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1 NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

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3 MEDICARE PART A UPDATE Wendy Weary, Sr. Provider Relations Representative, Provider Outreach & Education 2

4 PRE TEST Welcome! I m Paul Metto! What do you know? 3

5 AGENDA Medicare Part A Updates Wendy Weary, POE Interactive Tools & Upcoming Education Events Claim Submission and Payment Errors Data Analysis Correcting Claims with Medically Denied Lines Medical Review Clinical Perspective POE Clinical Consultants Lynn Kelly, RN and April Gause, LPN 4

6 DISCLAIMER This information is current as of August 16, Any changes or new information superseding this information is provided in articles with publication dates after August 16, 2017, posted on our website: CPT only copyright 2017 American Medical Association. All rights reserved. 5

7 PALMETTO GBA UPDATES Interactive Tools 6

8 UPDATES 7

9 PROVIDER ENROLLMENT APPLICATION STATUS LOOKUP 8

10 FORMS Teleconference/webcasts (Providers) In Person (Associations) Note: Please complete the form online 9

11 ADR RESPONSE CALCULATOR 10

12 CDR CALCULATOR 11

13 APPEALS DECISION TOOL 12

14 APPEALS CALCULATOR Have an Appeals questions? Dial into a special Appeals Ask the Contractor Teleconference (ACT) on October 19,

15 CLAIM SUBMISSION AND PAYMENT ERRORS Data Analysis 14

16 MAC CLAIM SUBMISSION ERRORS Claim Submission Error Data Includes: Claims in Returned To Provider (RTP) Claims That Have Rejected Claim Submission Error Help Self Service Tool Quarterly Top 10 Denials 15

17 PART A QUARTERLY TOTAL DENIALS DATA Part A Denial Code U NCD Claim Count % Denied to Total % Denied to Total w/denial Code w/any Denial Code excluding RTPs 157, , , , , , , , , , Relates to Dialysis Facilities 16

18 REASON CODE EDITING Reason Code Claim Reporting Detail Non payable G codes for functional therapy status Line item(s) non covered w/ GL, GY or TS modifier Line item(s) w/ GZ modifier no ABN provided to patient Claim is an exact duplicate of a previously processed claim Claim overlaps another for same provider & DOS whether any revenue code lines are equal or not U5233 Services fall within a Medicare Advantage (MA) enrollment. Failure to verify beneficiary eligibility prior to submission. Edit Logic Claims based data collection required for outpatient therapy Appropriately assigns liability to the beneficiary for payment Auto denial assigns liability to provider; expedites appeal process Reject. Check records for a previously processed claim Reject. Notification that you must adjust previously processed claim to add charges Reject. Bill MA Plan. Inpatient claims must be submitted to Medicare with CC 04 for benefit tracking purposes 17

19 MEDICAL NECESSITY EDITING Reason Code Claim Reporting Detail Line denied because medical necessity was not supported as outlined in Palmetto GBA's Local Coverage Determination (LCD) Edit Logic Review LCDs under Medical Policies on our website 54NCD Line denied because none of the Review relevant NCDs on the diagnoses support the medical necessity of the service as outlined in CMS National Coverage Determination (NCD) CMS website to determine what diagnoses support medical necessity of service 18

20 LOCATING LCD # IN DDE From Claim Inquiry Menu, select claim Go to Page 2 of the claim Press F2 from Claim Page 2 Obtain the FMR reason code Press F1 to review the FMR reason code Determine LCD denying the claim Review LCD on Palmetto GBA website 19

21 LOCATING LCD # IN DDE 20

22 LOCATING NCD # IN DDE Denial based on NCD Locate the NCD number in DDE From Claim Inquiry Menu select claim Go to Page 2 of a claim; Press F2 from Claim Page 2 Review the NCD# Field Go to CMS website to review the NCD number listed coveragedatabase/indexes/ncd alphabetical index.aspx 21

23 LOCATING NCD # IN DDE 22

24 ACTION Action to Take on Denials Review Medicare Coverage Database Review medical records If record support medical necessity submit an appeal within 120 days of denial Action NOT to Take on Denials Do not adjust claim to correct medically denied lines Do not bill beneficiary if: Service was denied as contractual obligation (CO) No Advance Beneficiary Notice of Non coverage (ABN) was signed & service is not statutorily excluded 23

25 IDENTIFY MEDICALLY REVIEWED ADJUDICATED CLAIMS Providers may not make adjustments (e.g., add services, change units) to claims that have been medically reviewed and denied Claim will edit with Reason Code 30940; not permitted to adjust partially or fully medically denied claim Reason code triggers because initial claim had at least one service medically reviewed 24

26 DIRECT DATA ENTRY (DDE) USERS DDE users can determine if claim is medically reviewed by looking on claim Page 2 (MAP1712) Look for the following on MAP171D: A 5XXXX reason code in the FMR field; A number in the NCD RESP field; or A NCD number in the NCD field MED REV RSNS field shows reason code associated with the line items 25

27 DDE MAP171D EXAMPLE 26

28 CORRECTING CLAIMS WITH MEDICALLY DENIED LINES Corrections, Reopenings & Appeals 27

29 CLAIM CORRECTIONS Adjustment bill (XX7) is to be completed online Original claim cancels & is replaced Adjusted claim will adjudicate & edit each line item Adjustment may only be performed on originally paid claims & not claims with medically denied lines If a service is denied (i.e. MUE denial), request a Redetermination for those denied lines 28

30 CORRECTING CLAIMS WITH MEDICALLY DENIED LINES Claims with medically denied lines may be corrected online as long as changes are not made to denied lines the medically denied line charges must be left as non covered Once adjustment has processed, you may request a Redetermination for the medically denied services All needed adjustments should be completed prior to submitting a request for a Redetermination 29

31 CLERICAL ERROR REOPENING Clerical error reopening may be submitted to correct minor errors or omissions that caused claim to deny Request by submitting a redetermination request form Specify it is for a clerical error reopening, be specific as to what correction is needed & submit an XX7 TOB Submission of Clerical Error Reopening does not extend time limit for filing a request for a Redetermination! 30

32 CLERICAL ERROR REOPENING MAY NOT BE SUBMITTED FOR: Redetermination that requires review of medical records Denials due to anything other than clerical error or omission Correcting unprocessable or returned claims that need to be resubmitted with corrected information Adding, changing, or removing KX, GA, GY or GZ modifiers Adding late charges, procedures, services or diagnosis codes not originally submitted on the claim Changing a procedure code, increasing units billed, or reducing units billed, even if under the allowed limit 31

33 ADDING LATE CHARGES File an online adjustment to add late charges. If there is a medically denied line, those lines may not be changed & must be left as non covered. Once corrected claim is paid, you may request a Redetermination for the medically denied lines Redetermination filing timeline begins from the paid date of the original claim, regardless of when you added the late charges If you must file an appeal asking for late charges to be added, please list added charges on the appeal form 32

34 TIPS TO REMEMBER TIPS Quickest, easiest & most accurate to submit a Reopening or Redeterminations request is via our Palmetto GBA eservices portal All needed adjustments must take place prior to submitting first level of Appeal Redetermination If an appeal has been submitted, do not adjust the claim If you need to adjust a claim that has been submitted for an appeal, you must submit a request to withdraw the appeal in writing 33

35 NEW MEDICARE CARD PROJECT Social Security Number (SSN) Removal Initiative 34

36 SOCIAL SECURITY NUMBER (SSN) REMOVAL By April 2019; MACRA requires removal of SSN from all Medicare cards & assignment of a Beneficiary Identification Number (BNI) When SSNs are replaced on all Medicare cards, CMS can better protect: Private health care & financial information Federal health care benefit & service payments 35

37 HICN VERSUS MBI NUMBER Health Insurance Claim Number (HICN) contains: Primary beneficiary account holder SSN plus Beneficiary Identification Code (BIC) 9 byte SSN plus 1 or 2 byte BIC Key positions 1 9 are numeric 36

38 HICN VERSUS MBI NUMBER Medicare Beneficiary Identifier (MBI) New Non Intelligent Unique Identifier 11 bytes Key positions 2, 5, 8, & 9 will always be alphabetic Key SSA HICN MBI Example A1 1EG4 TE5 MK73 Dashes for display purposes only 37

39 MBI IMPLEMENTATION MILESTONES Mar Sept 2016 Launch Phase I & II web content Listening sessions to external stakeholders MBI Generator in test environment May Sept 2017 Complete MBI development Medicare & You mailed w/info on MBI card Begin robust education outreach Apr 2018 Apr 16, 2019 Statutory deadline to All systems & processes able to issue MBI cards accept MBI Jan 2020 Begin MBI card HICN no longer distribution to 60M exchanged with beneficiaries limited exceptions Oct 2018 MBI returned on RA Expect launch of Look Up tool 38

40 TRANSITION PERIOD o Transition period: Apr Dec. 31, 2019 CMS to complete system/process updates & ready to accept/return MBI on April 1, 2018 o All stakeholders who submit/receive transactions with HICN must modify processes/systems to be ready to submit/exchange MBI by April 1, 2018 May submit either MBI or HICN during transition period 39

41 TRANSITION PERIOD o Beginning October 2018 to end of transition period, when a valid & active HICN is submitted on Medicare fee for service claims both HICN & MBI will be returned on remittance advice MBI will be where changed HICN currently is: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (ID Code) 40

42 MBI LOOK UP TOOL o Secure Portal = o In the future providers will access the beneficiary MBI Look up Tool via eservices Secure Portal look up tool at point of service (POS) In cases when patient doesn t have a new Medicare card at POS the look up tool will provide a mechanism to access the MBI securely without disrupting workflow 41

43 ACTION TO BE READY o Get ready to use the new MBI Format: Ask your billing & office staff if your system can accept 11 digit alpha numeric MBI If you use vendors to bill Medicare, ask them about their MBI practice management system changes & make sure they re ready for the change! 42

44 ACTION TO BE READY Refer to the NMC webpage! Medicare Card/index.html o Subscribe to weekly MLN Connects newsletter for updates & new information o Verify your patients addresses: If the address on file is different than the address from electronic eligibility transaction responses, ask your patients to contact SSA to update their Medicare records 43

45 MEDICAL REVIEW CLINICAL PERSPECTIVE Clinical Consultants, Provider Outreach & Education Lynn Kelly, RN and April Gause, LPN 44

46 OFFICE OF INSPECTOR GENERAL (OIG) 2017 WORK PLAN Focus Areas Hyperbaric Oxygen Chronic Care Management Therapy IPF Outlier Payments Drug Waste single use vial IRF patients not suited for Payments for service dates after intensive therapy dates of death Transitional Care Post Acute Care Policy Patient Management Discharge Status 45

47 PALMETTO GBA MEDICAL REVIEW Clinical Focus Areas Drugs and Biologicals J9310, J1745, J2505, J9035 Hyperbaric Oxygen Therapy G0277 Subsequent Hospital Care & Patient Status Codes Outpatient Cataract Removal DRG 470: Major Joint Replace/Reattach Lower Extremity w/o MCC IRF CMGs A,B,C,D Inpatient Psychiatric Facility DRG 885: Psychoses Skilled Nursing Facility RUG Codes DRG 291 Heart Failure & Shock w/mcc Post Pay 46

48 SERVICE SPECIFIC PROBES Service specific probe reviews results: Rituxan (Rituximab) Remicade (Infliximab) Hyperbaric Oxygen (HBO) SNF RUGs 47

49 RITUXAN (RITUXIMAB) Rituxan/Rituximab FDA approved uses: Non Hodgkin s Lymphoma (NHL) Chronic Lymphocytic Leukemia (CLL) Rheumatoid Arthritis (RA) Granulomatosis with Polyangiitis (GPA) (Wegener s Granulomatosis) & Microscopic Polyangiitis (MPA) Accepted Off label Uses Approved by Palmetto GBA LCD L

50 REMICADE (INFLIXIMAB) Remicade/Infliximab = tumor necrosis factor blocker approved for: Crohn s Disease Ulcerative Colitis Rheumatoid Arthritis Ankylosing Spondylitis Plaque Psoriasis LCD L

51 DOCUMENTATION REQUIREMENT TIPS TIPS Correct Beneficiary Correct Dates of Service (DOS) Valid order Correct medication Dosage/Frequency/Route Date of order Legible signature with credentials CMS: Signature Guidelines for Medical Review Purposes Order should include combination drugs if indicated 50

52 DOCUMENTATION REQUIREMENT TIPS Medical records must substantiate medical need: Disease, type of malignancy, if cancer is diagnosis Staging, if applicable All prior therapy & patient s response to that therapy For lymphoma patients receiving Rituximab Explanation of lymphoma type & previous treatments should be maintained in medical record 51

53 DOCUMENTATION REQUIREMENT TIPS Diagnosis should include relevant history to support medical necessity of administration & dosage Actual Medication Administration Record (MAR) Patient s current body surface area (BSA) & weight in kilograms (Kg) used to calculate dose given Units reported & billed should correspond 52

54 DOCUMENTATION REQUIREMENT TIPS Some biologicals are to be given in combination or in conjunction with other medications If there is a contraindication for the beneficiary, there should be clear documentation in the record as to the rationale for not following guidelines 53

55 OFF LABEL USE IN ANTI CANCER CHEMOTHERAPEUTIC REGIMEN If prescribed regimen varies from standard protocols for medication administration Compendia documentation or peer reviewed literature supporting off label use by treating physician may also be requested of the physician by the Medicare Contractor CMS MLN MM6191 CMS Internet Only Manuals (IOMs), Publication , Medicare Benefit Policy Manual, Chapter 15, Section

56 HYPERBARIC OXYGEN (HBO) G0277 PROBE REVIEW ACT HBO Therapy, April 20, Guide proper billing of HBO Services: 55

57 SNF ULTRA HIGH RUG CODES PROBE REVIEW 56

58 SNF ULTRA HIGH RUG CODES PROBE REVIEW Denial Code 5D504/ 5H504 Description NC SC VA WV Not Medically reasonable or necessary Requested records not submitted DOWN MR down code D507/ 5H507 SNF MDS not in national repository H day benefits are exhausted Probe to continue based on moderate charge denial rates & medium to high impact severity errors If significant billing aberrancies are identified, provider-specific review may be initiated 57

59 SNF 14 LOWER RUG CODES PROBE REVIEW 58

60 SNF 14 LOWER RUG CODES PROBE REVIEW Denial Code 5D504/ 5H504 Description NC SC VA WV Not Medically reasonable or necessary Requested records not submitted DOWN MR down code D501/ 5H501 5D507/ 5D507 Billed in error SNF MDS is not in national repository

61 COMPARATIVE BILLING REPORTS (CBR) DRG Coding Accuracy 60

62 COMPARATIVE BILLING REPORTS (CBR) CBRs show providers how they rank against their peers in their jurisdiction & nationally in billing for certain risk areas CBRs do not contain patient specific data; applies to all provider types CBRs are intended to be proactive statements that will help the provider identify potential errors in their billing practice 61

63 COMPARATIVE BILLING REPORTS (CBR) If future CBR analyses yield same or similar results Provider Specific Probe may be determined as necessary to ensure accuracy of the DRG assignments Current Part A CBRs: Cardiac Rehabilitation Patient Discharge Status codes 62

64 CARDIAC REHABILITATION CBR 63

65 CARDIAC REHABILITATION EDUCATION Clinical Corner: Cardiac Rehabilitation Module tory.html Focuses on coverage/documentation requirements Phases & Covered Services Components, Progress Notes & Setting Direct Supervision & Physician Requirements 64

66 RESOURCES Medicare National Coverage Determination (NCD) Manual Ch.1, Part 1, Sec Medicare Benefit Policy Manual , Ch. 15, Sec. 232 Palmetto GBA LCD L34412 Cardiac Rehabilitation Palmetto GBA Local Coverage Article A53775: Frequency & Duration for Cardiac Rehabilitation & Intensive Cardiac Rehabilitation Supplemental Instruction 65

67 PATIENT DISCHARGE STATUS CBR 66

68 OIG REVIEW = PALMETTO GBA FOCUS Medicare post acute care transfer policy OIG reviews found Medicare contractors made overpayments of approximately $12.2 million to hospitals that did not comply Medicare inappropriately paid 6,635 claims subject to post acute care transfer policy 67

69 MEDICAL REVIEW FOCUS A hospital inpatient is considered discharged from a PPS hospital when a patient is formally released from the hospital or dies in the hospital Two digit patient discharge disposition code Identifies status; where the patient is at conclusion of a healthcare facility encounter or at end of a billing cycle 68

70 ACUTE CARE TRANSFERS Discharge of hospital inpatient = Transfer for payment purposes if patient is readmitted same day to another hospital that is: Paid under PPS Excluded from PPS payment Non Medicare participating acute care hospital Critical Access Hospital (CAH) 69

71 POST ACUTE CARE TRANSFERS An Inpatient discharge is considered a transfer when patient's discharge is assigned & made to: Hospital or distinct part unit (DPU) excluded from PPS Skilled Nursing Facility (SNF) Home under a written plan of care for home health (HH) services from a HH agency & services begin within 3 days after date of discharge 70

72 PAYMENT Facilities excluded from IPPS: IRFs LTCHs Psychiatric Hospitals Children s Hospitals Cancer Hospitals Full PPS rate paid to transferring hospital: Payment to receiving hospital Basis of Reasonable Cost Rate of its respective payment system IRF PPS LTCH PPS 71

73 CODING AND BILLING If qualifying claim is submitted with a discharge status 01 discharge to home self care, Medicare overpayment edit looks for: Presence of a transfer claim to a SNF Cancer or Children s Hospital Psychiatric Hospital or Inpatient Rehab Facility LTC Facility that commences or continues within one day of the acute care discharge Transfer claim to home health care that commences or continues within three days of an acute care discharge 72

74 REASONS FOR EDIT Used to receive timely payment Helps avoid claim errors Omitting codes or incorrectly coding causes: Claim rejection, cancelation, incorrect payment Payment is made to receiving hospital at full IPPS rate Payment to transferring hospital is based on a per diem rate 73

75 MLN MATTERS NUMBER: SE and Education/Medicare Learning Network MLN/MLNMattersArticles/downloads/SE1411.pdf 74

76 POST TEST Thank you for attending! What did you learn? 75

77 76

78 MEDICARE PART B UPDATE Shannon Chase Sr. Provider Relations Representative Provider Outreach & Education 77

79 PRE TEST Welcome! I m Paul Metto! What do you know? 78

80 DISCLAIMER The information provided in this presentation was current as of 8/16/2017. Any changes or new information superseding the information in this presentation is provided in articles with publication dates after 8/16/2017, posted on our website at: CPT only copyright 2017 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2017 American Dental Association (ADA). All rights reserved. 79

81 AGENDA Medicare Part B Update New Medicare Card Top Inquiries Comprehensive Error Rate Testing (CERT) Resources Medicare Part B Clinical Overview 80

82 81

83 NEW MEDICARE CARD By April 2019 MACRA requires the removal of SSNs from all Medicare cards A Beneficiary Identification Number (BNI) will be assigned April 2018, new MBIs and cards begin to be issued This improves protection of private health care and financial information Note: Identifiers are fictitious and dashes for display purposes only; they are not stored in the database nor used in file formats 82

84 HICN VERSUS MBI Health Insurance Claim Number (HICN) o 9 byte SSN plus 1 or 2 byte Beneficiary Identification Code o Key positions 1 9 are numeric Medicare Beneficiary Identifier (MBI) o Non intelligent and unique o 11 characters in length o Key positions 2, 5, 8, & 9 will always be alphabetic o Only numbers and uppercase letters (no special characters) 83

85 TRANSITION PERIOD 84

86 TRANSITION PERIOD Beginning October 2018 to end of transition period, when a valid and active HICN is submitted on Medicare fee for service claims both HICN and MBI will be returned on remittance advice MBI will be where changed HICN currently is: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (ID Code) 85

87 MILESTONES OF MBI IMPLEMENTATION March September 2016 May September 2017 April October 2018 April 16, 2019 Launch Phase I & II web content Listening sessions with external stakeholders MBI Generator in test environment MBI development complete Medicare & You mailed with information about New Medicare Card All systems & Statutory processes able to deadline to issue accept MBI new cards Begin distributing new January 2020 cards with MBI to 60M HICN no longer beneficiaries exchanged, with MBI returned on limited exceptions the remittance advice Expect launch of Look Up Tool 86

88 LOOK UP TOOL In the future providers will access the beneficiary MBI in the eservices secure portal at: This will give providers a mechanism to access a beneficiary s MBI without disrupting workflow CMS is making systems changes so that when a provider checks a beneficiary s eligibility, the CMS HIPAA Eligibility Transaction System (HETS) will return a message on the response indicating that CMS mailed that particular beneficiary s new Medicare card 87

89 GET READY FOR THE MBI Your system may need to be updated to accept the new Medicare Beneficiary Identifier (MBI) If you use a billing vendor, ask them if they are making changes and what they are doing to prepare Use the MBI Format specifications to make changes to your systems 88

90 GET READY FOR THE MBI Verify patients addresses If the address on file is different than the address from electronic eligibility transaction responses, ask your patients to contact SSA to update their Medicare records Sign up for the weekly MLN Connects newsletter Reference the new Medicare card webpage Medicare Card/index.html 89

91 MACRA The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) made important changes to how Medicare pays those who give care to Medicare beneficiaries CMS MACRA webpage initiatives patientassessment instruments/value based programs/macra mipsand apms/macra mips and apms.html Two paths in the Quality Payment Program: Merit based Incentive Payment System (MIPS) Advanced Alternative Payment Models (AAPMs) 90

92 QUALITY PAYMENT PROGRAM The Carolinas Center for Medical Excellence (CCME) 91

93 QUALITY INNOVATION NETWORKS Technical assistance 92

94 TOP INQUIRY CATEGORIES Policy/Coverage Rules 379 General Information 511 Appeals 1,013 Financial Information 1,099 Eligibility 1,298 Claim Status 1,748 Billing Issues 1,773 Unprocessable 2,016 Provider Enrollment 2,018 Claim Denials 6,211 93

95 BASICS 94

96 SELF SERVICE TOOLS 10/9/

97 EDUCATION Self Paced Learning Ask the Contractor Teleconferences (ACTs) Provider Outreach and Education Advisory Groups (POE AGs) 96

98 MLN MATTERS New look! CMS 2017 MLN enews Click! Matters Articles Open Door Forums are located on the National Provider Calls and Events CMS Website 97

99 UNPROCESSABLE/REJECTED CLAIMS These do not have appeal rights You must correct and refile the claim correcting the missing, invalid or incomplete information Ask your clearinghouse to provide you with associated remarks code to explain why a claim was rejected A recorded presentation is under Self Paced Learning 98

100 COMPREHENSIVE ERROR RATE TESTING (CERT) November 2016 Report (National) Total Projected Improper Improper Payment Rate Claim Type Payment Payment Part A (Total) $272.3 $ % Part A(Excluding Hospital IPPS) $157.5 $ % Part A (Hospital IPPS) $114.8 $ % Part B $93.3 $ % DMEPOS $8.1 $ % Overall $373.7 $ % Palmetto GBA JM Part B

101 CERT RESOURCES 100

102 CERT ADDRESS Initial Additional Documentation Request (ADR) letters for CERT are sent to the billing provider address on file with the National Supplier Clearinghouse (NSC) for Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) suppliers, or the Medicare Administrative Contractor (MAC) If a provider/supplier has a specific CERT correspondence address, they can provide it to the CERT Customer Service Representative (CSR) once they are contacted by the CERT CSR after the first documentation request letter is sent. The address will be used only for subsequent ADR letters for that sampled claim. 101

103 PART B MEDICARE ADVISORY Application 102

104 CLAIM PAYMENT ISSUE LOG (CPIL) Innovation Application Success 103

105 RESOURCES Resource E Mail Updates Contact Us By Self Service Tools Location Provider Contact Center (PCC) Medical Policies Select Listservs (top right) PartB.PCC@PalmettoGBA.com (center of home page) (under Topics) 104

106 MEDICAL REVIEW CLINICAL OVERVIEW Jazz Harrison, RN Clinical Consultant Provider Outreach & Education 105

107 AGENDA Medicare Part B Clinical Overview Medical Review Top Denials CERT Top Denials Denial Verbiage Edit Effectiveness Letter Documentation Tips 106

108 TOP 10 PART B MR DENIALS Rank Action Code MR Comment MR Comment Description Denied Amount Count of Denied Lines 1 F10 NODOC DOCUMENTATION REQUESTED FOR THIS DATE OF SERVICE WAS NOT RECEIVED 44, OR WAS INCOMPLETE. 2 F26 BILER CLAIM BILLED IN ERROR PER PROVIDER. 29, F12 WRONG DOCUMENTATION RECEIVED CONTAINS INCORRECT/INCOMPLETE/INVALID 23, PATIENT IDENTIFICATION OR DATE OF SERVICE 4 F41 DNSRP INFORMATION SUBMITTED CONTAINS AN INVALID/ILLEGIBLE PROVIDER 10, SIGNATURE NOTMN PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPORT MEDICAL 14, NECESSITY OF SERVICES BILLED EMCNM DOCUMENTATION REQUESTED FOR THIS DATE OF SERVICE WAS NOT RECEIVED 4, OR WAS INCOMPLETE. 7 F06 NOSIG DOCUMENTATION LACKS THE NECESSARY PROVIDER SIGNATURE. 3, F18 BNSIG DOCUMENTATION RECEIVED LACKS THE NECESSARY BENEFICIARY OR 3, AUTHORIZED REPRESENTATIVE SIGNATURE ISIGN INFORMATION SUBMITTED CONTAINS AN INVALID/ILLEGIBLE PROVIDER 1, SIGNATURE NOTML PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT MEDICAL NECESSITY OF SERVICES BILLED. 5, Percent of Denied Lines to Total Lines Denied 107

109 CERT DENIALS MIRROR MR DENIALS The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims Based on the most recent annual report, the following is the Part B CERT top denial information for Jurisdiction M 108

110 CERT TOP DENIALS Lack of documentation in the medical record is the #1 reason for claims being denied for payment. Providers can fix that by documenting the following: History of illness from onset to decision for surgery Prior courses of treatment and results Current symptoms and functional limitations Physical exam detailing objective findings supporting history of illness Results of any special tests 109

111 CERT TOP DENIALS CERT Error code 31 Service incorrectly coded means the documentation submitted for review by the provider does not match the codes billed for the claim To prevent this error, make sure this documentation is included in and submitted with the record for review 110

112 CERT TIPS TIPS The following are some tips to prevent this error: Make sure the date(s) of service are documented Ensure the proper principle diagnosis and principle procedure is coded correctly Include all documentation to support the codes billed Use a checklist to ensure all of the essential pieces are included in the record Make sure that both sides of double sided documents are submitted Remember it is the billing provider s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation 111

113 CERT TOP DENIALS CERT Error Code: 21 Insufficient Documentationelements of the medical record that are imperative for Medicare payment are missing from the medical record sent in to the CERT contractor for review The following are some tips to prevent this error 112

114 CERT TIPS TIPS Remember it is the billing provider s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation Make sure that both sides of double sided documents are submitted Ensure the documentation has legible signatures and dates Ensure the correct CPT/HCPCS code is used if applicable Ensure the physician orders and documents the interventions performed Include test results and lab results if applicable Make sure the copy sent to the CERT contractor is legible Number the pages before making a copy, so it will be easy to see if one of the pages are missing Use a checklist to ensure all of the essential pieces are included in the record 113

115 MEDICAL REVIEW TOP DENIAL CATEGORIES Ambulance Evaluation and Management Eye procedures 114

116 TOP DENIAL REASONS FOR AMBULANCE A0427/A0429 A0427 Advanced Life Support emergency transport, level 1 A0429 Basic Life Support emergency transport F06 No signature(nosig) Documentation lacks the necessary provider signature F53 NORUN Documentation received lacks the necessary run report 115

117 TOP DENIAL REASONS FOR E/M F10 NODOC Documentation requested for this date of service was not received or was incomplete F26 BILER Claim billed in error per provider 116

118 TOP DENIAL REASONS FOR EYE PROCEDURES F12 WRONG Documentation received contains incorrect/incomplete/invalid patient identification or date of service 630 NOTML Payer deems the information submitted does not support medical necessity of services billed 117

119 LET S TAKE A CLOSER LOOK AT THE WHY BEHIND THE WHAT The denial verbiage may look the same, but pay attention to the action code 630 Documentation does NOT support Medical Necessity (when LCD is used) 529 Documentation does NOT support Medical Necessity (no LCD used) (LCD Local coverage determination) 118

120 HOW DO I KNOW WHAT WAS MISSING FROM THE RECORD? Once the claim is denied, Medical Review will send the provider an edit effectiveness letter This letter will notify the provider of the Charge Denial Rate(CDR) and give the Medical Review denial message It will also give direction for appeals and the Corrective Action Plan (CAP) 119

121 THE EDIT EFFECTIVENESS LETTER February 3, 2017 Provider name 100 D Hospital Dr Location Dear Provider: The purpose of this letter is to provide you with an update of your medical review status for Surgical Debridement CPT Your calculated denial rate for the provider specific review was 100%. A list of claims reviewed and the medical review determination can be found on the enclosed document. The specific denial reason(s) and educational information on how to avoid those denials are as follows: 296/NODOC: Documentation requested for this date of service was not received or was incomplete. Submit all documentation related to the services billed within 45 days of the date on the ADR letter. Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included. Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological, or laboratory results. For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to (803) /NOTMN: Payer deems the information submitted does not support the medical necessity of the services billed. Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological, or laboratory results. Verify that documentation to support the level of service billed is included. Please refer to the website at for links to applicable LCDs, NCDs, and the E/M Scoresheet Tool for documentation requirements. F06/NOSIG: Documentation lacks the necessary provider's signature. Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner. Verify that electronic signature meets the CMS signature requirements as listed in the 120

122 THE EDIT EFFECTIVENESS LETTER article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices located on our website at Submit a valid Signature Attestation with any documentation that lacks the rendering provider's signature. Do NOT resubmit altered documentation with late added provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices located on our website at F12/WRONG: Documentation received contains an incorrect/incomplete/illegible patient identification or date of service. Review all documentation prior to submission to ensure that it is for the correct patient and date of service. Ensure that patient identifiers are legible and complete. Ensure that the complete date of service is clearly and legibly noted on all documentation. Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field F43/INPSC: Invalid physician certification statement. Review documentation prior to submission to ensure that the complete signed certificate of medical necessity is included. F51/NOPSC: No physician certification statement submitted in the medical record. Review documentation prior to submission to ensure that a complete signed certification statement is included. Based on the results of this review, Palmetto GBA will continue to monitor your claims for an additional calendar quarter. Please review your denial reasons and update your Corrective Action Plan (CAP) if your initial CAP or previous updates have not effectively addressed them. Palmetto GBA would like to direct your attention to our Web sites at to provide further assistance and education regarding the proper documentation and billing of Evaluation and Management services so that you may correct the problems that have been identified Palmetto GBA E/M Help Center. At the Palmetto GBA Home Page, select Part B MAC NC, SC, VA, WV; then select Browse by Topic, then E/M Help Center 121

123 RESOURCES IN THE LETTER Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices. At the Palmetto GBA Home Page, select Part B MAC NC, SC, VA, WV; then select Browse by Topic, next select General, then select the article Prompt return of the medical documentation will minimize the impact of our review on your practice, both administratively and financially. Selected claims in which services are denied due to a lack of documentation being received cannot be resubmitted as a new claim. Palmetto GBA is required to recover funds for any Medicare overpayments related to these selected services should you resubmit new claims and subsequently receive payment. Additionally, this review does not exclude you from possible future reviews that may be the result of other specific reasons or issues. If providers have Medicare billing and coverage questions or questions concerning this letter, contact the Provider Contact Center at If providers are requesting specific education, please fill out the Provider Outreach and Education Request Form on the Palmetto GBA Web site under Forms. Palmetto GBA offers many educational options, including the opportunity for provider-specific education targeted to the particular needs of each health care provider. Complete this form, submit it online or send via fax to the telephone number at the bottom of the form. Sincerely, A/B MAC Medical Review Web Site Alerts If you have not already done so, we encourage you to sign up for our List-Serv. You will receive automatic notice of newly posted Medicare related information as well as the monthly Palmetto GBA Medicare Advisories. Being a subscriber on this list is the fastest way to find out about Medicare changes which may affect you. There is no charge for the service and we will not share your address with others. To enroll, simply go to the Palmetto GBA Web site ( and click on " Updates," near the top banner. Enter your login, contact, and user information; then select your contract and the topics that apply to your areas of interest. MR Part B Remain on CAP with Education Form 01/24/2017 Revision

124 DENIAL REASON 529 NOTMN Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services Medical records should chronologically report care a patient received. The record is used to record pertinent facts, findings, and observations about the patient s health history. It also assists physicians and other health care professionals in evaluating and planning the patient s immediate treatment and monitoring the patient s health care over time 123

125 529 NOTMN What process do you use to ensure the MN (medical necessity) component has been met? Checklists are useful when used/followed and contain identifiable components of the most commonly billed codes Who pulls the necessary documentation prior to submission? Who reviews the documentation to ensure the records reflect the correct code is being billed prior to submission? Who is reviewing the denials and tracking denial trends based on the remit? 124

126 529 NOTMN Documentation must be patient specific. Templates acceptable if specific for individualized patient and specific visit that day Show why further or unusual services are indicated, why this case is different Electronic Health Records (EHR) are fine, but must be specific for visit (watch for identical notes for each visit) While a service or test performed may be considered good medical practice Medicare prohibits reimbursement of services absent symptoms or complaints 125

127 DOCUMENTATION TIPS To submit justification supporting medical necessity of the services, include: History, physical and medication records Nurses notes and procedure notes Operative reports and pathology reports Physician s orders and progress notes Signatures/credentials of professionals TIPS Any other documentation deemed necessary to support medical necessity of services Documentation specifically requested by the ADR letter 126

128 DOCUMENTATION TIPS Documentation of each patient encounter should include: Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results Assessment, clinical impression, or diagnosis (the history and physical examination identifies appropriate subjective and objective information pertinent to the patient s presenting complaints) Medical plan of care (POC) Date and legible identity of the observer TIPS 127

129 DOCUMENTATION SUMMARY If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified The patient s progress, response to and changes in treatment, and revision of diagnosis should be documented Treatment plans should be consistent with diagnoses In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter 128

130 YOUR PROACTIVE APPROACH Use a tracking system for ALL medical record requests Log in the request and note the due date Review the request, pull the records Use checklists available on the Palmetto GBA website Review the records and authentication Do the records support each service billed? If records are for a diagnostic service you must include: Signed order for the services along with documentation of the medical necessity for each test Test results Document in the log when the documentation was submitted along with what documentation was submitted 129

131 POST TEST Thank you for attending! What did you learn? 130

132 131

133 ELECTRONIC DATA INTERCHANGE Kim Campbell, Manager EDI Operations 132

134 EDI ON PALMETTOGBA.COM 133

135 EDI OPTIONS 134

136 EDI ENROLLMENT ASSISTANCE 135

137 EDI ENROLLMENT INSTRUCTIONS GUIDE MODULE 136

138 EDI ENROLLMENT STATUS TOOL 137

139 ENROLLMENT LOOKUP 138

140 ENROLLMENT STATUS MESSAGES 139

141 GPNET ENHANCEMENTS Implementation from FTP to SFTP has been completed Provides faster and more secure environment Can receive PDF Files in your electronic mailboxes messages to submitters Submitters can upload and download data files For issues, contact your Network Service Vendor(NSV) prior to calling Palmetto Palmetto is notifying NSVs to any connectivity issues so they may alert their customers proactively NOTE: NSV Listing under EDI Connectivity Enhancement Option on 140

142 CONNECTIVITY ENHANCEMENTS 141

143 EDI SYSTEM STATUS TOOL 142

144 SYSTEM RELATED ISSUES o EDI System Status and Log will provide information concerning any front end issues including: o Connectivity o CEM edits o 999 and 277CA Reports o 835(ERA) Files o Availability of Direct Data Entry (DDE) System and eservices New Feature 143

145 EDI SYSTEM STATUS PAGE 144

146 EDI SYSTEM STATUS LOG 145

147 CEM EDIT UPDATE Example of a CEM edit on a 277CA Report: STC*A8:562:85**U*50******A8:128:85~ For a listing of all edits, please go to EDI/Technical Specifications/Medicare Fee for Service CEM Edits 146

148 EDIT ASSISTANCE Please have the following information: o Submitter ID o Transmission date o File ID(ISA13) o PTAN/NPI o Complete error message 147

149 SMART EDITS PART B 148

150 SMART EDIT INFORMATION 149

151 SMART EDITS PART A 150

152 SMART EDIT ON A 277CA REPORT STC*A3>23>41**U*********SMARTEDIT: SMARTEDIT INFO A POTENTIAL CODING ERROR WAS IDENTIFIED WITH THIS CLAIM. PLEASE SEE STC 2220D LOOP FOR SPECIFIC INFORMATION. IF YOU WISH TO CONTINUE WITHOUT UPDATES PLEASE RESUBMIT THE CLAIM IN ITS CURRENT STATE TO BYPASS ADDITIONAL SMARTEDITING.~STC*A3>23>41**U*********SMARTEDIT: PER CCI GUIDELINES PROCEDURE CODE HAS AN UNBUNDLE RELATIONSHIP WITH PROCEDURE CODE BILLED FOR THE SAME DATE OF SERVICE. REVIEW DOCUMENTATION TO DETERMINE IF A MODIFIER OVERRIDE IS APPROPRIATE~ For a listing of Smart Edits, please go to EDI/P ACE/P ACE Smart Edits Information NOTE: If using a clearinghouse/ billing service, please verify that you are receiving the complete edit message 151

153 SMART EDIT LISTING 152

154 DIRECT DATA ENTRY(DDE) IDS All active DDE IDs must be certified yearly Completed recertification for 2017 and any DDE ID s not recertified will be purged from the system will have to request for any purged DDE IDs to be re established If an individual leaves your employment, notify Palmetto GBA s EDI Department to deactivate the user ID If an individual had a user ID from a previous employer, that ID will be activated with the current provider when the application is received Note: Keep DDE ID user contact information current contact EDI if the and phone number have changed 153

155 DDE ID USER REMINDERS DDE User IDs: Cannot be shared or transferred Are assigned to an individual, not a provider or entity DDE IDs must be used every 30 days If DDE IDs are not used once every 30 days, they will be purged for non usage, and the user must apply for a new DDE ID If multiple failed attempts are made to log on user must contact Palmetto to avoid the DDE ID being purged for a security violation If a DDE ID is purged for security violations, you must respond to Palmetto to re establish the ID 154

156 eservices PORTAL 155

157 eservices Administrator Responsibilities: Set up their users and access Reset their user passwords Communicate with EDI Must log in at least once every 30 days to maintain access Passwords must be changed every 60 days Set up and use Multi Factor Authentication(MFA) Requirement beginning with new user, password resets and recertifications on April 1, 2017 MFA Code is only valid approximately 5 minutes 156

158 CONTACT INFORMATION UPDATES Please call us if the following changes: Provider Address Submitter Address EDI Contact Person Name Telephone/Fax Numbers Address Please keep the EDI contact information current 157

159 CONTACT INFORMATION o Telephone number: , please listen carefully to the options and have your PTAN, NPI and Submitter ID available o address for basic questions: Medicare.edi@Palmettogba.com o EDI Fax Numbers begin with 803 o EDI Helpdesk hours: 8 5 ET 158

160 PROVIDER ENROLLMENT Teresa Newton, Director Provider Enrollment 159

161 AGENDA Role of Provider Enrollment Life Cycle of an Enrollment Application Submitting Your Enrollment via PECOS Avoiding Processing Delays Revalidation Process Provider Enrollment Resources 160

162 ROLE OF PROVIDER ENROLLMENT Review, validate & process CMS Form 855 enrollment application, including supporting documentation, to ensure only eligible & qualified individuals and organizations participate in the Medicare Program Ensuring CMS requirements are consistently and accurately met Maintain PE records in Internet based PECOS, FISS and MCS 161

163 WHEN SHOULD YOU SUBMIT AN APPLICATION? Joining Medicare Program for the first time Anytime something changes with your facility/practice Ownership Changes Change of Ownership (CHOW) Stock Transfer Joining a new group Enrolling for the sole purpose of ordering and/or referring services Revalidating 162

164 PROVIDER ENROLLMENT GLOBAL VIEW Applications 163

165 SUBMITTING YOUR ENROLLMENT VIA PECOS What is PECOS? The Provider Enrollment Chain and Ownership System (PECOS) is a national database of Medicare provider and supplier enrollment information. PECOS is used to collect and maintain the data submitted on CMS 855 enrollment form. 164

166 PECOS SUBMISSIONS o Submit an initial Medicare enrollment application o View or submit changes to your existing Medicare enrollment information o Submit a Change of Ownership (CHOW) of the Medicareenrolled provider o Add or change reassignment of benefits o Reactivate an existing enrollment record o Withdraw from the Medicare Program o PECOS Provider Interface (PECOS PI) 165

167 BENEFITS OF USING PECOS Track your application Upload Digital Document Submit Electronic Signatures Submit or Update EFT (CMS 588) information Pay Application Fee (Pay.gov) Print Medicare enrollment information Add & Store Multiple Contact Information Fast Track View of Medicare Enrollment Information Transparency for Groups Accepting Reassignments Revalidation Notification Center Review and update NPI records as part of enrollment submission 166

168 BENEFITS OF USING PECOS Faster processing times Easier to Revalidate and make changes to enrollments Greater control and accuracy Fewer developments Cleaner applications Built in efficiencies that are in efficiencies in paper More applications approved Less rejections Less returns Less waste 167

169 CMS 855A AVOIDING DELAYS This application is used to enroll, revalidate or facilitate changes of: Institutional providers (i.e., Hospitals, Outpatient Physical Therapy, Rural Health Clinics, Skilled Nursing Facilities) that plan to bill Medicare for Part A medical services Most Common Development Reasons: LBN IRS Documentation Section 2B1 LBN/TIN Correction Application Fee Payment 4A Missing PTAN Section 6 Missing Data or incomplete for AO/DO Bill of Sale EFT Preprinted voided check CHOW Effective Date

170 CMS 855B AVOIDING DELAYS This application is used to enroll, revalidate or facilitate changes of: Clinics/Group Practices and Certain Other Suppliers (i.e., Clinical Laboratories, Ambulatory Surgical centers, Independent Diagnostic Testing Facilities, Mammography Centers) that plan to bill Medicare for Part B medical services that wish to reassign benefits to your practice Most Common Development Reasons: Section 2 Incorrect Provider Type, LBN, TIN Section 4 Updates to Practice Location Section 6 Missing Data or incomplete for AO/DO EFT Preprinted voided check IRS Documentation Final Adverse Action documents are not included or do not support requirements

171 CMS 855I AVOIDING DELAYS This application is used to enroll, revalidate or facilitate changes of: Physicians and Non Physician Practitioners that plan to bill Medicare for Part B medical services Most Common Development Reasons: Section 2 DEA, Graduation Year, SSN Section 3 Adverse Actions documentation not provided Section 4B Incomplete Licenses / Certifications NPI Name update Copy of DEA

172 CMS 855R AVOIDING DELAYS This application is used to reassign benefits and facilitate changes of: Reassigned benefits for Physicians and Non Physician Practitioners Most Common Development Reasons: Section 2 Group LBN Section 3 Section 6 Correct Signature Not submitting the CMS 855I simultaneously

173 REVALIDATION Section 6401 (a) of the Affordable Care Act Reinforces the revalidation requirements of 42 CFR all providers/suppliers must resubmit and recertify the accuracy of enrollment information every 5 years Establishes new screening requirements for new and existing providers Requires existing providers to be revalidated under new screening requirements 172

174 REVALIDATION CYCLE 2 Section 6401 (a) of the Affordable Care Act Reinforces the revalidation requirements of 42 CFR all providers/suppliers must resubmit and recertify the accuracy of enrollment information every 5 years Establishes new screening requirements for new and existing providers Requires existing providers to be revalidated under new screening requirements 173

175 REVALIDATION DUE DATES Due dates are on the last day of the month (e.g. Feb 28, March 31, April 30 etc.) Due dates are posted to CMS.gov Revalidation Due Date Lookup Tool Will display all currently enrolled providers Due Date TBD (To be determined) Posted 6 months before the revalidation due date Include crosswalk to reassignment information 174

176 PALMETTO GBA DELIVERY OF CYCLE 2 REVALIDATION NOTICES Electronically for eservice Users Provider s eservice administrator(s) & any other individual eservice user on a provider s account with the message inbox permission will receive the eletter in their inbox on Messages tab. notification that a revalidation letter has been sent through edelivery will be sent to the provider administrator(s) on the account Notes: Palmetto GBA automatically registered all active provider accounts to receive edelivery of revalidation notifications through eservices Any user with Secure Messages permission can see edelivery letters, but only administrators can elect to receive alerts for received letters Standard USPS mail for non eservice Users Provider enrollment revalidation notifications will be sent through the U.S. Postal Service 175

177 UNSOLICITED REVALIDATIONS Unsolicited revalidations are defined as: Revalidation submitted more than 6 months in advance of the due date TBD listed on the CMS.gov Revalidation Due Date Lookup Tool No notice received from Palmetto GBA requesting you to revalidate All unsolicited revalidations will be returned without processing If your intention is to submit a change to your provider enrollment record, submit a change of information application on the appropriate CMS Form

178 DEACTIVATIONS Avoid deactivation Submit revalidation application by due date and include all active practice locations and reassignments Respond to all development requests within 30 days of receipt Failure to take these actions could result in a hold on your Medicare payments and possible deactivation of Medicare billing privileges 177

179 REACTIVATION Deactivated providers/suppliers are required to submit a complete enrollment application to reactivate The provider/supplier will maintain their original PTAN, but will not be paid for services rendered during the period of deactivation (resulting in a gap in coverage) Note gap in coverage policy is not applicable to Part A Reactivation date is based on the receipt date of the new application 178

180 ECREDENTIALING INFORMATIONAL CLAIMS EDITS FOR REVALIDATION DUE DATE Every five years, CMS requires providers to revalidate their Medicare enrollment record Failure to respond to our notice to revalidate will result in a hold on Medicare payments & possible deactivation of Medicare enrollment Palmetto GBA returns informational claims messaging for providers that are due to revalidate This informational message will be provided on claims that have been adjudicated if a revalidation is due: Your Medicare enrollment record is due for revalidation. Failure to respond may result in a hold on payments and possible deactivation of your enrollment Please visit to confirm your revalidation due date 179

181 REVALIDATION RESOURCES Visit Reassignment crosswalk list MLN Matters SE1605 Provider Enrollment Revalidation Cycle 2 Revalidation Application Checklist 180

182 PROVIDER ENROLLMENT SELF SERVICE RESOURCES Internet based PECOS at dpecos.asp Application Status Lookup Tool Application Status Check via Palmetto GBA IVR

183 eservices Jessica Duffie Senior Systems Support Technician e Commerce 182

184 eservices Palmetto GBA s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eservices application. Palmetto GBA s eservices is a free internet based, provider self service secure application. 183

185 EXISTING eservice FUNCTIONS o Eligibility o Claims Status o eclaim Submissions (Part B only) o Clerical Error Claim Reopening Requests (Part B only) o Remittances Online o Financial Information o Financial Forms o Secure Forms o edelivery o ereview 184

186 KEEPING YOUR eservices ACCOUNT SECURE Palmetto GBA and CMS are dedicated to ensuring that access to Medicare data is secure. To do this, CMS requires all eservices users to comply with the following practices and requirements designed to secure access to your eservices account and the data available through it. o Minimum system requirements o Generic user names and account sharing is prohibited o 60 day lockout o Multi factor authentication (MFA) o Profile verification o Recertification 185

187 MFA Select the method to receive your MFA code. 186

188 MFA Enter the MFA code sent to you via text or

189 PROFILE VERIFICATION You will be prompted to complete profile verification as part of the initial account set up process and every 150 days from the last time profile verification was completed. Failure to complete profile verification within 210 days will result in deactivation of your account. o Verify/update information on your My Account tab o Click Submit button o Access the profile verification and use the link to verify your o Log into your account to complete the profile verification process 188

190 PROFILE VERIFICATION Profile verification example: 189

191 RECERTIFICATION You will be prompted to complete recertification 150 days from initial eservices registration and every 150 days from the last time recertification was completed. Failure to complete recertification within 210 days will result in deactivation of your account. o Click the Recertify Users button on your Admin tab o Select users who should still have access to eservices and click submit to recertify their access. Users not selected will be deactivated. 190

192 RECERTIFICATION Recertify Users button on the Admin tab: 191

193 RECERTIFICATION Recertify users screen 192

194 ACCOUNT LINKING Creating a one stop shop for all of your eservices accounts Benefits of Account Linking o ONE user ID and password o ONE profile verification o Access information and submit items for all of your eservices accounts from ONE location o See all of your accounts that are due for recertification with ONE click 193

195 ACCOUNT LINKING Drop down of linked accounts and recertification notifications 194

196 NEED HELP? Support Resources o eservices User Manual ( o eservices FAQs Select the eservices Portal topic from your line of business home page on Then click the eservices FAQs link to access a full list of FAQs associated with your LOB. o Didn t find an answer to your question? Contact your Provider Contact Center for additional assistance. 195

197 APPEALS Kathy Kardules, Director Part A/B Appeals 196

198 MEDICARE PART A & B APPEALS PROCESS Five Levels in the claims Appeals Process Appeal Progression must follow in Level Order Time, Resources & Costs Increase with each level Level 2 Level Level4 4 Level 3 Level 5 Reconsideration Qualified Independent Contractor (QIC) Judicial Review, U.S. District Court Medicare Appeals Council Level 4 Administrative Law Judge (ALJ) Level 1 Redetermination Conducted by MAC 197

199 UNDERSTANDING EACH LEVEL OF APPEAL Redetermination Conducted by a Medicare Administrative Contractor(MAC) Reconsideration by a Qualified Independent Contractor (QIC) Administrative Law Judge (ALJ) within the Office of Medicare Hearings & Appeals in the Department of Health and Human Services Review by the Appeals Council within the Departmental Appeals Board in the Department of Health and Human Services Judicial Review in Federal District Court 198

200 TIME LIMIT FOR FILING REQUESTS & AMOUNT IN CONTROVERSY 199

201 INITIAL DETERMINATIONS Initial determinations regarding claim benefits under Medicare Part A & B are made by the Medicare Administrative Contractors Requests for payments that do not meet the requirements for a Medicare claim are not considered an initial determination, and as such are not appealable 200

202 REDETERMINATIONS A Redetermination is an independent review of an initial determination on a claim by the A/B Medicare Administrative Contractor (MAC) & made by reviewers who were not involved in the initial claim determination De Novo Latin phrase meaning anew or afresh, used to denote the manner in which claims are adjudicated in the administrative appeals process. Adjudicators at each level of appeal make a new, independent & thorough evaluation of the claim(s)/service(s) at issue, and are not bound by the findings from a decision made by an adjudicator in a prior determination. 201

203 REQUESTING A REDETERMINATION CMS requires certain components to be present for the contractor to accept a request as valid If information is not present the request will be dismissed Filing an incomplete request does not extend the timeframe for filing the request 202

204 REQUESTS FOR REDETERMINATIONS SHOULD INCLUDE: Beneficiary Name Health Insurance Claim Number (HICN) Name & Address of the Provider Provider Number / NPI List of items that you are appealing Specific date(s) of service being appealed FISS DCN / MCS Claim Number (s) Name & signature of the party or representative of the party (initials are not acceptable) Evidence or supporting documentation you wish to submit 203

205 REDETERMINATION SUBMISSIONS Use our Palmetto GBA eservices tool at: Most efficient & effective method of submission Free and easy to use You control the data entered Reduces the potential for keying errors & misrouted mail Via fax at: Part A (803) Part B (803) Via hard copy: Part A Appeals Part A, Mail Code: AG 630, P.O. Box , Columbia, SC Part B Appeals Part B, Mail Code: AG 655, P.O. Box , Columbia, SC

206 REDETERMINATION SUBMISSIONS HELPFUL INFORMATION Do not submit the same request via multiple methods as like requests are considered duplicates and must be consolidated. This requires additional research that may delay processing If you are only appealing specific lines on the claim, clearly indicate which procedure code(s) you are appealing When submitting an appeal for denied service(s), if you re appealing multiple claims; write multiple claims on the redetermination request form & include all claims to be included You may also attach a spreadsheet of the affected claims being appealed. If appealing an overpayment, include a copy of the overpayment demand letter. Clearly identify which claims are being appealed or if you wish to appeal all claims in the overpayment, clearly state this on your request Decisions will be rendered within 60 days of receipt of the written request Be sure to sign your request Acceptable forms of signatures for redetermination requests are electronic, digital, and/or digitized signatures submitted via paper mail, facsimile, or a CMS approved secure Internet portal/application. At a minimum, this shall include a statement indicating that the document submitted was, electronically signed by or verified/approved by etc. 205

207 INCOMPLETE/INVALID REQUESTS Examples of incomplete requests include: Records submitted, but no request included Unsigned, initials only, signature on file notation, an illegible signature or a printed name only on the request Other documentation (such as a blank claim form) submitted to support the appeal request shall not be considered an acceptable/valid signature regardless of how the appeal request is submitted. Missing or invalid Health Insurance Claim Number (HICN) Date(s) of service are missing or do not match claim on file 206

208 SUPPORTING DOCUMENTATION Evidence or any & all documentation to support the request may include, but is not limited to: Items that are relevant to the case Physician s orders signed and dated Medical records for dates of service billed Test/lab results Office records/progress notes Good Documentation Is Signed and Dated Relevant and Legible Supportive of Billed Services Includes Test Orders and Results It is the Provider s responsibility to submit all appropriate documentation with request Appeals unit will request records from the entity that determined the overpayment or denial if it is a RAC, ZPIC/UPIC or SMRC. Providers are encouraged to include all documentation with the appeal & be very clear with what is being provided 207

209 DOCUMENTATION HELPFUL HINTS Please send only the minimum relevant documentation necessary to support the appealed service(s). Copies of Local Coverage Determinations (LCD s) or National Coverage Determinations (NCD s) are not necessary. No ASSUMPTIONS can be made: if it s not documented in the medical record then it did not happen Ensure all documentation is legible & properly signed Clearly label all pertinent information; e.g. orders, MAR, nursing chart notes, or physician notes Ensure all qualifying diagnosis(es) are billed on claim & supported in the medical record 208

210 INSUFFICIENT DOCUMENTATION No clinical note provided: no physician note, or note is vague or not relevant, or no clinical documentation provided No physician orders provided or evidence of intent to order No documentation to support that services ordered were performed or that units of service billed were rendered (e.g. MRI denied & billed on claim; however, MRI report wasn t provided or Avastin 300mg was billed & documentation only supports Avastin 100mg were given or ordered) Chart only notes diagnosis code, no other notations made No relevant treatment or clinical history provided Documentation missing important facts Includes documentation with invalid or missing signatures Illegible medical records 209

211 REDETERMINATION DECISIONS 1. Full reversal In this instance, you ll receive a revised Medicare Remittance Advice (RA) showing the paid service/claim. You will not receive a Medicare Redetermination Notice (MRN). Medicare contractors may need to adjust the overpayment & amount of interest charged (may apply these funds to any other debt that you might owe & then release any excess to you) 2. Partial reversal (Partially Favorable) In this instance you will receive both a Medicare Remittance Advice (RA) showing the paid service/claim portion allowed on appeal and a MRN letter explaining our decision, portion payable & what portion remain denied. The MRN will also provide further appeal rights. 3. Full Affirmation of the Initial decision With this unfavorable decision that upholds the initial determination, you will receive MRN letter explaining our decision. The MRN will also provide further appeal rights. 210

212 MEDICARE OVERPAYMENTS A Medicare overpayment is a payment you receive in excess of amounts properly payable under Medicare statutes & regulations. After Medicare identifies an overpayment, the overpayment amount becomes a debt owed to the Federal government Federal law requires the CMS & thus, MACs to try to recover all identified overpayments In Medicare, overpayments commonly occur due to: Insufficient documentation Medical necessity errors Administrative and processing errors 211

213 OVERPAYMENT IDENTIFICATION If you identify an overpayment you need to report it & arrange to return the overpaid amount within 60 days of identification or date the corresponding cost report is due When Medicare identifies an overpayment of $25.00 or more, the MAC initiates the overpayment recovery process by sending an overpayment demand letter requesting repayment 212

214 OVERPAYMENT DEMAND LETTERS Demand letters from MAC explain: Medicare made an overpayment When interest will begin to accrue if you do not repay the overpayment in full within 30 days Options to request immediate recoupment or Extended Repayment Schedule (ERS) Rebuttal/Appeal rights 213

215 OPTIONS WHEN DEMAND LETTER IS RECEIVED Make immediate payment Request immediate recoupment Request standard recoupment process (Automatic Offset/Withholding) Request Extended Repayment Schedule (ERS) Submit a rebuttal a Rebuttal is: Not Considered an Appeal, and Does not stop recoupment Request a redetermination to the appeal overpayment 214

216 LIMITATION ON RECOUPMENT Social Security Act Section 1893(f)(2)(a) provides limitations on the recoupment of Medicare overpayments It requires that when a valid first or second level appeal is received on an overpayment, subject to certain limitations, CMS & MACs cannot recoup overpayment until decision on redetermination and/or reconsideration Specifically, Section 1893 (f)(2)(a) of the Social Security Act protects providers physicians, & suppliers during initial stages of appeal process (both first level appeal contractor redetermination, and second level appeal Qualified Independent Contractor (QIC) reconsideration) by limiting the recoupment process for Medicare overpayments while appeals process is underway This affects the timeframes on recoupment 215

217 LIMITATION ON RECOUPMENT o Section 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) which amended Title XVIII of the Social Security Act to add to Section 1893 a new paragraph (f) addressing this process o For overpayments subject to this limitation on recoupment, Medicare will not begin overpayment collection of debts (or will cease collections that have started) when it receives notice that the provider has requested a Medicare contractor redetermination (first level of appeal) or a reconsideration by a Qualified Independent Contractor (QIC) o As appropriate, Medicare will resume overpayment recoveries with interest if the Medicare overpayment decision is upheld in the appeals process o If ALJ level process reverses the Medicare overpayment determination, Medicare will refund both principal & interest collected & also pay 935 interest on any recouped funds Medicare took from ongoing Medicare payments If a provider has any other outstanding overpayments, Medicare will apply the amount collected first to those overpayments & any excess monies will then be refunded back to the provider o Payment of 935 interest is only applicable to overpayments recovered under the limitation on recoupment provisions. Interest is only payable on the principal amount recouped. o Providers must note that when Medicare sends a demand letter notifying a provider of Medicare s intent to collect an overpayment, the provider may submit a letter of rebuttal that disputes the debt Rebuttal letter will not necessarily stop Medicare from beginning process of recouping that debt Only provider s timely & valid request for a redetermination or reconsideration will halt the recoupment 216

218 HOW TO STOP RECOUPMENT REDETERMINATION LEVEL Recoupment of overpayment can begin on day 41 from the first demand letter unless a valid redetermination request is submitted by 30 th day following date of first demand letter Timeliness of this request is important because if you don t send this request within 30 days, Medicare can begin to recoup on 41st day from date of Medicare demand letter. In addition, during this appeal process, while the Medicare contractor cannot recoup or demand the debt, it continues to age (its interest continues to accrue); and, once both levels of appeal are completed, if the appeal decision results in an affirmation of the overpayment decision, collection activities may resume within the designated timeframes 217

219 OVERPAYMENT REDETERMINATION REQUEST Same Submission Methods and requirements noted on previous slides, plus: Include a copy of the Overpayment Demand Letter with your Appeal Request If you are not able to include a copy of the actual letter, note the Account Receivable Number or Letter Number on your Redetermination Request Add a comment to the reason for Appeal, i.e.; Appealing the entire overpayment assessed, or Appealing the overpayment noted for claims for January 4, 2017 & January 8, 2017 dates of service Can also attach a spreadsheet 218

220 MAC ACTIONS UPON RECEIPT Upon receiving your valid request for redetermination of an overpayment, we ll take the following actions: Cease recoupment of the overpayment that is the subject of the appeal, or will not initiate recoupment if it has not yet started; Retain any amounts recouped, if they have already recouped before receiving the request for redetermination and apply them first to interest & then to principal; and Will continue to collect any other debts that you might owe, but will not withhold or place in suspense any monies related to this debt, while it is in the appeal status 219

221 OVERPAYMENT REDETERMINATION OUTCOMES Overpayment Redetermination has three possible outcomes: Full reversal of overpayment decision Our Finance Dept. will adjust the overpayment & amount of interest charged resulting in adjustment to overpayment amount; most often adjusted to zero balance Partial reversal (Partially Favorable) of overpayment decision Our Finance Dept. will recalculate the debt & adjust the overpayment balance amount still owed based on the findings & issue a revised demand letter for the newly calculated overpayment amount. This letter will state that contractor can begin recoupment no earlier than the 61 st day from date of the revised overpayment determination if they have not been notified by the QIC that you have requested a reconsideration. It will also state that in order to stop recoupment under the provisions of Section 935 of the MMA, you must request a valid second level appeal (reconsideration) of the overpayment Full Affirmation of the overpayment decision With this unfavorable decision that upholds the overpayment determination, our Finance department will issue the 2 nd & 3 rd demand letter (as appropriate), which will state they can begin to recoup no earlier than 61 st calendar day from the Medicare redetermination notice, if they have not been notified by the QIC that you have requested a reconsideration. It will also state that in order to stop recoupment under the provisions of Section 935 of the MMA, you must request a valid second level appeal (reconsideration) of overpayment 220

222 SUBSEQUENT LEVELS OF APPEAL Reconsideration Second Level of Appeal Filed to the Qualified Independent Contractor (QIC) Stops recoupment Administrative Law Judge (ALJ) Filed to the Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals within the Department of Health and Human Services Requires minimum amount in controversy = $ for requests filed on or after 1/1/2017 Does Not Stop recoupment Medicare Appeals Council Review Filed to the Medicare Appeals Council Administered by the HHH Departmental Appeals Board (DAB) Does Not Stop recoupment Judicial Review Conducted in U.S. District Court 221

223 REFERENCES/RESOURCES CMS MLNs: Medicare Parts A & B Appeals Process Medicare Overpayments Limitation on Recoupment (935) for Provider, Physician and Suppliers Overpayments CMS Internet Only Manuals: Publication , Chapter 29 Publication , Chapter 3 Questions? 222