General
These are currently the most asked questions at our Provider Contact Center. Please read the Q&A below to see if we can help you with your inquiry.
- Our facility purchases blood and blood products from the local American Red Cross. We provided one bag of apheresis blood product, which is equivalent to 8 units of HCPCS code P9035. HCPCS code P9035 is defined as 'PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT'. When we bill for the units of this HCPCS code, would we bill 1 unit since we administered 1 bag of this product, or 8 units since one bag is equivalent to 8 units?
- My claim was adjusted and the money was retracted. The type of bill was 13G. How can I determine why my money was retracted in this situation?
- My claim rejected with reason code T5052. Should I submit an appeal so the claim can be reprocessed?
- How should we bill insulin when it is given as part of a patient's Total Parental Nutrition (TPN)?
- Is a clinic patient considered new or established if he was treated in an off-site clinic of the hospital or the emergency department within the past 3 years?
- Would a patient be considered a new admission if they were in our facility prior to a denial of payment for new admissions (DPNA), went home, then were readmitted to skilled care again after four days?
- Who can I contact with questions concerning the content of my PS&R report?
- Can I write and request that my suspended claims be sent to the claims processing area to be worked?
- My claim was adjusted and the money was retracted. The type of bill was 11G. How can I determine why my money was retracted in this situation?
- Can you please explain what status location 'I B9997' means?
- How do providers obtain overlapping claim information?
- The Customer Service Representative advised me they no longer can refer my suspended claim to the claims processing department. Why?
- Can you tell me how much was paid on my claim?
- The beneficiary's name in FISS does not match what I verified in the CWF. How does the name get corrected in FISS to match CWF?
- If my claim is rejected, how can I determine if I should adjust the claim or rebill it completely?
- My claim was denied in error with reason code 7BON1. We were advised that these claims were going to be reprocessed. My claim has not been reprocessed yet. What should I do?
- My claim was denied so I submitted a redetermination. The denial was upheld so I submitted a reconsideration. Again the denial was upheld. I disagree with this decision. What is my next level of appeal?
- Can I request a redetermination on a claim in status location 'I B9997'?
- Can I request a Clerical Error Reopening on a claim that was submitted for a hearing and denied?
- Can I request a Clerical Error Reopening on a claim that was rejected stating the patient has a MA plan?
- Can I request an appeal on a suspended claim?
- My claim denied with reason code 5ARAN and each line item denied with reason code 5PHY1 indicating that the diagnosis requirements provided in LCD Y-1FF were not met. I verified that the claim does contain a valid diagnosis code per the LCD requirements. Should we appeal this denial?
- Can I request an appeal on a claim that is pending?
- Should I request a redetermination on a claim that rejected because the patient was enrolled in an HMO?
- Should I request a redetermination on a claim if a line item was rejected due to a home health episode?
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In this scenario, you would submit your claim with 8 units since one bag is equivalent to 8 units of product. The description of the HCPCS code states each unit, therefore you need to identify the total units of product that was transfused.
(Question based on May 2008 top written inquiries)
Date Posted: 07/28/2008
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Adjustment claims with type of bill 13G are called host adjustments. You can determine why your money was retracted by looking at the dcn of the 13G claim. If the dcn ends with a 'U', your claim is overlapping a home health episode. If you are not able to access FISS, you can obtain the dcn from the IVR claims option. MD/DC providers can access the IVR by dialing 1-866-488-0545 and PA providers can call 1-800-560-6170. An IVR quick reference guide is available on our website.
(Question based on June 2008 top written inquiries)Date Posted: 07/28/2008
My claim rejected with reason code T5052. Should I submit an appeal so the claim can be reprocessed?
Reason code T5052 indicates that the health insurance claim (HIC) number used on the claim is not on file. You should resubmit your claim under the correct HIC number. An appeal can only be considered on a finalized claim that is partially or fully denied. Please refer to the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on June 2008 top written inquiries)
Date Posted: 07/28/2008
How should we bill insulin when it is given as part of a patient's Total Parental Nutrition (TPN)?
Per the CMS IOM Publication 100-4, Chapter 20, Section 10, parenteral and enteral nutrition, and related accessories and supplies, are covered under the Medicare program as a prosthetic device. All Parenteral and Enteral (PEN) services furnished under Part B are billed to the Durable Medical Equipment Medicare Administrative Contractor (DMEMAC).
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
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If a patient visits a hospital clinic and has a medical record on file (within the last 3 years), the patient is considered established.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
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When a situation does not constitute a temporary or therapeutic leave, it would be considered a new admission and therefore subject to the DPNA.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
Who can I contact with questions concerning the content of my PS&R report?
Questions regarding the content of your PS&R report should be directed to Donna Silvio at 412-544-1841.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
Can I write and request that my suspended claims be sent to the claims processing area to be worked?
No, our claims processing area works the claims in the order they are received. You can obtain more information on suspended claims under the 'Hot Topics' section of the Highmark Medicare Services website.
(Question based on April 2008 top written inquiries)Date Posted: 07/28/2008
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Adjustment claims with type of bill 11G are called host adjustments. You can determine why your money was retracted by looking at the dcn of the 11G claim. If the dcn ends with a 'T', your claim is overlapping a home health episode. If the dcn ends with a 'Z', you need to verify your patient status code. If you are not able to access the FISS, you can obtain the dcn from the IVR. You should select the claims option and upon entering the requested information, the dcn will be provided. MD/DC providers can access the IVR by dialing 1-866-488-0545 and PA providers can call 1-800-560-6170. An IVR quick reference guide is available on our website.
(Question based on June 2008 top phone inquiries)
Date Posted: 07/28/2008
Can you please explain what status location 'I B9997' means?
Status location I B9997 means that the claim is inactive. In order to receive payment for this type of claim, the provider needs to resubmit a new claim.
(Question based on April 2008 top phone inquiries)
Date Posted: 07/28/2008
How do providers obtain overlapping claim information?
Providers who render recurring services on a monthly basis should request information about inpatient stays from their patients when the services are provided. This will help decrease the number of overlapping claim rejections a facility receives. However, if a claim is billed and is overlapping another facility's claim, the customer service representatives (CSRs) can provide overlapping claim information processed by any Medicare contractor. For PA providers, please call 1-800-560-6170 and for MD/DC providers call 1-866-488-0545. Also, CMS provides listings of provider numbers, provider names, addresses and the assigned Fiscal Intermediary. To access these listings, follow these instructions:
a) access The Centers for Medicare and Medicaid Services (CMS) website.
b) access 'Research, Statistics, Data & Systems
c) access Cost Reports under Files For Order
d) access whatever provider type on the left hand side
e) scroll down to Frequent Reports and select Provider ID Information(Question based on April, May & June 2008 top phone inquiries)
Date Posted: 07/28/2008
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The claims processing department is currently working on the suspended claim inventory. Providers can access information regarding suspended claims from the Part A homepage under the Newsroom Article titled "Claims Processing Timeliness Reminder". The claims are processed on a first in, first out basis so our CSRs are not able to provide a timeframe when your claim will be finalized.
(Question based on May & June 2008 top phone inquiries)
Date Posted: 07/28/2008
Can you tell me how much was paid on my claim?
Providers can obtain this information through the IVR utilizing the Claim Details function under the Claim Status option. Instructions on using the IVR can be found online for PA providers and for MD/DC providers.
(Question based on May 2008 top phone inquiries)
Date Posted: 07/28/2008
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The Customer Service Representatives can correct the beneficiary's name in FISS to match CWF. Please call 1-800-560-6170 (PA providers) or 1-866-488-0545 (MD/DC providers).
(Question based on May & June 2008 top phone inquiries)
Date Posted: 07/28/2008
If my claim is rejected, how can I determine if I should adjust the claim or rebill it completely?
Providers only need to adjust rejected claims if they are posted to the Common Working File (CWF). Rejected claims not posted to the CWF can be resubmitted. You can determine if a claim has been posted to the CWF by verifying the tape-to-tape field on claim page 32. If this field is populated with an 'X', the claim was not posted to the CWF and you should resubmit the claim. If there is not an 'X' in this field, you will need to adjust the claim.
(Question based on June 2008 top phone inquiries)
Date Posted: 07/28/2008
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If you still have claims that were denied with 7BON1 in error, you can call the customer contact center and we will refer the claim to be reprocessed. The telephone number for the customer contact center for MD/DC providers to call is 1-866-488-0545 and for PA providers is 1-800-560-6170.
(Question based on June 2008 top phone inquiries)
Date Posted: 07/28/2008
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The next level of appeal is the administrative law judge (ALJ). Information is available in the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on June 2008 top written inquiries)
Date Posted: 07/28/2008
Can I request a redetermination on a claim in status location 'I B9997'?
No, claims in status location 'I B9997' are in an inactive status. A claim must be finalized before a redetermination request can be submitted. This information was published in the Medicare Part A News for May 2007. Also. please reference the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
Can I request a Clerical Error Reopening on a claim that was submitted for a hearing and denied?
No, the Appeals department cannot reopen a claim for which a hearing decision has been rendered.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
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No, an appeal can only be considered on a finalized claim that is partially or fully denied. Please reference the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
Can I request an appeal on a suspended claim?
No, an appeal can only be considered on a finalized claim that is partially or fully denied. Please reference the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on April 2008 top written inquiries)
Date Posted: 07/28/2008
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Providers with claims that were denied inappropriately due to line item reason code 5PHY1 should not appeal the denial. Highmark Medicare Services will identify all the affected claims and will reprocess them internally.
(Question based on May 2008 top written inquiries)
Date Posted: 07/28/2008
Can I request an appeal on a claim that is pending?
No, an appeal can only be considered on a finalized claim that is partially or fully denied. Please reference the Quick Reference Guide for Medicare Part A Appeals. If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.
(Question based on April, May & June 2008 top written inquiries)
Date Posted: 07/28/2008
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No, you should only request an appeal on a claim that is fully denied or partially denied. If your claim rejected due to HMO enrollment, you should submit the claim to the patient's HMO.
(Question based on June 2008 top written inquiries)
Date Posted: 07/28/2008
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No, you should only request an appeal on a claim that is fully denied or partially denied. If there is a line item that was rejected on your claim due to a home health episode, you should submit your service to the home health for payment. Highmark Medicare Services created a Quick Reference Guide for Medicare Part A Appeals which is available on our website. Also, please reference The Quick Reference Guide for Filing Adjustment and Cancel Claims.
(Question based on June 2008 top written inquiries)
Date Posted: 07/28/2008