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MEDICARE PART A UPDATE

Wendy Weary, Sr. Provider Relations Representative, Provider

Outreach & Education

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PRE‐TEST

Welcome! I’m Paul Metto! What do you know?

www.surveymonkey.com/r/JMAMACtoberfestPreTest

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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

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DISCLAIMER This information is current as of August 16, 2017. Any changes or new information superseding this information is provided in articles with publication dates after August 16, 2017, posted on our website: www.PalmettoGBA.com/jma

CPT only copyright 2017 American Medical Association. All rights reserved.

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www.PalmettoGBA.com/jma

PALMETTO GBA UPDATES Interactive Tools

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EMAIL UPDATES

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PROVIDER ENROLLMENT APPLICATION STATUS LOOKUP

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FORMS

Teleconference/webcasts (Providers)

In‐Person (Associations)

Note: Please complete the form online

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ADR RESPONSE CALCULATOR

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CDR CALCULATOR

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APPEALS DECISION TOOL

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APPEALS CALCULATOR

Have an Appeals questions?

Dial into a special Appeals Ask the Contractor Teleconference (ACT) on

October 19, 2017

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CLAIM SUBMISSION AND PAYMENT ERRORS

Data Analysis

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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

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PART A QUARTERLY TOTAL DENIALS DATA Part A Denial

Code

31814 31324 31241 31947 38200 U5233 38038 54NCD 55503 36330

Claim Count % Denied to Total % Denied to Total w/Denial Code w/any Denial Code excluding RTPs

157,263 25.7 4.2 152,359 25.0 4.1 51,452 8.4 1.4 28,559 4.7 0.7 19,582 3.2 0.5 17,752 2.9 0.5 14,974 2.4 0.4 17,399 2.8 0.5 13,513 2.2 0.4 12,943 2.1 0.4

Relates to Dialysis Facilities 16

REASON CODE EDITING Reason Code

Claim Reporting Detail Edit Logic

31814 Non‐payable G‐codes for functional therapy status

Claims‐based data collection required for outpatient therapy

31324 Line item(s) non‐covered w/ GL, GY or TS modifier

Appropriately assigns liability to the beneficiary for payment

31241 Line item(s) w/ GZ modifier ‐ no ABN provided to patient

Auto denial ‐ assigns liability to provider; expedites appeal process

38200 Claim is an exact duplicate of a previously processed claim

Reject. Check records for a previously processed claim

38038 Claim overlaps another for same provider & DOS whether any revenue code lines are equal or not

Reject. Notification that you must adjust previously processed claim to add charges

U5233 Services fall within a Medicare Advantage (MA) enrollment. Failure to verify beneficiary eligibility prior to submission.

Reject. Bill MA Plan. Inpatient claims must be submitted to Medicare with CC 04 for benefit tracking purposes

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Reason Code

Claim Reporting Detail Edit Logic

55503 Line denied because medical Review LCDs under Medical necessity was not supported as

outlined in Palmetto GBA's Local Policies on our website

Coverage Determination (LCD) 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

MEDICAL NECESSITY EDITING

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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

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LOCATING LCD # IN DDE

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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

http://www.cms.gov/medicare‐coverage‐database/indexes/ncd‐alphabetical‐index.aspx

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http://www.cms.gov/medicare-coverage

LOCATING NCD # IN DDE

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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

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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 30940 triggers because initial claim had at least one service medically reviewed

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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

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DDE MAP171D EXAMPLE

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CORRECTING CLAIMS WITH MEDICALLY DENIED LINES

Corrections, Reopenings & Appeals

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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

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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

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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!

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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

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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

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TIPS TO REMEMBER Quickest, easiest & most accurate to

TIPS

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

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NEW MEDICARE CARD PROJECT Social Security Number (SSN)

Removal Initiative

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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

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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

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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 Example SSA HICN 123‐45‐6789‐A1 MBI 1EG4‐TE5‐MK73

Dashes for display purposes only

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2016‐2017

MBI IMPLEMENTATION MILESTONES

2016‐2017 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

2018‐2020 Apr 2018 Apr 16, 2019

Statutory deadline to All systems & issue MBI cards processes able to

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

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TRANSITION PERIOD o Transition period: Apr. 2018 ‐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

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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)

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MBI LOOK‐UP TOOL o Secure Portal = https://palmettogba.com/eservices 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

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https://palmettogba.com/eservices

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!

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ACTION TO BE READY Refer to the NMC webpage! https://www.cms.gov/Medicare/New‐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

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https://www.cms.gov/Medicare/New-Medicare-Card/index.html

MEDICAL REVIEW CLINICAL PERSPECTIVE

Clinical Consultants, Provider Outreach & Education

Lynn Kelly, RN and April Gause, LPN

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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

https://oig.hhs.gov

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http:https://oig.hhs.gov

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 ‐ 66984 DRG 470: Major Joint Replace/Reattach Lower Extremity w/o MCC IRF CMGs A,B,C,D 0701‐0704 Inpatient Psychiatric Facility ‐ DRG 885: Psychoses Skilled Nursing Facility RUG Codes DRG 291 Heart Failure & Shock w/MCC ‐ Post Pay

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

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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 L35026

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REMICADE (INFLIXIMAB) Remicade/Infliximab = tumor necrosis factor blocker approved for: Crohn’s Disease Ulcerative Colitis

LCD L35667

Rheumatoid Arthritis Ankylosing Spondylitis Plaque Psoriasis

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DOCUMENTATION REQUIREMENT TIPS Correct Beneficiary

TIPS

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

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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

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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

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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

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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 100‐02,

Medicare Benefit Policy Manual, Chapter 15, Section 50.4.5

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HYPERBARIC OXYGEN (HBO) G0277 PROBE REVIEW ACT‐HBO Therapy, April 20, 2017 www.palmettogba.com/jma

Guide proper billing of HBO Services:

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www.palmettogba.com/jma

SNF ULTRA HIGH RUG CODES PROBE REVIEW

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SNF ULTRA HIGH RUG CODES PROBE REVIEW Denial Code

Description NC SC VA WV

5D504/5H504

Not Medically reasonable or necessary

60.66 82.25 63.94 94.43

56900 Requested records not submitted 33.10 14.11 12.30 2.41

5DOWN MR down code 6.24 0.88 21.55 3.16

5D507/5H507

SNF MDS not in national repository

0.0 1.74 2.21 0.0

5H508 100-day benefits are exhausted 0.0 0.42 0.0 0.0

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• 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

SNF 14 LOWER RUG CODES PROBE REVIEW

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SNF 14 LOWER RUG CODES PROBE REVIEW Denial Code

Description NC SC VA WV

5D504/5H504

Not Medically reasonable or necessary

90.42 70.94 87.08 98.34

56900 Requested records not submitted

3.35 26.73 9.25 1.66

5DOWN MR down code 0.67 0.0 3.67 0.0 5D501/5H501

Billed in error 5.57 0.0 0.0 0.0

5D507/5D507

SNF MDS is not in national repository

0.0 2.32 0.0 0.0

COMPARATIVE BILLING REPORTS (CBR)

DRG Coding Accuracy

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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

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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

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CARDIAC REHABILITATION CBR

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CARDIAC REHABILITATION EDUCATION Clinical Corner: Cardiac Rehabilitation Module www.palmettogba.com/elearn/ClinicalCornerCardiacRehab/S tory.html

Focuses on coverage/documentation requirements Phases & Covered Services Components, Progress Notes & Setting Direct Supervision & Physician Requirements

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www.palmettogba.com/elearn/ClinicalCornerCardiacRehab/S

RESOURCES Medicare National Coverage Determination (NCD) Manual Ch.1, Part 1, Sec. 20.10

Medicare Benefit Policy Manual 100‐02, 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

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PATIENT DISCHARGE STATUS CBR

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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

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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

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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)

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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

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PAYMENT Facilities excluded Full PPS rate paid to from IPPS: transferring hospital:

IRFs Payment to receiving hospital LTCHs Basis of Reasonable Cost Psychiatric Hospitals Rate of its respective payment Children’s Hospitals system

Cancer Hospitals IRF PPS LTCH PPS

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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

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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

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MLN MATTERS® NUMBER: SE1411

https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/downloads/SE1411.pdf

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network

POST‐TEST

Thank you for attending! What did you learn?

www.surveymonkey.com/r/JMAMACtoberfestPostTest

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MEDICARE PART B UPDATE Shannon Chase

Sr. Provider Relations Representative Provider Outreach & Education

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PRE‐TEST

Welcome! I’m Paul Metto! What do you know?

www.surveymonkey.com/r/JMBMACtoberfestPreTest

78

www.surveymonkey.com/r/JMBMACtoberfestPreTest

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:

www.PalmettoGBA.com/JMB

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.

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www.PalmettoGBA.com/JMB

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

Medicare Part B Clinical Overview

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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

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)

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TRANSITION PERIOD

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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)

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2016

March – September 2016

• Launch Phase I & II web content

• Listening sessions with external

stakeholders • MBI Generator in

test environment

– 2017

May – September 2017

• MBI development complete

• Medicare & You mailed with

information about New Medicare Card

2018 – 2020

April –October April 16, 2019 2018

• 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

MILESTONES OF MBI IMPLEMENTATION

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LOOK‐UP TOOL In the future providers will access the beneficiary MBI in the eServices secure portal at: https://palmettogba.com/eservices

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

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https://palmettogba.com/eservices

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

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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 https://www.cms.gov/Medicare/New‐Medicare‐Card/index.html

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https://www.cms.gov/Medicare/New-Medicare-Card/index.html

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

https://www.cms.gov/medicare/quality‐initiatives‐patient‐assessment‐instruments/value‐based‐programs/macra‐mips‐and‐apms/macra‐mips‐and‐apms.html

Two paths in the Quality Payment Program: Merit‐based Incentive Payment System (MIPS) Advanced Alternative Payment Models (AAPMs)

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https://www.cms.gov/medicare/quality-initiatives-patient

QUALITY PAYMENT PROGRAM

The Carolinas Center for Medical Excellence (CCME)

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QUALITY INNOVATION NETWORKS Technical assistance

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TOP INQUIRY CATEGORIES Policy/Coverage Rules

General Information

Appeals

Financial Information

Eligibility

Claim Status

Billing Issues

Unprocessable

Provider Enrollment

Claim Denials 6,211

2,018

2,016

1,773

1,748

1,298

1,099

1,013

511

379

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BASICS

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SELF SERVICE TOOLS

10/9/2017 95

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

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MLN MATTERS®

New look!

Click! CMS 2017 MLN

eNews Matters Articles Open Door Forums are located on the National Provider Calls and Events CMS Website

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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

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November 2016 Report (National)

Total Projected Improper Improper Payment Rate Claim Type Payment Payment

Part A (Total) $272.3 $26.4 9.7% Part A (Excluding Hospital

IPPS) $157.5 $22.0 14.0%

Part A (Hospital IPPS) $114.8 $4.4 3.8%

Part B $93.3 $10.9 11.7% DMEPOS $8.1 $3.7 46.3% Overall $373.7 $41.1 11.0%

COMPREHENSIVE ERROR RATE TESTING (CERT)

12.7 13.9 16.4 17.9

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Palmetto GBA JM Part B

2013 2014 2015 2016

CERT RESOURCES

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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.

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PART B MEDICARE ADVISORY

Application

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CLAIM PAYMENT ISSUE LOG (CPIL)

Innovation Application Success

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RESOURCES

Resource Location

E‐Mail Updates www.PalmettoGBA.com/JMB Select Listservs (top‐right)

Contact Us By Email [email protected]

Self‐Service Tools www.PalmettoGBA.com/JMB (center of home page)

Provider Contact Center (PCC) 855‐696‐0705

Medical Policies www.PalmettoGBA.com/JMB (under Topics)

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www.PalmettoGBA.com/JMBwww.PalmettoGBA.com/JMBmailto:[email protected]/JMB

MEDICAL REVIEW CLINICAL OVERVIEW

Jazz Harrison, RN Clinical Consultant

Provider Outreach & Education

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

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TOP 10 PART B MR DENIALS Rank Action

Code MR Comment

MR Comment Description Denied Amount

Count of Denied Lines

Percent of Denied Lines to Total Lines Denied

1 F10 NODOC DOCUMENTATION REQUESTED FOR THIS DATE OF SERVICE WAS NOT RECEIVED OR WAS INCOMPLETE.

44,432 398 33.4

2 F26 BILER CLAIM BILLED IN ERROR PER PROVIDER. 29,704 285 23.9 3 F12 WRONG DOCUMENTATION RECEIVED CONTAINS INCORRECT/INCOMPLETE/INVALID

PATIENT IDENTIFICATION OR DATE OF SERVICE 23,882 166 13.9

4 F41 DNSRP INFORMATION SUBMITTED CONTAINS AN INVALID/ILLEGIBLE PROVIDER SIGNATURE.

10,991 108 9.1

5 529 NOTMN PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPORT MEDICAL NECESSITY OF SERVICES BILLED.

14,090 94 7.9

6 015 EMCNM DOCUMENTATION REQUESTED FOR THIS DATE OF SERVICE WAS NOT RECEIVED OR WAS INCOMPLETE.

4,314 43 3.6

7 F06 NOSIG DOCUMENTATION LACKS THE NECESSARY PROVIDER SIGNATURE. 3,475 32 2.7 8 F18 BNSIG DOCUMENTATION RECEIVED LACKS THE NECESSARY BENEFICIARY OR

AUTHORIZED REPRESENTATIVE SIGNATURE. 3,626 12 1.0

9 066 ISIGN INFORMATION SUBMITTED CONTAINS AN INVALID/ILLEGIBLE PROVIDER SIGNATURE.

1,215 11 0.9

10 630 NOTML PAYER DEEMS THE INFORMATION SUBMITTED DOES NOT SUPPORT MEDICAL NECESSITY OF SERVICES BILLED.

5,161 10 0.8

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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

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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

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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

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CERT TIPS The following are some tips to prevent this error: Make sure the date(s) of service are documented

TIPS

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

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CERT TOP DENIALS CERT Error Code: 21 — Insufficient Documentation‐elements 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

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CERT TIPS… Remember it is the billing provider’s responsibility to

obtain any necessary information required for the record

TIPS

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

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MEDICAL REVIEW TOP DENIAL CATEGORIES Ambulance Evaluation and Management Eye procedures

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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

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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

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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

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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)

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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)

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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 11042-11047. 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 re-open/redetermination request form by fax to (803) 699-2427.

529/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 www.PalmettoGBA.com/medicare 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 non-physician practitioner.

Verify that electronic signature meets the CMS signature requirements as listed in the 120

THE EDIT EFFECTIVENESS LETTER article ‘Medicare Medical Records: Signature Requirements Acceptable and

Unacceptable Practices’ located on our website at www.PalmettoGBA.com/medicare. 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 www.PalmettoGBA.com/medicare.

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

www.PalmettoGBA.com/medicare 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

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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 855-696-0705. 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 email 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 email address with others.

To enroll, simply go to the Palmetto GBA Web site (www.PalmettoGBA.com/medicare) and click on "E-mail 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 10

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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

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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?

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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

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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

TIPS

Signatures/credentials of professionals Any other documentation deemed necessary to support medical necessity of services

Documentation specifically requested by the ADR letter

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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

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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

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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

POST‐TEST

Thank you for attending! What did you learn?

www.surveymonkey.com/r/JMBMACtoberfestPostTest

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www.surveymonkey.com/r/JMBMACtoberfestPostTest

ELECTRONIC DATA INTERCHANGE Kim Campbell, Manager

EDI Operations

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EDI ON PALMETTOGBA.COM

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http:PALMETTOGBA.COM

EDI OPTIONS

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EDI ENROLLMENT ASSISTANCE

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EDI ENROLLMENT INSTRUCTIONS GUIDE MODULE

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EDI ENROLLMENT STATUS TOOL

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ENROLLMENT LOOKUP

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ENROLLMENT STATUS MESSAGES

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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 www.Palmettogba.com/medicare

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www.Palmettogba.com/medicare

CONNECTIVITY ENHANCEMENTS

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EDI SYSTEM STATUS TOOL

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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

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EDI SYSTEM STATUS PAGE

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EDI SYSTEM STATUS LOG

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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

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

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SMART EDITS – PART B

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SMART EDIT INFORMATION

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SMART EDITS – PART A

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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 99213 HAS AN UNBUNDLE RELATIONSHIP WITH PROCEDURE CODE 90471 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

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SMART EDIT LISTING

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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 email and phone number have changed

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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

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eSERVICES PORTAL

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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

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CONTACT INFORMATION UPDATES Please call us if the following changes: Provider Address Submitter Address EDI Contact Person Name Telephone/Fax Numbers Email Address

Please keep the EDI contact information current

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CONTACT INFORMATION o Telephone number: 1‐855‐696‐0705, please listen carefully to the options and have your PTAN, NPI and Submitter ID available

o Email address for basic questions: [email protected]

o EDI Fax Numbers begin with 803 o EDI Helpdesk hours: 8 – 5 ET

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mailto:[email protected]

PROVIDER ENROLLMENT Teresa Newton, Director Provider Enrollment

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

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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

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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

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PROVIDER ENROLLMENT GLOBAL VIEW

Applications

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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.

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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 Medicare‐enrolled 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) ‐https://pecos.cms.hhs.gov

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http:https://pecos.cms.hhs.gov

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

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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

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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

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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

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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

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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

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REVALIDATION Section 6401 (a) of the Affordable Care Act Reinforces the revalidation requirements of 42 CFR §424.515 ‐‐ 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

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REVALIDATION CYCLE 2 Section 6401 (a) of the Affordable Care Act Reinforces the revalidation requirements of 42 CFR §424.515 ‐‐ 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

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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

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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. Email 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 email alerts for received letters

Standard USPS mail for non‐eService Users Provider enrollment revalidation notifications will be sent through the

U.S. Postal Service

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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 855

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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

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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

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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 https://data.cms.gov/revalidation to confirm your revalidation due date

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https://data.cms.gov/revalidation

REVALIDATION RESOURCES Visit https://data.cms.gov/revalidation Reassignment crosswalk list

MLN Matters SE1605 ‐Provider Enrollment Revalidation – Cycle 2

Revalidation Application Checklist

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https://data.cms.gov/revalidation

PROVIDER ENROLLMENT SELF SERVICE RESOURCES Internet‐based PECOS at www.cms.gov/MedicareProviderSupEnroll/04_Internetbase dPECOS.asp

Application Status Lookup Tool www.palmettogba.com Application Status Check via Palmetto GBA IVR – 855‐696‐0705

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http:www.palmettogba.comwww.cms.gov/MedicareProviderSupEnroll/04_Internetbase

eSERVICES Jessica Duffie

Senior Systems Support Technician e‐Commerce

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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.

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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

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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

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MFA Select the method to receive your MFA code.

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MFA Enter the MFA code sent to you via text or email.

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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 email and use the link to verify your email

o Log into your account to complete the profile verification process

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PROFILE VERIFICATION Profile verification email example:

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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.

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RECERTIFICATION Recertify Users button on the Admin tab:

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RECERTIFICATION Recertify users screen

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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

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ACCOUNT LINKING Drop‐down of linked accounts and recertification notifications

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NEED HELP? Support Resources o eServices User Manual (www.palmettogba.com/eServicesuserguide)

o eServices FAQs — Select the ‘eServices Portal’ topic from your line of business home page on www.palmettogba.com. 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.

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http:www.palmettogba.comwww.palmettogba.com/eServicesuserguide

APPEALS Kathy Kardules, Director

Part A/B Appeals

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Level 4

Level 4

MEDICARE PART A & B APPEALS PROCESS

Redetermination – Conducted by MAC

Reconsideration – QualifiedIndependentContractor (QI

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