Provider Customer Service - JE Part B

Q1. How can providers submit a "corrected" claim?
A1. All claim submissions are considered new claims. A claim should only be resubmitted if the claim rejects for missing, invalid, or incomplete information. When a claim processes, a provider should follow the reopening or appeal process to make corrections to the claim.

Q2. Does Medicare pre-authorize services? If so, how should a provider obtain pre-authorization for prescription drugs for a beneficiary?
A2. With the single exception of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) services, Part B Medicare does not perform prior authorization of any service. All part B services are paid based upon reasonableness and necessity of the services performed and supplied and is determined on a case-by-case basis.

Prescription drugs are covered under Medicare Part D. A beneficiary has many Medicare Part D drug plans available to choose from. Refer to the back of the Medicare Part D card for contact information to obtain a pre-authorization. This information is not available through the PCC.

Medicare Part A has a new prior authorization program, Prior Authorization for Certain Outpatient Department (OPD) Services for hospitals. Noridian would like to remind providers that if a facility's service is deemed not medically necessary, the individual rendering provider's related services would also be considered non-covered. Physicians and Non-Physician practitioners (NPPs) are encouraged to work with the facility to provide them with all necessary documentation.

If a provider doubts the medical necessity of their service, he/she may safeguard themselves by having the beneficiary sign a waiver of liability Advance Beneficiary Notice of Noncoverage (ABN) prior to having the service performed. Be aware routine usage of an ABN is forbidden by Medicare.

Q3. If a patient does not want Medicare to be billed, can a patient skip using Medicare?
A3. Section 1848(g)(4)(A) of the social Security Act requires all Eligible Specialties to submit claims for their Medicare patients. If an eligible provider does not wish to submit a claim, they are required to provide all required Opt Out paper work to Medicare and their patients prior to seeing the patient.

The Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 40 states,

"The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary's legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare. However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare."

Q4. How does a provider request a Denial Only letter?
A4. Providers who are eligible to enroll in Medicare must do so if he/she provides covered services to a Medicare beneficiary. Under the Mandatory Claim Submission rule, it is a requirement that providers and suppliers submit Medicare claims for all covered services on behalf of Medicare beneficiaries.

Medicare does not, however, enroll and provide coverage for services rendered by all practitioners from whom a Medicare beneficiary may receive services. The following practitioner's services are not reimbursed by Medicare (not an all-inclusive list): acupuncturist, massage therapist, non-ambulance transport service.

For non-eligible providers rendering services to a Medicare beneficiary, where the beneficiary is liable, the beneficiary must complete and submit the below items to Noridian. Be sure it is sent it to the appropriate address. See the Mailing Addresses webpage.

• CMS1490S Form (practitioner may assist)
• Provider's itemized bill (required)
• Provider statement indicating that they are unable to bill Medicare because he/she does not meet provider required credentials

The beneficiary will receive a Noridian Medicare Summary Notice (MSN) identifying the claim denial. They must contact their secondary insurance for instruction on how to submit the claim to them for payment. Patients may contact 1-800-MEDICARE with questions related to the status of the claim as the Noridian Provider Contact Center (PCC) is not able to assist them.

Q5. Where can a provider find who the patient has elected for his/her Part D/drug coverage?
A5. The PCC CSRs do not have access to a beneficiary's Part D coverage information. Physician or suppliers must contact the beneficiary to confirm who he/she has elected for coverage. If they are unaware of who they have elected, he/she must contact the Beneficiary Call Center (1-800- MEDICARE). This information may also be accessed via NMP.

Q6. Can providers waive cost-sharing for Medicare Patients?
A6. Providers are required to collect any outstanding deductible and coinsurance from the beneficiary not covered by a supplemental insurance unless they meet one of the following exceptions:

• Qualified Medicare Beneficiaries (QMB) do not owe deductibles for covered services.
• The provider may waive any or all of the charges when the provider has clear internal processes that cover both Medicare and non-Medicare patients, and documents the financial hardship waiver when one is given.

Q7. Will resubmitting or reopening an adjusted claim cancel the recoupment?
A7. Providers may review Noridian's Overpayment and Recoupment page for appropriate actions that may be taken in response to an overpayment. Neither reopening a claim nor submitting a corrected claim will stop the original claim from being recouped.

Q8. If there is an offset on a Remittance Advice (RA), is there a way a provider can find out what patient it is for without speaking to customer service?
A8. The Noridian Medicare Portal (NMP) can provide all claim details by using the Financial Control Number (FCN) if the FCN is based on a withholding of a claim. While in NMP, select the Claim Specific Remittance Advice option. Remove the first two digits of the FCN (which identifies the region). The next 13 numbers can be entered as the Internal Control Number (ICN) for the search. Once the search is completed, the claim information for which the offset occurred will be provided.

Q9. A claim is denied for timely filing. Can anything be charged to the beneficiary?
A9. Per the CMS Internet Only Manual (IOM) Publication 100-04, Chapter 1, Section 70.4, "The provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made." If the patient is a Qualified Medicare Beneficiary, the provider may not charge them for any Medicare cost sharing.

Q10. A provider submitted a Redetermination request on a claim that denied for timely filing but got a letter indicating that a claim denied for timely file cannot be appealed. Are there exceptions to this?
A10. A claim must be filed within one year from the date of service. Any claims submitted after that time frame will receive a timely filing denial. Please note that for a claim to be considered timely, the claim must be filed without any incomplete or invalid information. Thus, any unprocessable claims submitted prior to the timely filing denial do not count towards the one-year time limit.

Timely filing denials are not afforded appeal rights. However, there are exceptions in the which are found in the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Sections 70-70.4. Common exceptions are retroactive Medicare entitlement, retroactive disenrollment from a Medicare Advantage Plan, and a State Medicaid Agency recouping its money from the provider, and administrative errors caused by the Medicare program. If providers feel they qualify for an exception, please send an timely filing waiver request to our office. Be sure to include any copies of official letters from the State Medicaid office, the Social Security Office, or other official entity. You may use the Redetermination Request Form, the General Written Inquiries Form, or a letter to submit the request. Please note, even the Redetermination form is used, this is not a level of appeal.

For claims that have been reviewed by the Recovery Auditor Contractor (RAC) or other review entity and recouped, Noridian Healthcare Solutions (Noridian) encourages providers to appeal those claims rather than resubmit them. Indicate on the Part B Redetermination Form the changes that need to be made and include the demand letter and audit detail summary along with any pertinent documentation. We will process the claim with the requested changes. Re-billing could cause duplicate payment, potential delay of payment, or could result in further overpayment action. The Part B Redetermination Form can be found on our website under the Forms tab after selecting the proper Jurisdiction: /.

Q11. What pieces of information does the Provider Contact Center require for a claim inquiry?
A11. As of September 29, 2021, callers must have the following information readily available for all claim related inquires:

• The National Provider Identifier (NPI)
• The Provider Transaction Access Number (PTAN)
• Tax Identification Number (TIN)
• Medicare Beneficiary Identifier (MBI) or patient's most current Medicare number
• Beneficiary's full first and last name
• The date of service (DOS) of the claim in question
• A copy of the remit, Medicare Summary Notice (MSN), or Electronic Remittance Advice (ERA)
• The Claims Adjustment Reason Code (CARC) of the claim in question

Q12. If I do not know my Provider Transaction Number (PTAN), how can I request it?
A12. PTANs can be requested through Provider Enrollment, Chain, and Ownership System (PECOS). Please follow the steps provided on the PTAN webpage.

Q13. When providers ask CSRs which procedure code or diagnosis code they should bill with, why are they told to contact a coder or the American Medical Association (AMA)?
A13. It is the provider's responsibility to determine the correct procedure and diagnosis code for a patient based on what is furnished to the Medicare beneficiary. CSRs are not professional coders and do not have the experience to determine the proper use of codes. Address questions regarding Current Procedural Terminology (CPT) codes to the AMA. Questions regarding ICD-9-CM or ICD-10-CM diagnosis codes, contact the American Hospital Association's Coding Clinic. See more information in the CMS IOM, Publication 100-09, Chapter 6, Section 30.1.1.

Q14. Why do I have to use the Interactive Voice Response (IVR)?
A14. Because of CMS Change Request (CR) 3376, providers are required to use the IVR application to access basic inquires such as eligibility, claim status, and certain financial information such as check information and the breakdown of payments and withholdings for specific remittance dates. Our customer service representatives are available to answer questions that cannot be answered by the IVR.

Q15. Where can a provider obtain supplemental insurance information for a patient and if it is set up for automatic crossover?
A15. Medicare contractors are unable to provide supplemental insurance information for routine eligibility checks. Providers are advised to verify with the patient if they have any insurances besides Medicare. Automatic crossovers are set up by the supplemental insurance. If a claim is selected for crossover, it will display below the claim information on the Medicare remittance that the claim was selected for crossover.

Q16. How long will it take for a claim to process?
A16. Per CMS regulations, all "clean" claims, or claims that do not require additional research or investigation, must be paid or denied within 30 days of receipt. If a paid claim does not pay in that time, interest is paid. The standard processing time for claims before payment is made is at least 14 days of processing for electronic claims, and at least 29 days for paper claims.

Q17. My patient has a Medicare Advantage Plan and Medicare. Who pays first?
A17. Medicare Advantage Plans are replacements to traditional Medicare. If a patient has a Medicare Advantage Plan, providers do not bill Medicare unless the patient is in a Clinical Trial or Hospice stay.

Q18. When Medicare is secondary, will Medicare pick-up the primary deductible/coinsurance?
A18. Medicare is not a supplemental insurance. Medicare will take into consideration what the primary insurer pays and allows; however, will not pay above the allowed amount had we been the primary payer. See the MSP Payment Calculation Examples webpage to see how Medicare makes their payment.

Q19. What do I do if Medicare recouped a claim twice?
A19. Medicare does not ‘double recoup’ claims. When a claim is adjusted, a remit will be sent to the provider informing them it has been reprocessed. The remit will have a Provider Level Balance (PLB) reason code FB (forward balance). A PLB reason code of FB is not a recoupment. It is notifying the provider the claim had already paid previously. Providers can refer to the ICN the Forwarding balance is for and review the PREV PAID amount under the ICN. The PREV PAID is the amount the claim had already previously been paid and should be compared to the current paid amount. If the previous paid amount is more, then the net amount on the remit will be zero, and the provider owes the difference. If the previous paid is less, then Medicare is paying the provider the difference between the previous paid and current paid amount.

There may be times when a provider mails a check to Noridian, but the claim has already offset on a Medicare remit. This offset will be identified as a Withholding (WO) on a provider’s remit. If the debt has already been offset prior to receiving the provider’s check, the check will be applied to any other outstanding debts the provider owes. If the provider owes no other money to Medicare, Noridian will reissue the check to the provider in the form of a special payment. In these situations, Noridian will mail the provider a letter within 30 days informing them of how the check will be applied. Providers are advised to watch their mail for these letters.

Providers may refer to Noridian’s Overpayment and Recoupment for further details.

Q20. What amount does Medicare use when calculating a beneficiary's therapy cap?
A20. The Medicare allowed amount is applied towards the therapy cap limit. This is true even if Medicare is secondary.