still need to forward those notes to the physician at some point.

Last Reviewed: 12/19/2024

Answer: A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on July 15, 2022.

Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A web page.

Last Reviewed: 12/19/2024

Answer: You can’t adjust a claim to correct a medically denied line. You must submit a Redetermination: 1st Level Appeal form along with a corrected claim.

Last Reviewed: 12/19/2024

Answer: "Forwarding balance" means that a negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous Remittance Advice (RA). A reference number (the original ICN and the patient's Medicare ID number) is applied for tracking purposes.

What Does That Mean?

• A negative value represents a balance that will be moved forward to a future remittance payment advice. This means that an overpayment for a specific claim or claims (on this remittance) has been created because Medicare has paid for a service that should not have been allowed or has paid too much for a service. Your remittance notice will show the corrected allowed amounts for the adjusted claim(s).
• A positive value represents a balance that is being applied from a previous remittance advice. This means we are notifying you that we have completed an adjustment on a claim or claims (included in this remittance) and we have determined that an additional payment is due in part or in full for a previously processed service(s). Your remittance notice will show the corrected allowed amounts for the adjusted claim(s). A reference number (the original ICN and the patient's Medicare ID number) will be provided for tracking purposes.

Last Reviewed: 12/19/2024

Answer: A PTAN is the Provider Transaction Access Number, which is also known as the six-digit provider number, OSCAR number or legacy number. Providers will be asked for their PTAN when calling the provider contact center (PCC).

Last Reviewed: 12/19/2024