Provider Customer Service Frequently Asked Questions (FAQs)

Q1. 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?
A1. 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.

Q2. A claim is denied for timely filing. Can anything be charged to the beneficiary?
A2. 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."

Q3: Can a claim be changed from Medicare primary to Medicare secondary (or vice versa) through the reopening process?
A3: A reopening cannot be requested to change the primary payer on a claim. If a claim was denied and the primary payer needs to be changed, it can be resubmitted. If a claim has been paid and the primary payer needs to be changed, the MSP Form can be used to adjust appropriately.

Q4. Is it possible to have a stale-dated check reissued?
A4. If the original check is returned to Noridian along with a request to have it reissued or if the check had been previously returned to Noridian as undeliverable and required research, a stale-dated check may be reissued. Contact the Provider Contact Center as this must be verified by our Recoupment department as a possibility.

Q5. How does a provider request a Denial Only letter?
A5. 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): any type of counselor, 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.

Q6. 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?
A6. A claim that is denied because it was not filed timely is not afforded appeal rights. See the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.

Medicare regulations, 42 CFR 424.44, allow that where a Medicare program error causes the failure of a provider to file a claim for payment within the time limit in section 70.1, the time limit will be extended through the last day of the sixth calendar month following the month in which the error is rectified by notification to the provider or beneficiary.

If a claim is denied for timely filing as the result of an administrative error due to a government agency, such as a Medicaid agency recouping money due to Medicare entitlement by the patient at the time of the service or an error with the patient's Social Security Administration (SSA) entitlement, the claim(s) may be resubmitted with a comment in Item 19 of the CMS-1500 claim form (or electronic equivalent) that indicates there was an administrative error. The comment in Item 19 for Medicaid recoupments should state "Medicare Buy Back" and for SSA retroactive entitlements, the comment should state "SSA Error-Retroactive Entitlement."

Paper claims should include a copy of the letter that indicates the date range for the claims involved or the effective date of the Medicare entitlement. Claims must be submitted by the last day of the sixth calendar month following notification that the error has been corrected by the government agency. The timely filing limit cannot be extended beyond December 31 of the third calendar year after the year in which the services were furnished. (For services furnished during October – December of a year, the time limit may be extended no later than the end of the fourth year after that year.)

Q7. What amount does Medicare use when calculating a beneficiary's therapy cap?
A7. The Medicare allowed amount is applied towards the therapy cap limit. This is true even if Medicare is secondary.

Q8. Does Medicare preauthorize services? If so, how should a provider obtain pre-authorization for prescription drugs for a beneficiary?
A8. Under Medicare law, payment for services and supplies is based upon the reasonableness and necessity of the services performed and supplied and is determined on a case-by-case basis. Medicare is unable to preauthorize coverage of an anticipated service or supply. If a provider is in doubt as to whether Medicare will cover a service or supply for a specific patient, 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. A waiver holds the beneficiary liable for the service should it be denied for medical necessity reasons. If an ABN is obtained, the service must be appended with a GA modifier.

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.

Q9. 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)?
A9. 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.

Q10. Why can't a provider see all his/her appeals within NMP?
A10. There are times that a submitted appeal must be forwarded to a different department such as Medicare Secondary Payer. In these situations, the appeal cannot be viewed within NMP. To check the appeal status, contact the PCC.

Q11. Where can a provider find who the patient has elected for his/her Part D/drug coverage?
A11. 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.

Q12. Why are providers required to have a Clinical Laboratory Improvement Amendments (CLIA) number on a claim when completing CLIA waived tests or appending modifier QW?
A12. CLIA waived is a categorization of tests and doesn't exempt the lab from having to be certified. The law requires all labs to obtain a CLIA number and certificate regardless of the type of test they are performing. The CLIA number identifies the type of tests a lab is certified to perform and needs to be submitted on the claim submission. See CMS FAQs on CLIA.

Q13. When Medicare is secondary, will Medicare pick-up the primary deductible/coinsurance?
A13. 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.

Q14. If I do not know my Provider Transaction Number (PTAN), how can I request it?
A14. PTANs can be requested through Provider Enrollment, Chain, and Ownership System (PECOS). Please follow the steps provided on the PTAN webpage.

Q15. Why do I have to use the Interactive Voice Response (IVR)?
A15. 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.

Q16. Is there a place I can check claim status or eligibility online?
A16. The Noridian Medicare Portal (NMP) is a free, web-based provider portal used to perform Medicare eligibility, claim status and single-claim remittance advice, appeal status inquiries, and redetermination submissions over the Internet.

Q17. Does a patient's Medicare plan cover out of network benefits?
A17. Out of network benefits do not apply to Medicare. If a provider is enrolled in Medicare and a patient is present in the US, at the time of service, the provider may see the patient.

Q18. How can providers submit a "corrected" claim?
A18. 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.

Q19. My patient has a Medicare Advantage Plan and Medicare. Who pays first?
A19. If a patient has a Medicare Advantage Plan, providers do not bill regular Medicare unless the patient is in a Clinical Trial or Hospice stay.

Q20. How long will it take for a claim to process?
A20. 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.


Last Updated Apr 01, 2020