Tuesday, December 8, 2015

Railroad Medicare Denials: Top Reasons and Procedures

The Palmetto GBA Denial Resolution tool includes resources for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you pick up the phone.

•    Access denial reasons in plain language
•    Scroll through the titles to locate your procedure
•    Use the Palmetto GBA search engine to search by remark code
Following are five of the top reasons that services submitted to Palmetto GBA are denied:
•    The patient is enrolled in hospice care. Services of the patient’s designated attending physician and services that are unrelated to the patient’s terminal condition may be paid separately, but modifiers are required to note these exceptions.
•    'Noncovered services' are never covered. They include eye refraction, 'well person' exams and hot/cold packs used in physical therapy.
•    Bundling due to 'National Correct Coding Initiative' are denied most often for these reasons: pulse oximetry, heparin, creatinine (blood) and some supplies
•    Medicare is secondary, but the claim was submitted as primary. The MSP Lookup Tool can help guide you as to whether another insurer may be involved. Verify whether Medicare is the primary or secondary insurer for specific patients by using the Palmetto GBA Online Provider Services (OPS) application.
•    Pre- and post-op visits are included in the global surgery package. Tip: Access the CMS Medicare Physician Fee Schedule Database (MPFSDB) to determine the global period for surgical procedures. The Palmetto GBA Modifier Lookup tool provides step-by-step instructions for accessing the MPFSDB as well as guidance on how to submit 'exceptions' to the global surgery package.
Use the Denial Resolution tool to determine whether your denials for these services are correct or whether there are other steps you should take before submitting these claims (look in the 'Self-Service Tools' section).

Railroad Medicare Electronic Claim Required: Denials

Denial Reason, Reason/Remark Code(s)

•    MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.  
•    MA117: Not covered unless submitted via electronic claim
•    MA44: Alert, no appeal rights. Adjudicative decision based on law
•    96: Non-covered charge(s)     
•    The Administrative Simplification Compliance Act (ASCA) already requires claims to be submitted electronically to Medicare, with a few exceptions
•    If you received a letter from Palmetto GBA requesting documentation that you qualify to submit paper claims, you must return the letter with the requested documentation within the specified time frame
•    If you do not supply the requested documentation within the time frame or if you do not qualify for a waiver to submit paper claims, you are required to file electronic claims to Palmetto GBA 
•    Contact the EDI Technical Support Center with questions regarding ASCA waiver letters or to request more information on free electronic billing software (PC Ace Pro32)

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