Palmetto GBA, Jurisdiction 11 MACProvider Outreach and Education

2013 Part A Workshop Series

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DisclaimerThis presentation was current at the time it was published. Medicare policy may change so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

CPT/CDT Copyright

• CPT only copyright 2012 American Medical Association. All rights reserved.

• The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved.

Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 3

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Agenda

• Claim Reviews Comprehensive Error Rate Testing (CERT) Updates Recovery Audit Contractor (RAC) Redeterminations

• Medicare Updates Regulations, Change Requests (CRs) and Medicare

Learning Network Matters (MLN) Articles

• Important Billing Information• Did You Know?

Palmetto GBA Tips and Reminders

Comprehensive Error Rate Testing (CERT) Updates

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CERT

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**Documentation Matters**

Do it right the first time!

CERT

Remember this one?

“If it isn’t documented – it wasn’t done!”

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CERT

One more…

Look at your facility’s medical records…

Based on the principles of basic clinical documentation, would you pay?

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CERT

Last One…

We follow the $…

You are ultimately responsible for gathering and presenting all required documentation for any

services you billed and received payment for.

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CERT

• What is CERT?Federally mandated program created by the

Centers for Medicare & Medicaid Services (CMS) to measure the paid claims error rate for Medicare claims submitted to Medicare Administrative Contractors (MACs)

Ensures that the Medicare program is paying claims correctly

The CERT program measures national, contractor-specific, and service-specific paid claim error rates

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CERT

• How is CERT Administered? The CERT program uses a random and a service-

specific sampling of claims.There are two contractors responsible for

administering the CERT program on behalf of CMS.The CERT review contractor selects samples of claims from

Palmetto GBA.For each claim selected, the CERT documentation

contractor (CDC) requests medical records, from the physicians and suppliers that billed for the services, and prepares the documentation for review.

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CERT

• Why is the medical record important?The review contractor uses medical record

documentation to verify that the services were billed correctly

Ensure Palmetto GBA’s decisions regarding the payment and processing of the claim(s) were accurate and based on sound policy

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CERT

• Why should providers be concerned? Claims billed, paid, or processed incorrectly are categorized

as errors. Claims paid to Medicare providers in error are classified as

overpayments or underpayments, and Palmetto GBA is mandated to issue refund requests to our providers for all overpayments.

In addition, CERT errors can potentially have a negative impact on providers

Claims being subject to prepayment and/or post-payment review by our Medical Review Department

Found to be out of compliance with the Medicare provider enrollment agreement by not responding to CERT requests

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CERT Medical Records Request

• After a claim is identified as part of the sample, CERT requests the associated medical records and other pertinent documentation from the provider that submitted the claim

• The initial request for medical records is made via letter

• If the provider fails to respond to the initial request within 30 days, CERT sends at least three subsequent letters

• The CERT contractor also places phone calls to the providers to collect the documentation

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Role of Provider

• Providers play a role in the reduction of error rates. When a medical records request is received, it is imperative that the provider does the following: Be alert and prepared for medical record

requests.You have up to 75 days to return the requested

information.

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Compliance Benefits

• Some of the benefits of provider compliance are listed below:Prevents unnecessary denials and need to request an

appealAssures appropriate reimbursement of provider's

claimsReflects a positive impression of a provider's industry

by having a low error rateMay prevent additional medical review of the providerDemonstrates compliance with Medicare provider

enrollment agreement

Responding to a CERT request

• What will you receive from CERT? Information on the CERT processHIPAA compliance informationWhat documentation to submitTimeframe for responding to the requestClaim information

Note: An ORIGINAL bar coded sheet will be included that you must use with your mailed response or used if you decide to fax your documentation

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• Your documentation is the basis for determining the CERT error rate!All procedures, diagnoses, and modifiers

submitted on a claim to Medicare should be supported by information in the patient’s medical record

The “medical need” for services and procedures must also be documented in the patient’s medical record

The legible signature of the person that performed the service is required: Change Request 6698 – Signature Requirements

Documentation

CERT

Upon receipt of medical records, CERT medical review professionals conduct a review of the claims and submitted documentation to determine whether the claim was paid properly

These review professionals consist of:NursesMedical doctorsCertified coders

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CERT

Before reviewing documentation, the medical reviewers look at:Common Working File (CWF)

Ensure the claim is not a duplicate

CMS Eligibility SystemConfirm the person receiving the services was an eligible

Medicare beneficiaryVerify there is no other entity responsible for paying the

claim (Medicare is primary)

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CERT

When performing claim reviews, CERT ensures compliance with: Medicare statutes and regulations Billing Instructions National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Coverage in CMS Instructional Manuals (i.e., IOM)

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CERT

• Based upon the review of the medical records, claims identified as containing improper payments are categorized into the appropriate error category

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CERT

An improper payment is defined as: Any payment that should not have been made or that

was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements

• Overpayments

• Underpayments

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• The reasons for CERT errors in the latest quarterly report include: No documentation Insufficient documentation Medically unnecessary services Incorrect coding Other

• Note: Providers need to share these errors with the physicians. It is important that providers have a plan in place to correct CERT error rates.

CERT Errors

No Documentation

The provider fails to respond to repeated requests for the medical records,

OR

The provider responds that they do not have the requested documentation

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Insufficient Documentation

The medical documentation submitted is inadequate to support payment for the services billed Unable to determine if some of the services allowed were

actually providedProvided at the level billed, andThe services were medically necessary

A specific documentation element that is required as a condition of payment is missing:Physician signature on an order, orA form required to be completed in its entirety

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Medical Necessity

Adequate documentation from the medical records submitted and can make an informed decision that the services billed were not medically necessary based upon Medicare coverage policies

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Incorrect Coding

The provider or supplier submits medical documentation supporting A different code than that billed The service was performed by someone other than the billing

provider or supplier The billed service was unbundled A beneficiary was discharged to a site other than the one

coded on a claim

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Other

Does not fit into any of the other categoriesDuplicate payment errorNon-covered service

A service incurred by the patient that is not covered by Medicare

Unallowable serviceA service incurred by the patient that is not allowed by

Medicare

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• Palmetto GBA strives at every workshop and education event to stress the importance of reducing CERT error rates

• CERT information is updated quarterly

• Documentation/Signature Guidelines are posted on our website

CERT and Palmetto GBA

How Can A ProviderLearn More?

CERT resources published on the J11 Part A website at www.PalmettoGBA.com/J11A

CMS CERT website www.cms.gov/CERT

CMS Program Integrity Manual http://www.cms.gov/manuals/downloads/pim83c12.pdf

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Recovery Audit Contractor (RAC)

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RAC

• Recovery Auditors (formerly known as Recovery Audit Contractors or RACs)

• RACs detect and correct past improper payments

• CMS Recovery Audit Program• http

://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/index.html

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RAC Regions

• Medicare RAC Region C: Connolly, Inc. • States: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK,

SC, TN, TX, VA, WV, Puerto Rico and U.S. Virgin Islands

• www.connollyhealthcare.com/RAC

• Search Approved Audit Issues

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So What Contractors Do What??

• CERT, RAC, ZPIC Responsibilities:• Identify improper payments

• Submit claim adjustment to the MAC

• Respond to any audit specific questions you may have, such as their rationale for identifying the potential improper payment

• MAC (Palmetto GBA) Responsibilities:• Issue demand letters

• Perform the claim adjustments based on CERT, RAC, ZPIC’s review

• Handle administrative concerns such as timeframes for payment recovery and the redetermination (appeals) process

• Include the name of the initiating CERT, RAC, ZPIC and their contact information in the related demand letter

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What Contractors Do What??

• MAC (Palmetto GBA) Responsibilities…

• Demand demands will be sent to the same address as any other demand letter that is sent from the MAC

• The address that is used to mail the demand letters is the provider’s physical address

Redeterminations Also Known As (AKA) Appeals

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Redeterminations

• Appeals Process• Provider has 120 days from the date on the remit to

file appeal• Attach copy of denial letter and Request for

Redetermination Form

• Appeals Forms: www.PalmettoGBA.com/J11A• Select Resources/Forms/ Part A/Select Your State/Appeals• Select Redetermination (appeal) of an initial claim determination

adjustment decision• First level appeal on a Medicare claim (Palmetto GBA)• RAC overpayment appeal• CERT overpayment appeal• ZPIC overpayment appeal

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What Is The Status of My Appeal?

• Before calling to obtain the status of an appeal, providers should do the following:• Has it been more than 60 days since Palmetto GBA

received the Appeal? • Palmetto GBA has up to 60 days from the date of receipt of

the request to complete a review of the documentation and render a decision

• If it has been more than 60 days since Palmetto GBA received the request, providers should first check the Direct Data Entry (DDE) system to see if a decision has been rendered

• Once a decision has been rendered on an appeal, information is loaded to the remarks field on the original claim

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What Is The Status of My Appeal?

• Palmetto GBA does not issue letters for fully favorable appeals

• For a partially favorable decision, the provider will receive a letter that explains that only partial payment can be made and why

• When the decision is affirmed, also known as an unfavorable decision, the provider will receive a letter that will explain the reason for the decision as well as further appeal rights

• In some cases, a request for a redetermination will not be considered valid and will, therefore, be dismissed• If a request for a redetermination is dismissed, the provider will

receive a letter that explains why the appeal was dismissed

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Redeterminations Through Online Provider Services (OPS)

• Redeterminations can be submitted online through OPS

• If you submit a redetermination through OPS, you can then check the status of that redetermination in OPS

• OPS is available free of charge to Palmetto GBA providers

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Medicare Updates

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Medicare Resources

• Important Medicare Resources

http://www.cms.gov/Medicare/Medicare.htmlMedicare Fee-for-Service Payment

Provider Centers

http://www.cms.gov/manuals/CMS Internet Only Manuals (IOMs)

Medicare Resources

• Resources… http://www.cms.gov/MLNMattersArticles

Explanation of Change Requests, training guides, articles, educational tools, booklets, brochures, fact sheets, web-based training courses

http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index.html?redirect=/quarterlyproviderupdatesComprehensive resource published by CMS on the first

business day of each quarter listing all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers

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Change Request 7260

• Modification to CWF, FISS, MCS and VMS to Return Submitted Information when there Is a CWF Name and HIC Number Mismatch Effective date: October 1, 2012 Implementation date: October 1, 2012

MM7260

Change Request 7260

• Summary of changes: This CR changes the current CWF and shared system processes so that if there is a HICN and name mismatch within CWF, the submitter will receive the information it originally submitted when the claim is returned

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Change Request 8129

• Therapy Cap Values for Calendar Year (CY) 2013Effective Date: January 1, 2013 Implementation Date: January 7, 2013

• Summary of changes:Occupational Therapy (OT) cap $1900Physical Therapy (PT) and Speech Language

Pathology (SLP) combined cap $1900

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MM8129

TDL 13144

• The American Taxpayer Relief Act of 2012• Section 601- Medicare Physician Payment Update

Zero percent update of Medicare Physician Fee Schedule (MPFS) THROUGH December 31, 2012

• Section 603 – Extension Related to Payment for Medicare Outpatient Therapy Services Extends exceptions process

Append KX modifierOutpatient therapy in Critical Access Hospitals (CAHs) now counts

toward the cap and threshold totals Note: CAH outpatient therapy is NOT limited itself by the caps

and thresholds

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TDL 13144

• Section 603 – Extension Related to Payment for Medicare Outpatient Therapy Services continued . . .Extends the “prior authorization” process

There is no “prior authorization” process in 2013Once a claim is received that has outpatient therapy services

that exceed the $3700 threshold, the claim will suspend and the provider will receive an additional development request (ADR)

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Change Request 8005

• Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy ServicesEffective for therapy services with dates of service

(DOS) on/after January 1, 2013Effective Testing period January 1 – June 30, 2013Claims will be returned/rejected for date of DOS on/after July

1, 2013

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MM8005

Change Request 8005

• Summary of changes: Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act implements a new claims-based data collection requirement for outpatient therapy services requiring reporting with: 42 new non-payable functional G-codes and Seven new modifiers on claims for PT, OT and SLP

services

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Change Request 8005

• Functional reporting on the UB04 claim form applies to:Skilled Nursing Facility (SNF) Inpatient Part B

Type of Bill (TOB) 22X on Part A MAC ClaimsSNF Outpatient on Part A MAC Claims

TOB 23X on Part A MAC ClaimsHome Health (Part B only)

TOB 34X on Part A MAC ClaimsOutpatient Rehabilitation Facility (ORF)

TOB 74X on Part A MAC Claims

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Change Request 8005

• Functional reporting on the UB04 claim form applies to: Comprehensive Outpatient Rehabilitation Facility (CORF) on

Part A MAC ClaimsTOB 75X on Part A MAC Claims

Outpatient Hospital, including the emergency roomTOB 12X on Part A MAC ClaimsTOB 13X on Part A MAC Claims

NEW Critical Access Hospital (CAH) claimsTOB 85X on Part A MAC ClaimsNote: CAHs are included in functional reporting and their outpatient

therapy is counted towards the caps and thresholds totals, but outpatient therapy provided in a CAH is NOT subject to the caps and thresholds limitations

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Change Request 8005

• Documentation Requirements:Documentation must be included in the beneficiary’s

medical record of therapy services for each required reporting

Documentation must be completed by: The qualified therapist furnishing the therapy services The physician/NPP personally furnishing the therapy

services The qualified therapist furnishing services incident to the

physician/NPP The physician/NPP for incident to services furnished by

“qualified personnel” who are not qualified therapistsThe qualified therapist furnishing the PT, OT, or SLP services

in a CORF

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Change Request 8005

• New Progress Report Requirement:Progress reporting required on or before every 10th

treatment dayPreviously, the progress report was due every 10th

treatment day or 30 calendar day, whichever was less

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Change Request 8005

• Palmetto GBA References:Job aids

Outpatient Therapy Functional Reporting Claim Requirements Job Aid

Outpatient Therapy Functional Reporting Documentation Requirements Job Aid

Frequently Asked Questions (FAQs)

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Change Request 8105

• Update for Amendments, Corrections and Delayed Entries in Medical DocumentationEffective date: January 8, 2013 Implementation: January 8, 2013

• Summary of changes: The purpose of this CR is to provide instructions to contractors regarding amended, corrected, and delayed entries in medical records

MM8105

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Change Request 8007

• New Informational Unsolicited Response (IUR) Process to Identify Previously Paid Claims for Services Furnished to Incarcerated Medicare BeneficiariesEffective date: April 1, 2013 Implementation date: April 1, 2013

MM8007

Change Request 8007

The intent of this CR is to create a new IUR process to identify and perform retroactive adjustments on any previously paid claims which may have been paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was incarcerated

As with all IURs they receive, the MACs shall initiate overpayment recovery procedures to retract any Medicare Part A and/or Part B payments and generate adjustments to update or cancel the claims on CWF and contractor history

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Change Request 8009

• New Informational Unsolicited Response (IUR) Process to Identify Previously Paid Claims for Services Furnished to Medicare Beneficiaries Classified as "Unlawfully Present" in the United States Effective date: April 1, 2013 Implementation date: April 1, 2013

MM8009

Change Request 8009

• Summary of changes: The intent of this CR is to create a new IUR process to

identify and perform retroactive adjustments on any previously paid claims which may have been paid erroneously during periods when the beneficiary data in the EDB did not reflect the fact that the beneficiary was unlawfully present in the United States

As with all IURs they receive, the MACs shall initiate overpayment recovery procedures to retract any Medicare Part A and/or Part B payments and generate adjustments to update or cancel the claims on CWF and contractor history

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Change Request 8044

• Manual Updates to Clarify Skilled Nursing Facility (SNF) Claims Processing Effective date: April 1, 2013 Implementation date: April 1, 2013

MM8044

Change Request 8044

• Summary of changes: The intent of this CR is to notify providers that CMS

has updated the manuals by adding policy CLARIFICATIONS pertaining to the SNF consolidated billing provision and claims processing but no new policies

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Change Request 8044

• Manual clarifications including information on: The Definition of An Inpatient for Starting or Ending a Benefit Period Part B Consolidated Billing and exclusions Emergency Services Hospice care Certain Chemotherapy Drugs Ambulance Services Screening and Preventive Services Therapy Services The Three Day Qualifying Hospital Stay Daily Skilled Service The Definition of a Beneficiary's Home for Part B Durable Medical

Equipment (DME) coverage

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MLN Matters Article SE1249

HIPAA Eligibility Transaction System (HETS) to Replace Common Working File (CWF) Medicare Beneficiary Health Insurance Eligibility Queries Provider Action Needed

The Centers for Medicare & Medicaid Services (CMS) is publishing this article to advise you to immediately begin transitioning to HETS for your eligibility information.

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SE1249

Important Billing Information

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PET for Solitary Pulmonary Nodule (SPN)

• Palmetto GBA covers PET scan for SPN• The following codes must be on the UB04:

SPN – ICD-9 Code 793.11CPT code

78811, 78812, 78813, 78814, 78815 or 78816

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PET for Solitary Pulmonary Nodule (SPN)

• The following must be on the UB04 continued . . . In the 'remarks' section ONE of the following

diagnostic reasons must be present: indeterminate prior chest x-ray must be written as: 1XR indeterminate prior CT scan must be written as: 2CT biopsy proven or strong suspicion of malignancy must be

written as: 3BX Notes:

Remarks must be written exactly as above (i.e. 1XR, 2CT or 3BX)

If more than one diagnostic test was performed, submit only the test that lead to performing the PET scan

This information must be the ONLY information in remarks on this claim

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PET for Solitary Pulmonary Nodule (SPN)

• Effective for dates of service February 1, 2013 and after

• If the patient has a diagnosis of SPN but the PET scan is being performed for a reason unrelated to the SPN itself, do not code the 793.11 in the PRIMARY diagnoses field

• The SPN should be reported on the claim as a SECONDARY diagnosis

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HOT OFF THE PRESS - Sequestration Information!

March 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 70

TDL 12438

• Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration” Medicare FFS claims with dates-of-service or dates-of-

discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments

• Note: Beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction

March 2013 Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 71

Data Analysis

• Palmetto GBA generates monthly data analysis reportsTop 15 billing errorsMedical review denialsTop CERT claims errors

• We then make quarterly updates to our website sections

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Top Billing Error

• Reason Code 15202

• FISS Narrative: When this reason code is received on an

inpatient hospital or inpatient Skilled Nursing Facility (SNF) claim (TOB 11x, 21X or 18x), it typically means that a discrepancy exists between the covered days billed and the covered accommodation units billed

• Important Note: Accommodation units are recognized as revenue codes 010x-021x, excluding 018x (leave of absence) and 019x (sub-acute care)

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Top Billing Error

• Reason Code 15202 continued . . .

• Resources and Tips to Avoid or Correct RTP Claim: Verify the covered days and that the accommodation unit/revenue code lines are billed appropriately. Examples of billing issues include: Non-covered Revenue code 018x or 019x are not counted as covered A line level edit has assigned on the accommodation

unit/revenue code line

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Top Billing Error

• Reason Code 15202 continued . . .

• Resources and Tips to Avoid or Correct RTP Claim Continued . . . Days billed do not match accommodation

unit/revenue code and charges are billed as non-coveredAn exception to this rule for TOB 11x would be when an

occurrence span code 70 is present due to cost outlier situation

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Top Billing Error

• Reason Code 15202 continued . . .

• Resources and Tips to Avoid or Correct RTP Claim Continued . . . Non-covered days are present and only

accommodation unit/revenue code lines have been billed as non-coveredAncillary charges for non-covered days should be billed as

non-covered

Outpatient claims should not be billed with days and/or accommodation unit/revenue codes

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Top Billing Error

• Reason Code 15202 continued . . .

• SNF Specific Resources and Tips: All revenue code 0022 units must match the

accommodation units/revenue codes If reporting a leave of absence (LOA) with occurrence

span code (OSC) 74; must report revenue code 0180 days without charges

The OSC 74 dates must reflect the days the patient was absent at midnight from the SNF and match the 0180 unit count

When billing with a 30 patient status code; count the day/units as covered

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Top Billing Error

• Reason Code 15202 continued . . .

• SNF Specific Resources and Tips Continued . . .When reporting lower level of care (occurrence code

22); count the day/unitsNote: that the date the patient moves to a lower level of care,

is the “Through” date of that claim.

If applicable, refer to Section 40.8 Billing in Benefits Exhaust and No Payment Situations (PDF, 448 KB)

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Top Billing Error

• Reason Code 15202 continued . . .

• Explanation and Suggestion:• If a correction is required to the accommodation units/revenue

code line, you will have to delete the entire line and re-key the line before resubmitting the claim

• Review the days available in the Common Working File (CWF)• If you submitted an outpatient claim, delete days and/or

accommodation units/revenue code lines before resubmitting the claim

• To correct the RTP claim, make the necessary corrections and resubmit the claim

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What do you do?

Expedite Reimbursement -Track your claims!

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Status/Location

• S/LOC = Status/Location of the claim• Know the Status and Location of your claims at

all timesStatus tells you what you can or cannot do to the

claimLocation tells you where the claim is located in the

claims processing system

DDE Status/Location Codes

Status

Explanation

P The claim is completely processed (either fully or partially paid)

D The claim is completely processed and was denied

R The claim is completely processed and was rejected

S The claim is still in process Note: [no provider intervention can be made other than responding to Additional Documentation Request (ADR) if applicable]

T The claim has been returned to provider (RTP) for correction

I The Intermediary has either inactivated OR specially processed your claim. *RTPs more than 60 days old and suppressed claims are moved to an “I B9997” status for 3 yrs then purged

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Status/Location

• Example: S/LOC = T/B9997First Position is Claims Current Status

‘T’ status = Claim needs corrections

Second Position is the Claim Processing Type ‘B’ = claim is electronic ‘M’ = claim is manual Medical review may be processing

The Third and Fourth Positions are the Location of the Claim

Last Two Positions are For Additional Location Information

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Claims Submission Error Help

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Status and Locations of Claims

• Additional information available related to the status and location of claimswww.PalmettoGBA.com/J11A

• Electronic Data Interchange (EDI)• Software and Manuals• Direct Data Entry (DDE) Manual

Did You Know?

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Provider Enrollment Revalidation Initiative

• Notices will be sent through March 2015!• J11 Part A/HHH

475 Revalidations planned to be mailed between 1/31/2013 through 3/29/2013

• Provider Enrollment Resources:Provider Enrollment Application Status Lookup tool

https://pecos.cms.hhs.gov

www.pay.gov

Event Registration Portal

• Every user will need to create a user profile• Once created, you must login to the system in

order to be able to register for events• See our Navigating Palmetto GBA’s Event

Registration Portal Job Aid for more detailed instructions: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Home%20Health%20and%20Hospice~Learning%20Education~Job%20Aids~8YZHU82488?open&navmenu=||

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Event Registration Portal

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EDI System Status Log

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Foresee Survey

Web Site Enhancements Based Off Data Analysis

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Online Provider Services(OPS)

Are You Using OPS?

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OPS

• The OPS application provides real-time information access over the Web for the following online services:EligibilityClaims statusRemittances OnlineFinancial Information (payment floor and last 3 checks

paid)

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OPS• The OPS application provides real-time information

access over the Web for the following online services: NEW!

Secure Forms- Redeterminations can be submitted online in OPS

E-offset- Request immediate offset of demanded overpayments or Request permanent immediate offset for all future

overpaymentsE-check functionality-

Submit a check to repay a Medicare overpayment

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OPS

• Latest UpdatesAdded phone number and extensionE-mail validation requiredAdded provider, billing service or clearinghouse

selection

• Goal of UpdatesAllows OPS staff to be able to contact the OPS user

quickly

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OPS• Lock-out

Removes or inactivates users if they have not logged in within 90 days of the current date

If all Provider Administrators are inactive, all users are removed

If there is at least one active Provider Administrator, no active users will be removed

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OPS

• The removal process runs nightly• If removed, the Provider User must contact their

active Provider Administrator for access and a new User ID

• If the entire account is removed, the Provider Administrator must register again

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OPS

• COMING SOON: Palmetto GBA proposes to implement the following functions: Secure messaging

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OPS

• Support/TroubleshootingContact Us on each pageFrequently Asked Questions (FAQs) on

PalmettoGBA.com/J11AAccess to Technology Support Center (TSC) for

inquiry and issue resolution @ 866-749-4301

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International Classification of Diseases (ICD-10)

• A key element of the data foundation of the United States’ health care system will undergo a major transformation

• Although the ICD-10 deadline has changed to October 1, 2014, it is important to continue planning for the transition to ICD-10

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ICD-10

• This transition will have a major impact on anyone who uses health care information that contains a diagnosis and/or inpatient procedure code, including: Hospitals Health care practitioners and institutions Health insurers and other third-party payersElectronic-transaction clearinghousesHardware and software manufacturers and vendorsBilling and practice-management service providersHealth care administrative and oversight agenciesPublic and private health care research institutions

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ICD-10

• A critical step in planning for the transition is to conduct an impact assessment of how the new code sets will affect your organization

• Your impact assessment should include: Documentation ChangesReimbursement StructuresSystems and Vendor ContractsBusiness PracticesTesting

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Educational Resources

• Available on the J11 Part A home pageClick on the Resources link and you’ll find links to the

following tools:FormsDepartmental information such as Appeals, Audit

Reimbursement and Provider EnrollmentTools and Calculators

Click on the Learning and Education linkJob Aids on topics including overpayments, outpatient

therapy functional reporting and the Medicare claims processing system

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Educational Resources

• Other Important Resources:http://www.cms.gov/Medicare/Medicare.html

Medicare Fee-for-Service Paymenthttp://www.cms.gov/manuals/

CMS Internet Only Manuals (IOMs)http://www.cms.gov/MLNMattersArticles

Explanation of Change Requests, training guides, articles, educational tools, booklets, brochures, fact sheets, web-based training courses

Be sure to check your monthly Medicare Advisory

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Additional Information

• For additional information on any of the topics covered during our presentation todayVisit the J11 Part A website at

www.PalmettoGBA.com/J11APlease direct your questions to the J11 Part A

Provider Contact Center (PCC) at 866-830-3455

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Thank You!

• Thank you for participating in the educational session today

• Please ensure that you and your staff review the change requests we covered in more detail

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