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Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education 2013 Part A Workshop Series 1.

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Presentation on theme: "Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education 2013 Part A Workshop Series 1."— Presentation transcript:

1 Palmetto GBA, Jurisdiction 11 MAC Provider Outreach and Education 2013 Part A Workshop Series 1

2 2 Disclaimer This 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.

3 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

4 4 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

5 Comprehensive Error Rate Testing (CERT) Updates 5

6 CERT 6 **Documentation Matters** Do it right the first time!

7 CERT Remember this one? “If it isn’t documented – it wasn’t done!” 7

8 CERT One more… Look at your facility’s medical records… Based on the principles of basic clinical documentation, would you pay? 8

9 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. 9

10 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 10

11 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. 11

12 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 12

13 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 13

14 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 14

15 15 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.

16 16 Compliance Benefits Some of the benefits of provider compliance are listed below:  Prevents unnecessary denials and need to request an appeal  Assures appropriate reimbursement of provider's claims  Reflects a positive impression of a provider's industry by having a low error rate  May prevent additional medical review of the provider  Demonstrates compliance with Medicare provider enrollment agreement

17 Responding to a CERT request What will you receive from CERT?  Information on the CERT process  HIPAA compliance information  What documentation to submit  Timeframe for responding to the request  Claim 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 17

18 18 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

19 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:  Nurses  Medical doctors  Certified coders 19

20 CERT  Before reviewing documentation, the medical reviewers look at:  Common Working File (CWF)  Ensure the claim is not a duplicate  CMS Eligibility System  Confirm the person receiving the services was an eligible Medicare beneficiary  Verify there is no other entity responsible for paying the claim (Medicare is primary) 20

21 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) 21

22 CERT Based upon the review of the medical records, claims identified as containing improper payments are categorized into the appropriate error category 22

23 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 23

24 24 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

25 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 25

26 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 provided  Provided at the level billed, and  The services were medically necessary  A specific documentation element that is required as a condition of payment is missing:  Physician signature on an order, or  A form required to be completed in its entirety 26

27 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 27

28 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 28

29 Other  Does not fit into any of the other categories  Duplicate payment error  Non-covered service  A service incurred by the patient that is not covered by Medicare  Unallowable service  A service incurred by the patient that is not allowed by Medicare 29

30 30 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

31 How Can A Provider Learn More?  CERT resources published on the J11 Part A website at   CMS CERT website   CMS Program Integrity Manual  31

32 Recovery Audit Contractor (RAC) 32

33 RAC Recovery Auditors (formerly known as Recovery Audit Contractors or RACs) RACs detect and correct past improper payments CMS Recovery Audit Program Systems/Monitoring-Programs/Recovery-Audit- Program/index.htmlhttp://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/Recovery-Audit- Program/index.html 33

34 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 Search Approved Audit Issues 34

35 35 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

36 36 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

37 Redeterminations Also Known As (AKA) Appeals 37

38 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: 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 38

39 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 39

40 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 40

41 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 41

42 42 Medicare Updates

43 43 Medicare Resources Important Medicare Resources   Medicare Fee-for-Service Payment  Provider Centers   CMS Internet Only Manuals (IOMs)

44 Medicare Resources Resources…   Explanation of Change Requests, training guides, articles, educational tools, booklets, brochures, fact sheets, web-based training courses  Guidance/Regulations-and- Policies/QuarterlyProviderUpdates/index.html?redirect =/quarterlyproviderupdates Guidance/Regulations-and- Policies/QuarterlyProviderUpdates/index.html?redirect =/quarterlyproviderupdates  Comprehensive 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 44

45 45 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

46 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 46

47 Change Request 8129 Therapy Cap Values for Calendar Year (CY) 2013  Effective Date: January 1, 2013  Implementation Date: January 7, 2013 Summary of changes:  Occupational Therapy (OT) cap $1900  Physical Therapy (PT) and Speech Language Pathology (SLP) combined cap $ MM8129

48 TDL 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 modifier  Outpatient 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 48

49 TDL Section 603 – Extension Related to Payment for Medicare Outpatient Therapy Services continued...  Extends the “prior authorization” process  There is no “prior authorization” process in 2013  Once 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) 49

50 Change Request 8005 Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy Services  Effective for therapy services with dates of service (DOS) on/after January 1, 2013  Effective Testing period January 1 – June 30, 2013  Claims will be returned/rejected for date of DOS on/after July 1, MM8005

51 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  S even new modifiers on claims for PT, OT and SLP services 51

52 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 Claims  SNF Outpatient on Part A MAC Claims  TOB 23X on Part A MAC Claims  Home Health (Part B only)  TOB 34X on Part A MAC Claims  Outpatient Rehabilitation Facility (ORF)  TOB 74X on Part A MAC Claims 52

53 Change Request 8005 Functional reporting on the UB04 claim form applies to:  Comprehensive Outpatient Rehabilitation Facility (CORF) on Part A MAC Claims  TOB 75X on Part A MAC Claims  Outpatient Hospital, including the emergency room  TOB 12X on Part A MAC Claims  TOB 13X on Part A MAC Claims  NEW Critical Access Hospital (CAH) claims  TOB 85X on Part A MAC Claims  Note: 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 53

54 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 therapists  The qualified therapist furnishing the PT, OT, or SLP services in a CORF 54

55 Change Request 8005 New Progress Report Requirement:  Progress reporting required on or before every 10 th treatment day  Previously, the progress report was due every 10 th treatment day or 30 calendar day, whichever was less 55

56 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) 56

57 57 Change Request 8105 Update for Amendments, Corrections and Delayed Entries in Medical Documentation  Effective 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

58 58 Change Request 8007 New Informational Unsolicited Response (IUR) Process to Identify Previously Paid Claims for Services Furnished to Incarcerated Medicare Beneficiaries  Effective date: April 1, 2013  Implementation date: April 1, 2013 MM8007

59 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 59

60 60 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

61 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 61

62 62 Change Request 8044 Manual Updates to Clarify Skilled Nursing Facility (SNF) Claims Processing  Effective date: April 1, 2013  Implementation date: April 1, 2013 MM8044

63 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 63

64 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 64

65 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. 65 SE1249

66 Important Billing Information 66

67 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  CPT code  78811,  78812,  78813,  78814,  or 

68 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 68

69 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 in the PRIMARY diagnoses field The SPN should be reported on the claim as a SECONDARY diagnosis 69

70 HOT OFF THE PRESS - Sequestration Information! March 2013Palmetto GBA - Jurisdiction 11 Medicare Administrative Contractor (MAC) 70

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

72 Data Analysis Palmetto GBA generates monthly data analysis reports  Top 15 billing errors  Medical review denials  Top CERT claims errors We then make quarterly updates to our website sections 72

73 Top Billing Error Reason Code 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) 73

74 Top Billing Error Reason Code 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 74

75 Top Billing Error Reason Code 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- covered  An exception to this rule for TOB 11x would be when an occurrence span code 70 is present due to cost outlier situation 75

76 Top Billing Error Reason Code 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-covered  Ancillary 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 76

77 Top Billing Error Reason Code 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 77

78 Top Billing Error Reason Code continued... SNF Specific Resources and Tips Continued...  When reporting lower level of care (occurrence code 22); count the day/units  Note: 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)Billing in Benefits Exhaust and No Payment Situations 78

79 Top Billing Error Reason Code 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 79

80 What do you do? Expedite Reimbursement -Track your claims! 80

81 81 Status/Location S/LOC = Status/Location of the claim Know the Status and Location of your claims at all times  Status tells you what you can or cannot do to the claim  Location tells you where the claim is located in the claims processing system

82 DDE Status/Location Codes StatusExplanation PThe claim is completely processed (either fully or partially paid) DThe claim is completely processed and was denied RThe claim is completely processed and was rejected SThe claim is still in process Note: [no provider intervention can be made other than responding to Additional Documentation Request (ADR) if applicable] TThe claim has been returned to provider (RTP) for correction IThe 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 82

83 83 Status/Location Example: S/LOC = T/B9997  First 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

84 84 Claims Submission Error Help

85 85 Status and Locations of Claims Additional information available related to the status and location of claims  Electronic Data Interchange (EDI) Software and Manuals Direct Data Entry (DDE) Manual

86 Did You Know? 86

87 87 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 https://pecos.cms.hhs.gov 

88 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: nsf/DocsCat/Providers~Jurisdiction%2011%20H ome%20Health%20and%20Hospice~Learning% 20Education~Job%20Aids~8YZHU82488?open &navmenu=|| nsf/DocsCat/Providers~Jurisdiction%2011%20H ome%20Health%20and%20Hospice~Learning% 20Education~Job%20Aids~8YZHU82488?open &navmenu=|| 88

89 Event Registration Portal 89

90 EDI System Status Log 90

91 91 Foresee Survey

92 Web Site Enhancements Based Off Data Analysis 92

93 Online Provider Services (OPS) Are You Using OPS? 93

94 OPS The OPS application provides real-time information access over the Web for the following online services:  Eligibility  Claims status  Remittances Online  Financial Information (payment floor and last 3 checks paid) 94

95 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 overpayments  E-check functionality-  Submit a check to repay a Medicare overpayment 95

96 OPS Latest Updates  Added phone number and extension  validation required  Added provider, billing service or clearinghouse selection Goal of Updates  Allows OPS staff to be able to contact the OPS user quickly 96

97 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 97

98 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 98

99 OPS COMING SOON: Palmetto GBA proposes to implement the following functions:  Secure messaging 99

100 OPS Support/Troubleshooting  Contact Us on each page  Frequently Asked Questions (FAQs) on PalmettoGBA.com/J11A  Access to Technology Support Center (TSC) for inquiry and issue

101 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

102 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 payers  Electronic-transaction clearinghouses  Hardware and software manufacturers and vendors  Billing and practice-management service providers  Health care administrative and oversight agencies  Public and private health care research institutions 102

103 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 Changes  Reimbursement Structures  Systems and Vendor Contracts  Business Practices  Testing 103

104 Educational Resources Available on the J11 Part A home page  Click on the Resources link and you’ll find links to the following tools:  Forms  Departmental information such as Appeals, Audit Reimbursement and Provider Enrollment  Tools and Calculators  Click on the Learning and Education link  Job Aids on topics including overpayments, outpatient therapy functional reporting and the Medicare claims processing system 104

105 Educational Resources Other Important Resources:   Medicare Fee-for-Service Payment   CMS Internet Only Manuals (IOMs)   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 105

106 Additional Information For additional information on any of the topics covered during our presentation today  Visit the J11 Part A website at  Please direct your questions to the J11 Part A Provider Contact Center (PCC) at

107 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 107


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