Quarterly Frequently Asked Questions (FAQs): November 2019

Question: What is the best way for me to understand why a claim was denied? 

Answer: When Palmetto GBA denies a Medicare claim, the remittance advice (RA) includes claim adjustment reason and remark codes to explain how the claim was handled. A full list of the reason and remark codes is maintained on the Washington Publishing Company website. Additionally, the official paper and electronic remittance notices from Palmetto GBA include a definition of each reason and remark code used on claims identified on the remittance advice. Use the Palmetto GBA Interactive Remittance Advice tool for help reading the RA.

If you receive your RAs from any other source, e.g., a vendor or clearinghouse, and you are not receiving any or all of the reason or remark codes, reach out to those entities and ask that they provide that information on future RAs. Without all the applicable reason and remark codes, providers will have significant issues in understanding how a claim was processed, and additional time and resources will be required for you to research those claim rejections and denials.   

Question: If I know that I submitted a claim but the IVR, eServices and the Provider Contact Center tell me the claim is not on file, what does that mean?

Answer: There are a number of reasons why a claim may not be on file. The most common reasons are listed below.

  • An electronic claim was stopped by a Palmetto GBA Advanced Communication Engine (ACE) or Smart Edit at the time of transmission and required provider action to review and possibly correct an issue. The claim would need to be resubmitted before the claim can enter the claim processing system.
  • A provider’s billing company, vendor or clearing house did not forward the claim to Palmetto GBA even though the provider may have sent the claim for submission to one of those entities. When checking claim status through the eServices portal, claims with over 13 detail lines in a 'pending' status will not appear in the portal until the claim has processed.
  • The patient, date of service, provider information or dollar amount submitted on the claim was different than the information provided when verifying the claim status

Question: When a claim denies as a duplicate is there a way to determine what previously processed claim is causing a claim to deny as a duplicate?

Answer: The internal control number (ICN) of the initially paid claim will appear on the Palmetto GBA remittance notice. Providers may use the Palmetto GBA eServices status tool to identify the previously paid claim. Providers should also be able to see a previous payment for the same service in their patient account file. On the occasion where both the originally adjudicated claim and the denied claim were processed relatively close together, the paid claim may have finalized and is waiting for payment to be issued but the duplicate denial is sent on the next remittance notice. The claim status function of the Palmetto GBA eServices tool can assist in these instances to identify the initially paid claim. 

Question: When should the JW modifier be used?

Answer: The JW modifier should be used to show the drug amount of a single-dose vial that was discarded/not administered to any patient.

Question: How should the JW modifier be submitted?

Answer: Use of the JW HCPCS modifier, billed on a separate line, will provide payment for the amount of the single-use vial discarded drug or biological. For example, a single use vial is labeled to contain 100 units of a drug with 95 units administered to the patient and five units discarded. The 95 unit dose is billed on one line, while the discarded five units should be billed on another line by using the JW HCPCS modifier. Both lines would be processed for payment.

Question: Do multi-use vials qualify for coverage of the discarded or wasted portion?

Answer: No, the coverage of discarded drugs applies only to single-use vials. Multi-use vials are not subject to payment for discarded amounts of drugs or biological.

Question: Can the JW modifier be used for Competitive Acquisition Program (CAP) drugs?
Answer: No, HCPCS modifier JW is not used on claims for CAP drugs.

Question: How can physicians/providers discard less drugs or biological?

Answer: The Centers for Medicare & Medicaid Services (CMS) encourages physicians to schedule patients in such a way that they can use drugs and biological most efficiently.

Question: How should the claim be submitted when the dose of the drug or biological administered is less than the billing unit, and the drug is administered from a single dose vial?

Answer: Do not submit the HCPCS modifier JW if the billing unit is greater than the amount administered. Bill the lowest billing unit based on the HCPCS code. Do not bill separately for the discarded amount. For example, one billing unit for a drug is equal to 10 mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3 mg of the remaining drug is discarded. The 7 mg dose is billed using one billing unit that represents 10 mg of drug administered and discarded.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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