Quarterly Frequently Asked Questions (FAQs): January 2020

Appeals

Question: Can I file a late appeal (if the 120 days have passed)?

Answer: A “Redetermination: First Level Appeal — Late Submission” form can be submitted with all required information and documentation. The submitter should be prepared to include a reason the request is late.

Claim Denials

Question: I have a claim denial for my patient being enrolled in a skilled nursing facility (SNF). Can you provide the name?

Answer: Yes. The name of the SNF can be released as it directly affects the submission of your claim for the patient.

Question: My claim denied as a duplicate, but I performed the service more than once. Can I be paid?

Answer: Yes. You may need to file an appeal with documentation to differentiate between the submissions, e.g., the time the services were rendered. The determination is based on the information you submit.

Adjustments

Question: How can I change information that is not considered a simple clerical error?

Answer: More complicated requests must be submitted in writing. Use the Redetermination form for a first level appeal.

Beneficiary Inquires

Question: Can Medicare tell me if a procedure code is covered?

Answer: Medicare services are based on medical necessity. The claim would need to be submitted based on the services that were rendered. For allowed amounts, refer to the Physician Fee Schedule.

Administrative Billing Issues

Question: How can I file a claim using the Medicare Beneficiary Identifier if the patient doesn’t have a copy of their card?

Answer: If you are enrolled in eServices, the MBI Tool can provide the MBI number assigned to the beneficiary for proper claim submission.

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

Other Palmetto GBA Sites

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RRB Specialty MAC Beneficiaries

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