1. After submitting an electronic claim, I called your office and they had not received the claim, what happened to it?
2. I called your office to inquire about the Medicare eligibility of a patient and I was told that Medicare was prohibited from releasing that information. Is that true?
3. How do I enroll as a Medicare provider?
4. My claim was denied because the patient was enrolled in an HMO. How would I know this before I render a service?
5. I performed a laboratory test on a patient and the claim was denied for a lack of referring UPIN number in order to process the claim.
6. My claim was denied due to the fact that the patient was receiving Home Health Care services, why was that?
7. My claim was denied stating that the diagnosis wasn't valid. I checked the ICD-9 book and found that it was current.
8. Where do I send my claim forms?
9. When should I use a GY modifier?
10. When should I begin using the National Provider Identifier?
11. Am I required to apply for electronic funds transfer for my Medicare payments?
12. Where can I find the Medicare Remit Easy Print software?
13. Where can I find the new CMS 1500 forms?
14. How do I contact the new DMERC carrier for New York State?
15. I received a denial on some of my claims that stated, “This provider was not certified/eligible to be paid for this procedure/service on this date of service”. To my knowledge nothing has changed. Why would I receive that denial?
16. My application for provider enrollment was returned to unprocessed. What are some reasons why that would happen?
17. How do I sign up for electronic remittance advice?
18. How can I obtain claim information without waiting for a customer representative?
19. Where can I find the forms to request electronic remittances files? (3/07)
20. When I check the status of a claim, that I submitted a week ago, the automated response system tells me that they are not working on anything at this time what does that mean? (3/07)
21. I used to receive paper copies of my remittances, but I no longer do, why is that? (3/07)
22. When should I begin using the new CMS-1500 forms? (3/07)
23. Where do I find the prices for the drug codes? (3/07)
24. Where do I put the NPI on the new CMS 1500 forms? (3/07)
25. How do I change my address? (3/07)
26. I submitted a claim for a patient that I saw in Queens County but it was rejected stating that the service was out of area? (3/07)
27. For Physical Therapy services, which amount is applied to the therapy cap, the approved amount of the paid amount? (3/07)
28. What is the Physician’s Quality Reporting Initiative? (7/07)
29. When I submit a claim with a legacy provider number and an NPI which number will I receive on my remittance notice? (7/07)
30. How do I notify you that I have a National Provider Identifier? (7/07)
31. Why did I receive rejection, which stated that the provider number was not valid on my claims that were submitted electronically? (7/07)
32. How can I make sure that my patient’s claims are crossed over to their secondary carrier? (7/07)
33. What is a Prepayment Review? (7/07)
34. What forms do I complete to join a group? (7/07)
35. How long does it take to process the reactivation of my provider number? (7/07)
36. Will providers be able to access a list of NPI numbers for use in billing? (7/07)
37. Can I submit the Medicare legacy provider number after May 23, 2008
38. Which drugs are paid based on the Average Sales Price methodology? (1/08)
39. What is the revalidaton process? (1/08)
40. What is the physical therapy limit for 2008? (1/08)
1. After submitting an electronic claim, I called your office and they had not received the claim, what happened to it?
In some instances, there are errors in the claim files that are submitted by billers. If there are errors in one of the claims, then that claim will not appear in the system that adjudicates the claim. The customer service representative will not have access to information on that claim. You must fix the problem and resubmit the claim. If you have a question concerning these types of errors, contact the Electronic Data Interchange department at 646 458-6721 or 646 458-6611.
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2. I called your office to inquire about the Medicare eligibility of a patient and I was told that Medicare was prohibited from releasing that information. Is that true?
The Privacy Act is a Federal Law designed to protect the privacy of Medicare beneficiaries. Eligibility information is not one of the issues covered by the law. Medicare carriers can release eligibility information to a provider. If you wish to inquire about the eligibility of a beneficiary, you can simply call our provider line. You must be able to provide us with the beneficiary's name, address, Medicare ID number and date of birth.
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3. How do I enroll as a Medicare provider?
To enroll with Medicare a provider must complete an application form. For CMS 855I is used for individual providers and form CMS 855B is used for provider groups. To obtain copies of the forms you may contact us at 877 868-7965. For more information on completing provider enrollment forms, visit our Provider Enrollment page at www.ghimedicare.com/provider/enrollment.html
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4. My claim was denied because the patient was enrolled in an HMO. How would I know this before I render a service?
When a patient visits your office, you may inquire with them to see if they have any insurance other than Medicare Fee-for-Service. Also, you or your office staff may contact our office at (877) 868-7965 to obtain whether or not the patient is enrolled in a Medicare Health Maintenance Organization.
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5. I performed a laboratory test on a patient and the claim was denied for a lack of referring UPIN number in order to process the claim.
All diagnostic tests billed to Medicare require the Unique Provider Identification Number of the provider that ordered or referred the test. Even though you submitted your provider number, we also need your UPIN number in order to process the claim.
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6. My claim was denied due to the fact that the patient was receiving Home Health Care services, why was that?
The Balanced Budget Act of 1997 called for the development and implementation of a Prospective Payment System for Home Health Care Services. Under this law, certain services like physical therapy and certain supplies provided to a beneficiary while under a Home Health Care stay should be reimbursed by the Home Health Care Agency and not the Part B Carrier. The provider of those services should make an arrangement with the home health agency to obtain payment for services provided to the patient.
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7. My claim was denied stating that the diagnosis wasn't valid. I checked the ICD-9 book and found that it was current.
As of January 1, 2003, all claims submitted to Medicare will be processed with ICD-9 codes that correspond to the date of service.
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8. Where do I send my claim forms?
Queens County providers should submit their claims to GHI Medicare Division - P.O. Box 2870, New York, NY 10116. If you wish to submit electronically, please contact our Electronic Data Interchange Department at (646) 458-6721.
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9. When should I use a GY modifier?
The GY modifier should be used in the following situations:
1) When you think that a service will be denied because it is not a Medicare benefit or it is specifically excluded by Medicare law.
2) When you think that an service will be denied because it does not meet the requirements of a "benefit" as defined in Medicare law
3) When you are submitting a claim for a service in order to obtain a Medicare denial for secondary insurance purposes.
The use of the GY modifier does not influence Medicare's decision to pay or deny. If you use the GY modifier on a payable service Medicare will still make payment. However if you correctly apply the GY modifier to a non covered service Medicare will process and deny the service in question. If the service is denied as being excluded from Medicare coverage the beneficiary will be liable for all charges.
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10. When should I begin using the National Provider Identifier?
Providers have been able to use the National Provider Identifier in electronic claim submission since January 3, 2006. They should also have submitted the legacy (PIN) number in addition to the NPI in order to assure proper processing and payment of claims. Beginning October 2, 2006, providers may submit the legacy provider number and/or the NPI on X12 837 claims. After May 23, 2007, providers will only be able to submit the National Provider Identifier in all claims.
For paper claims, providers will not be able to use the NPI number until January 2, 2007. At that time, providers may use either the newly revised CMS 1500 (08-05), which provides a space for the NPI, or the old version of the form (12-90). After April 2, 2007, only the revised form may be used.
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11. Am I required to apply for electronic funds transfer for my Medicare payments?
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12. Where can I find the Medicare Remit Easy Print software?
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13. Where can I find the new CMS 1500 forms?
Providers can purchase the CMS 1500 forms at:
American Medical Association,
P. O. Box 10946
Chicago, IL 60610
1-800-621-8335
North Shore Graphics
281 Warner Avenue
Roslyn Heights, NY 11577
1-516-484-2802
U.S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
(202) 512-1800
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14. How do I contact the new DMERC carrier for New York State?
On January 6, 2006, CMS announced that it had awarded contracts to the four specialty MACs that will handle administration of Medicare claims for DME. The DMERC carrier for Jurisdiction A is National Heritage Insurance Company. The states included in DME MAC Jurisdiction A are: Connecticut, Delaware, New York, New Jersey, Pennsylvania, Maine, Maryland, Massachusetts, New Hampshire, Rhode Island and Vermont.
You may call NHIC at 1-866-419-9458. In order to submit claims, mail them to:
DME – Drug Claims
P.O. Box 9145
Hingham, MA 02043-9145
DME – Mobility/Support Surfaces Claims
P.O. 9147
Hingham, MA 02043-9147
DME – Oxygen Claims
P.O. Box 9148
Hingham, MA 02043-9148
DME – PEN Claims
P.O. Box 9149
Hingham, MA 02043-9149
DME Specialty Claims
P.O Box 9165
Hingham, MA 02043-9165
DME – Written Inquiries
P.O Box 9146
Hingham, MA 02043-9146
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15. I received a denial on some of my claims that stated, “This provider was not certified/eligible to be paid for this procedure/service on this date of service”. To my knowledge nothing has changed. Why would I receive that denial?
In order to assure that only qualified health care providers and suppliers are enrolled in Medicare, CMS instituted regulations that would consolidate enrollment and ensure consistency. One of which is that enrolled providers or suppliers who do not bill the program for two consecutive quarters will be deactivated until they have active bills. If your provider number was deactivated you must complete the appropriate CMS 855 forms. They can be accessed at http://www.ghimedicare.com/provider/enrollment.html
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16. My application for provider enrollment was returned to unprocessed. What are some reasons why that would happen?
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17. How do I sign up for electronic remittance advice?
Providers who are interested in signing up for electronic remittance advice files should complete the Request for Electronic Remittance form if they already have a Biller Id number. If they do not have a Biller Id number, then they have to also complete the Request for a Biller Id form. Both forms are located at http://www.ghimedicare.com/provider/forms.html.
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18. How can I obtain claim information without waiting for a customer representative?
If you call the Provider Relations Department at 877 868-8965 your call will first be routed to the Interactive Voice Response System. At this point, if you press #2, you will obtain claim information. Here you can obtain the status of the claim, the denial reason, and detailed line item information. This option reduces the wait time encountered when waiting for a live customer service representative.
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19. Where can I find the forms to request electronic remittances files? (3/07)
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20. When I check the status of a claim, that I submitted a week ago, the automated response system tells me that they are not working on anything at this time what does that mean? (3/07)
If the automated system tells you that we are not working on a claim that was submitted to our office it could mean that either you
- submitted a paper claim that was unprocessable (i.e. wrong Medicare number, wrong provider number) or
- submitted an electronic claim that contained invalid information
- submitted a claim to a clearinghouse and it was submitted to the carrier on paper rather than electronically
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21. I used to receive paper copies of my remittances, but I no longer do, why is that? (3/07)
If you signed up to receive electronic remittance files, and have been receiving them for at least 45 days, you will no longer receive paper remittance notices.
If you would like to receive a paper copy of your remittance notice you may call our Provider Service line at 877-868-6975.
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22. When should I begin using the new CMS-1500 forms? (3/07)
The original deadline for providers to submit the old CMS-1500 (12/90)form was March 31, 2007. Due to issues with the printing of the new CMS 1500 form that deadline was postponed until further notice. The target deadline is now June 1, 2007; however, stay posted to this site for further information.
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23. Where do I find the prices for the drug codes? (3/07)
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24. Where do I put the NPI on the new CMS 1500 forms? (3/07)
On the new claim forms (CMS 1500, (8/05)),
· Item 24J replaces 24K on the CMS 1500 (12/90)
· Item 17B replaces item 17 or 17A on the CMS 1500 (12/90)
· Item 32A replaces item 32 on the CMS 1500 (12/90)
· Item 33a replaces item 33 on the CMS 1500(12/90)
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25. How do I change my address? (3/07)
If you want to change your address, you must complete the CMS 855I. You must also submit notification of you National Provider Identifier and a CMS 588 form if you are not already receiving electronic funds transfer. You may find the forms at http://www.ghimedicare.com/provider/forms.html.
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26. I submitted a claim for a patient that I saw in Queens County but it was rejected stating that the service was out of area? (3/07)
If your claim is denied stating that the patient is out of area, then you must make sure that you have a provider number for GHI and if the patient lives outside of Queens, then you must put their address in box 32 on the claim form.
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27. For Physical Therapy services, which amount is applied to the therapy cap, the approved amount of the paid amount? (3/07)
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28. What is the Physician’s Quality Reporting Initiative? (7/07)
The Physician Quality Reporting Initiative establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. The program will run from July 1, 2007 until December 31 2007. Professionals will report a designated set of quality measures on claims for dates of service that occur during that period of time. For more information on this program, visit the CMS website at http://www.cms.hhs.gov/pqri
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29. When I submit a claim with a legacy provider number and an NPI which number will I receive on my remittance notice? (7/07)
If you submit a claim with both a legacy provider number and an NPI, the remittance will be returned with only an NPI after October 1, 2007.
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30. How do I notify you that I have a National Provider Identifier? (7/07)
After providers have obtained an NPI number, that information is then forwarded to the Medicare carriers by the National Plan and Provider Enumeration System. Providers may then use that number in claim submission.
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31. Why did I receive rejection, which stated that the provider number was not valid on my claims that were submitted electronically? (7/07)
This may happen for several reasons. First, verify that you have submitted claims with that provider number within the past year. If you received this denial recently, you or your software vendor may not be entering the group provider number in the correct field in you billing software. Check with your vendor to make sure that the group provider number is being entered in the 2010 AA loop.
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32. How can I make sure that my patient’s claims are crossed over to their secondary carrier? (7/07)
Beginning June of 2007, CMS will issue Medigap Carriers, Medigap claim-based crossover identifiers for inclusion on incoming Medicare claims.
Effective with claims filed to Medicare on October 1, 2007:
All participating providers that have been granted a billing exception under the Administrative Simplification Compliance Act should enter CMS’ newly assigned Coordination of Benefits Medigap claim based identifier within block 9-D of the incoming CMS 1500 claim for purposes of triggering Medigap claim-based crossovers.
All other participating providers shall enter the newly assigned 5-digit COBA Medigap claim based identifier, left justified and followed by spaces, within the NM109 portion of the 2330 B loop of the incoming HIPAA ANSI X12-N 837 professional claim.
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33. What is a Prepayment Review? (7/07)
Providers who have been placed on Probe (Post payment Review) review and have a high error rate may be subjected to prepayment review for the HCPCS code with the high error rate. These providers will be notified by mail that the prepayment review will be undertaken for a three to six month period until the provider establishes an understanding of the policies governing the codes and is billing appropriately. The goal is to reduce and eventually eliminate the error rate for these providers.
Providers who establish a satisfactory error rate within this time frame, or upon review of significant sample of claims (usually 100) will receive a letter advising them that they are no longer subject to review.
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34. What forms do I complete to join a group? (7/07)
If you are going to join an already established group and are reassigning your benefits to that group, you have to complete the CMS 855I and the CMS 855R forms. You must also provide:
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A copy of your NPI Notification that you received from the National Plan and Provider Enumeration System (NPPES) that is under your Social Security Number
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A copy of your NPI notification that you received from the National Plan and Provider Enumeration System (NPPES) that is under the groups Employee Identification Number
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A copy of your New York State License, all professional school degrees or certificates, and/or evidence of qualifying course work.
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A copy of the CMS 588 Electronic Funds Transfer Authorization Agreement if you are not receiving EFT.
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35. How long does it take to process the reactivation of my provider number? (7/07)
The processing time for reactivating a provider number is 60 calendar days from the date of receipt.
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36. Will providers be able to access a list of NPI numbers for use in billing? (7/07)
The Freedom of Information Act allows the disclosure of National Plan and Provider Enumeration System Data Elements. CMS will shortly publish a list of data elements for providers to access. If providers need to make updates, changes or deletions, they should contact NPPES at 1-800-465-3202.
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37. Can I submit the Medicare legacy provider number after May 23, 2008
Submission of an NPI for a billing provider, pay to provider or an ordering/referring provider is mandatory effective May 23, 2008. Legacy numbers cannot be reported on any claims sent to Medicare on or after May 23, 2008? (1/08)
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38. Which drugs are paid based on the Average Sales Price methodology? (1/08)
Drugs that are based on the Average Sales Price methodology include:
- the majority of drugs that are not paid on a cost or prospective payment basis
- all ESRD drugs (furnished by both hospital-based and ESRD facilities)
- certain covered outpatient drugs
- drugs and biologicals with pass-through status under the Outpatient Prospective Payment System
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39. What is the revalidaton process? (1/08)
The revalidation process captures information that is entered into the Provider Enrollment Chain Ownership System (PECOS). If a provider never completed an CMS 855 form, he will need to, in order to revalidate his Provider Identification Number.
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40. What is the physical therapy limit for 2008? (1/08)
The annual limit on the allowed amount for outpatient physical therapy and speech language pathology combined is $1,810. The limit for occupational therapy is $1,810.
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