General
Question: My claim denied but I don’t understand why I can’t bill the patient for certain denied services. The claim shows the dollar amount as a contractual obligation, one I am not able to bill the patient for, why?
Answer: There are several reasons your remittance notice may list a dollar amount as a contractual obligation, meaning you cannot bill the patient for that dollar amount listed. Those instances may include (not an all-inclusive list):
- When no initial determination has been made because required information is missing, invalid, or incomplete, e.g., invalid CPT®, HCPCS, ICD-10 code or claims that require conditional information that is missing. You must correct the claim and resubmit as a new claim with the required information. Review your remittance advice for the Remittance Advice Remark Code (RARC) for details regarding what is missing or needed.
- Claims denied as a duplicate of a previously processed claim. If the service is not a duplicate, you may request an appeal. If the claim is a true duplicate, you may not bill the patient for that second, duplicate charge.
- Claims submitted to the wrong entity, e.g., Railroad Medicare claims, claims where a patient has a Medicare Advantage plan, Medicare is the secondary insurer, a liability claim, etc., must be submitted to the correct entity and the patient should not be billed until the claim is submitted to the correct insurer.
Question: When I check the status of my claim, I get the message that the claim is not on file. What does that mean?
Answer: A status inquiry resulting in notification that the claim is not on file may be due to:
- Your clearinghouse or billing company has not yet submitted your claim to Palmetto GBA. Verify with that entity and request the date that Palmetto GBA confirmed receiving the electronic claim. Work with that entity to understand the timeliness of your claim’s submissions directly to Medicare.
- You checked the status of a claim using the wrong provider PTAN/NPI or the wrong patient information or date of service. Verify the information and check the status again. The IVR or eServices portal is looking for a claim status solely on the information you provided, and it must match what was submitted on the claim.
- A paper claim (if you are eligible to submit paper claims) that has not been received by Palmetto GBA through the postal service or other courier
- An electronic claim that rejected upon submission because of a Palmetto GBA Smart edit (Advanced Communication Engine [ACE] Smart Edit). Claims returned on a provider’s 277CA report due to a Smart edit must be reviewed and resubmitted or reviewed, corrected/updated and resubmitted before they will be entered into the claims processing system and be identifiable when checking a claim status.
Reference: Jurisdiction M Part B — Claims.
Question: My patient has a red, white and blue Medicare card, but my claim denied indicating the patient does not have Medicare coverage. Why?
Answer: A red, white and blue Medicare card is sent to every patient when they initially enroll in original Medicare or as part of the roll out of the new Medicare Beneficiary Identifier (MBI) numbers several years ago. Since the time a patient’s card was mailed, the patient’s circumstances and eligibility may have changed, and the patient simply retained their old card. Medicare eligibility is maintained by Social Security. A Medicare beneficiary or their authorized representative may reach out to 1–800–Medicare or the Social Security office to discuss their Medicare eligibility.
Question: My claim says that something was missing, invalid, or incomplete and Medicare can’t process the claim. How do I figure out what is missing and once I figure that out, what do I need to do?
Answer: Review your remittance advice for the Remittance Advice Remark Code (RARC) for details regarding what is missing, incorrect or invalid and make necessary corrections and resubmit your claim.
Question: I submit an appeal and then must wait. What are the time frames for Medicare to process my appeal and is there a way for me to check the status of my appeal?
Answer: Medicare Administrative Contractors generally issue a decision within 60 days of the date they receive the redetermination request. When a first level appeal (redetermination) is submitted directly through the Palmetto GBA eServices portal, providers may follow the status of the individual appeal within eServices. The status of appeals submitted to Palmetto GBA by fax or mail may be checked using the Palmetto GBA Redetermination Status Tool.
References
- eServices User Manual
- Part B IVR User Guide (PDF)
- MLN006562 – Medicare Parts A & B Appeals Process (PDF)
Provider Enrollment
Question: I submitted my application and haven’t heard anything. When I call the Provider Contact Center (PCC), Palmetto GBA tells me that a request for clarification or missing enrollment application information had been sent to my practice. I never received the request. How do I find out what is needed, get a copy of that request, and respond so my application can continue process?
Answer: Let the PCC representative know that you did not receive the letter and would like to know what information was requested. You can also let the PCC know that you would like a copy of the letter.
Reference: Jurisdiction M Part B — Provider Enrollment Email Communications.
Question: How can I find out who my provider’s provider enrollment authorized representatives are?
Answer: Providers that enrolled, revalidated, or updated a provider enrollment file through PECOS can identify their authorized representatives through PECOS. If you do not have access to PECOS, please coordinate with the person(s) within your organization that handles enrollment.
References
- Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
- I&A Frequently Asked Questions (FAQs) (PDF)
Question: The person that enrolled us through PECOS is no longer with our practice so we can’t log into PECOS. How can we get access to PECOS?
Answer: The instructions to resolve this issue can be found on the CMS website by accessing the Identity & Access Frequently Asked Questions (FAQ) document.
Reference: I&A Frequently Asked Questions (FAQ) (PDF).
Question: My application has been pending for a long time. How can I check the status of my provider enrollment application?
Answer: Providers can access the status of their provider enrollment application:
- Through PECOS Welcome to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
- By visiting the Palmetto GBA website and using the Provider Enrollment Application Status Lookup Tool. Enter your PTAN, NPI, or Document Control Number (DCN). Be certain to search using numbers that are relevant to the specific enrollment application you submitted. Status information is updated approximately 24 hours after each transaction. Information in the Provider Enrollment Application Average Processing Time educational article provides the average days you can expect for Palmetto GBA to complete the processing of enrollment applications.
References
- Provider Enrollment Application Status Lookup Jurisdiction J Part B
- Provider Enrollment Application Status Lookup Jurisdiction M Part B
- Jurisdiction M Part B — Provider Enrollment Application Average Processing Time
Last Reviewed 3/20/2024
Question: My claim was rejected. The entire dollar amount of my claim was listed as Group Code, CO: contractual obligation. What do I need to do?
Answer: Use the Claim Adjustment Reason and Remittance Advice Codes on your remittance advice to determine the claim error. Until the claim is submitted with all necessary information, Palmetto GBA may not make a claim determination. You may not bill the patient until the claim is corrected and resubmitted with the necessary information.
Tips- Do not submit a rejected claim as an appeal or simple claim reopening. Correct and resubmit the claim
- Only certain CPT®/HCPCS codes require submission of additional information
- Use the PWK submission process to submit required additional documentation for electronic claims
- Electronic billers must use the appropriate electronic claim loop and segments to bill indicating how a primary insurer handled the claim
Question: I run a report every 30 days identifying Medicare claims not paid. Staff call on each claim to ask for an explanation. The Palmetto GBA representative pulls up the claim, gives the date a claim was received and tells us the claim has paid/denied/rejected or is still being processed. Sometimes the date that Palmetto GBA received the claim is not the date that we submitted the claim to our clearinghouse. Why is there a difference in dates and what can we do so that we don’t have to call on each one of these for an explanation?
Answer
- Remember when using another entity to send you claims to Medicare, that entity may have processes and protocol that may cause a claim to be delayed in being forwarded to Medicare
- The “payment floor” establishes a waiting period during which time, the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made. Medicare Claims Processing Manual (PDF), Section 80.2.1.2. Before calling the Palmetto GBA provider contact center for an explanation, be sure that staff has applied all received remittance advice to patient’s accounts.
- If your biller or clearinghouse receives your Medicare remittance advice, be certain you have verified if the claim(s) in question have already been processed and included on a remittance notice not yet sent to you from your third-party contractor
- If you bill electronically, review your 277 CA report or query your claim submitter to determine if your claim may have hit a Palmetto GBA Smart Edit that requires action before the claim can be resent to Palmetto GBA for consideration
- Check the Palmetto GBA Claims Payment Issues Log to see if there is a claim processing issue that affected your claims
Question: I sometimes resubmit my claims if I haven’t gotten payment. Is this the right thing to do?
Answer: No. Resubmitting claims that have already been submitted may end up denying as a duplicate or may cause the initial claim still being processed, to deny against the new claim. Providers should use the Palmetto GBA eServices Portal or the Palmetto GBA Interactive Voice Response (IVR) system (PDF) to check the status of claims. Don’t forget to check your electronic 277CA report to determine if a claim may require action after hitting a PC ACE Smart Edit. Reference: Jurisdiction M Part B — Smart Edits Listing and 277CA Enhancement.
Question: Where does Palmetto GBA get the frequency limits that might be used when processing claims?
Answer: There are a number of Medicare coverage guidelines that may affect the frequency or number of services that a Medicare Administrative Contractor must use when adjudicating claims. Not every services has a frequency edit and not all frequency edits are published.
- National Coverage Determinations — MCD Search
- Lab National Coverage Determinations — Lab NCDs — ICD-10 | CMS
- Local Coverage Determinations and Articles — MCD Search Results
- National Correct Coding Initiative Medically Unlikely Edits (not all are published) — Medicare NCCI Medically Unlikely Edits | CMS
- Medicare Preventive Services — MLN006559 – Medicare Preventive Services
Question: I run a report every 30 days to identify any first level appeals that are still pending. Staff then call Palmetto GBA for an explanation. Is there is an easier way to check the status of our redeterminations?
Answer: Yes. The Palmetto GBA eServices Portal can be used to check the status of your first level appeals. Use the “Claims” tab and enter the claim’s ICN and a date range. Any appeal received by Palmetto GBA will populate. From there, a provider may open, view, and print any appeal determination letter issued by Palmetto GBA. Use the Palmetto GBA eServices Portal User Guide for details on accessing this information. Palmetto GBA has 60 days from the date of receipt to process your first level appeal. Be sure to build in additional time for delivery of your appeal determination letters if you receive your letters through U.S. Mail.
Providers will not receive an appeal decision letter for favorable appeals. When a first level appeal decision is favorable, the claim is adjusted, and the provider will receive a new Remittance Advice and can see the favorable decisions in the Palmetto GBA eServices Portal. Favorable Decision Flyer — Part and Part B Appeals (PDF). Reference: Jurisdiction M Part B — Detailed Confirmation of Redeterminations.
Last Reviewed: 3/20/2024
Top Five Inquiries: February 1 – April 30, 2023
| Inquiry Category | Jurisdictions J and M |
|---|---|
| Payment Explanation: Claim Status and Claim Not on File | 17,997 |
| Misrouted Telephone or Written Inquiry: General Information | 11,263 |
| Contractual Obligation Not Met | 9,439 |
| Part B Entitlement/Eligibility | 9,411 |
| Frequency/ Dollar amount Limitation: Claim Denials | 5,498 |
Question: I bill electronically through a clearinghouse. How do I know if I should call Palmetto GBA or my clearinghouse when I have not gotten paid for a claim?
Answer: Because you submit claims first to your clearinghouse and the clearinghouse then forward your claims electronically to Palmetto GBA, always start with your clearinghouse.
- Confirm you submitted your claim to your clearinghouse and that your clearinghouse received the claim
- Confirm the date that your clearinghouse submitted your claim to Palmetto GBA
- Has it been at least 14 days since the clearinghouse submitted your electronic claim?
- Confirm your clearinghouse did not receive a Palmetto GBA Smart Edit claim rejection for the claim on the 277CA report. Claims rejected on the 277CA report require action to review, correct and resubmit or review and resubmit. Failure to work these claim rejections means the claim was never accepted into the claim processing system for adjudication.
- Check the status of your claim in the Palmetto GBA eServices portal
- Reach out to your clearinghouse if you find:
- There is a delay between when you submit your claims to your clearinghouse and when your clearinghouse submits your claim to Palmetto GBA
- You find your clearinghouse never submitted the claim to Palmetto GBA
- You find that the claim was rejected on the 277CA report and needs to be reviewed and resubmitted
- Other issues not meeting the contract requirements between you and your clearinghouse
Question: The patient’s Medicare Advantage plan isn’t paying claims or accepting claims the same way that Palmetto GBA does. Who do I call to have my Medicare Advantage plan questions answered?
Answer: You should reach out directly to the patient’s Medicare Advantage Plan. CMS provides oversight and direction to the Medicare Advantage Plans. Palmetto GBA is not able to address these types of Medicare Advantage Plan questions.
Question: Do I automatically have to write off any amount on the remittance advice with a group code of CO, contractual obligation?
Answer: We recommend you review the entire explanation of benefits for a claim. In some instances, the initial determination may be a contractual obligation amount because you need to submit the claim to another insurer, something is missing incomplete or invalid. In certain cases, depending on the rejection reason, you may be able to correct and resubmit a claim with invalid or missing information and the group code may then change from CO to another group code.
Question: I billed a claim using the patient’s name and MBI number that the patient gave me, but Palmetto GBA is denying my claim for eligibility, why?
Answer: Providers should obtain a copy of the patient’s Medicare card and use the MBI number and name as it appears on the patient’s Medicare card and pay close attention as to whether the patient has Railroad Medicare benefits. Providers should also query patients regarding whether they may have switched to a Medicare Advantage plan which replaced traditional Medicare. Providers may also use the Palmetto GBA eServices portal to verify eligibility before submitting a claim. Welcome to Palmetto GBA eServices.
Question: When I disagree with a Medicare Medically Unlikely Edit (MUE) how do I get Medicare to consider more services then the MUE for my individual patient?
Answer: You may exercise your appeal rights by requesting a first level appeal. Be certain to include documentation to support the medical necessity of the number of services you billed. The claim along with any documentation you submit and the CMS MUE specific information, the claim will be reviewed, and a determination made as to whether additional units of service can be allowed. If the initial claim determination is affirmed, your decision letter will include any additional appeal rights you may be afforded. Reference: Jurisdiction M Part B — Medically Unlikely Edits (MUEs).
Last Reviewed: 3/20/2024
Top Five Inquiries: November 1, 2022 – January 31, 2023 Inquiry
| Inquiry Category | Jurisdictions J and M |
|---|---|
| Payment Explanation: Claim Status and Claim Not on File | 22,505 |
| Eligibility/Entitlement | 9,589 |
| Contractual Obligation Not Met | 8,534 |
| Misrouted Telephone or Written Inquiry: General Information | 5,519 |
| Frequency/ Dollar Amount Limitation: Claim Denials | 5,192 |
Question: What are my options for verifying claim status?
Answer: Claim status can be verified through the Palmetto GBA eServices portal or through the Palmetto GBA Interactive Voice Response (IVR) system. We encourage you to verify the date your claim was initially submitted and understand that the date you send a claim to a billing company or clearinghouse may not be the same day that your claim was forwarded to and received by Palmetto GBA for consideration. Once received and processed, Palmetto GBA must apply a payment floor. The payment floor establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. The payment floor represents the earliest date contractors may release payment for a completed clean claim. You should not expect Medicare payment for a claim until after the waiting period ends.
eServices: Once logged in you will have to have permission to access the Claims tab. Once you open the Claims tab, the claims status screen will appear. The few required fields are marked as required. Other fields are optional. Reference: eServices User Manual (Section 4.0).
IVR: Call your jurisdiction’s Provider Contact System and answer the survey prompt then select Option 3 for the IVR. Use the Part B IVR User Guide to walk you through the steps to verify claim status using the IVR. Reference: Part B IVR User Guide.
Question: Why when I check the claim status in eServices, through the IVR or with a customer service representative, might I get the response that my claim is not on file?
Answer: There are several reasons.
- If a paper claim, the claim may not have been delivered to Palmetto GBA, or if the claim was received through the U. S. mail, the claim may not yet have been entered into the claim processing system
- Your billing company or clearinghouse may not have forwarded the claim to Palmetto GBA
- Your electronic claim may have been stopped by billing software and additional action may be required to move the claim to transmit to Medicare
- Your claim may have hit a Palmetto GBA Advanced Communication Engine (ACE) SMART edit that generated a rejection alert on the submitters 277CA report. Check with the entity that submitted your claim as claims that reject for a Palmetto GBA SMART edit will require action to review and update the claim if necessary, and then retransmit the claim to Palmetto GBA.
Question: When Medicare rejects my claim, why does my Remittance Advice (RA) show a CO group code and the entire submitted charge listed as a contractual obligation indicating I can’t bill the patient for the service?
Answer: CMS expects providers to submit claims with accurate and complete information so that the claim can be processed. When a claim is rejected because required information is missing, incomplete or invalid, the entire submitted charge for that service is identified as a contractual obligation and the provider is not afforded appeal rights. The remittance advice will indicate what information is missing, incomplete or invalid using Claim Adjustment Remark Codes. The provider must correct the claim, provide the necessary information, and resubmit the claim. Once the claim has all the necessary information, Palmetto GBA will adjudicate the claim and the dollar amount in the contractual obligation field could likely change based on the claim determination. Reference: Claim Rejections and Billing Errors.
Question: Is there a way to check a patient’s Medicare eligibility online?
Answer: Absolutely. Chapter 6 of the Palmetto GBA eServices manual walks you through the steps to verify eligibility. Additionally, the Palmetto GBA User Manual can help you with verifying the next eligible date for covered preventive services and more. Reference: eServices User Manual.
Question: What is the best way for me to know who I should call when I have a question?
Answer: The Palmetto GBA Contact Us web page includes information on contacting Palmetto GBA as well as information on when you may have to contact an entity outside of Palmetto GBA to address certain questions. A link to the Palmetto GBA Contact Us web pages are listed in the Resource section below.
All general inquiries to Palmetto GBA should be directed to the provider contact center (PCC). If assistance is needed from another area within Palmetto GBA, the PCC will utilize an internal escalation process to help in assisting you. You can use the Part B IVR User Guide (PDF) and Palmetto GBA Part B IVR Call Flows (PDF) resources to assist you in navigating the Interactive Voice Response (IVR) system.
Questions Regarding claims for patients enrolled in a Medicare Advantage plan or questions about a Medicare Advantage plan’s procedures or policies must be directed to the Medicare Advantage plan.
Resource: Contact Us.
Question: I am getting denials indicating Medicare does not pay for as many services as I have billed why?
Answer: There could be several reasons for this type of denial. The most frequent reasons are denials based on a National or Local Coverage Determinations that include direction on the frequency/units of a service that can be billed. Another reason may be that the number of services/units you billed exceed the CMS National Correct Coding Initiative Medically Unlikely Edits (MUEs). CMS does not publish all MUEs. Links to the published MUEs and national and local coverage determinations are listed below. If you receive a claim denial, after reviewing the applicable information for the service you billed, you may exercise your appeal rights and submit documentation with your appeal to support the frequency of services billed. Some of the MUE edits may require you exercise your appeal rights beyond the first level of appeal, a reconsideration.
Resources
- CMS National Coverage Determinations: National Coverage NCD Report Results
- Palmetto GBA Jurisdiction M Part B Local Coverage Determinations and Articles: Jurisdiction M Part B — LCDs, NCDs, Coverage Articles
Last Reviewed: 3/20/2024