Retroactive billing for an opt extension center and medicare

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Question: For traditional prepayment reviews, how do we start the medical review process when we are about to bill procedure codes that you are currently reviewing? Do we need to contact you? How does the medical review process start? Answer: Providers are notified of their involvement in our medical review program when individual ADR letters are sent to them.

Providers are not required to contact our MR department to start the medical review process. Question: Did your process change? Our facility used to receive a large amount of ADR letters, but we have not received any for some time. If the provider is signed up for eServices, and is enrolled to receive their ADR letters via eServices, then that would be a place to start.

To confirm if you are enrolled in eServices and if your ADR letters would be delivered via that method, or if they would be received via mail, I would encourage you to contact our Provider Contact Center at —— to confirm which route your ADR letters are being sent to you. Addendum: Please also verify if the codes you previously received ADR letters for are currently under review.

Question: Can you provide a documentation example of a technical component-only claim? For example, TC? Answer: A TC claim requires a signed order for the procedure including diagnosis.

Can I fax the notes to —? Make sure to put your ICN on the form. You should also contact our Provider Contact Center at ——, to confirm that we have your up-to-date address information on file. Question: Will providers receive a letter that contains a rationale for claims that are downcoded? Answer: Providers will be notified of MR's findings by way of their Claim Review determination letters for traditional Railroad Medicare reviews, and by way of educational calls and claim review determination letters for our complex medical reviews.

Question: If your ADR letters are sent separately and we miss one, is there another way that we will be informed that our claims are being reviewed before a denial is received? Answer: Individual ADR letters will be sent for each of your claims that will be reviewed. Perhaps if a provider misses one of their ADR letters, they may receive a call from a member or our MR department due to nonresponse during our complex medical reviews.

Is there an equation or percentage that Palmetto GBA follows? Question: If claims with a date of service of are denied, can these claims be appealed? Question: If I did not see any procedure codes in today's presentation that my practice bills, should I still expect to receive an ADR letter for my practice? Question: Will your ADR letters be specific in stating the information that you are requesting? Our ADR letters will provide specific details that will assist you in knowing what information we are requesting.

Question: If an independent laboratory receives an ADR request for physician notes that they have to request from the ordering provider, can the laboratory submit the documentation that they have until they receive the requested documentation from the ordering provider? If rendering providers do not have the requested documentation, it is still their responsibility to obtain this documentation, but they may submit any documentation to Railroad Medicare that may support their claim.

Answer: Pre-payment reviews are performed on newly billed claims that you are currently submitting. However, postpayment reviews are performed on claims that were previously paid. Therefore, those reviews can be performed on dates of services that prior to Addendum: October 1, , through September 30, , is the current review period, it is not the date of service range for claims under review.

Pre-payment and postpayment reviews can be performed on dates of service prior to October 1, Question: If I contact your medical review department, will they be able to tell me if any ADRs have been mailed to us? Is that correct? If yes, have TPE letters already started to go out to providers?

That was an automatic switch we did to enable providers to get this information more quickly and to get the information consistently into their eServices account. There is also an option to receive an email when those TPE letters go out, so if you are the admin for the account you can check and make sure you are also receiving the email notifications for those TPE letters. Question: We submit a small number of claims to Railroad Medicare. Does this mean that we will always be in a constant state of review?

Answer: Not necessarily. Question: Can you possibly review codes besides the ones presented in this presentation? If so, will we be made aware of these changes? Answer: Updates can occur with the codes that we are currently reviewing this option year. If changes are made, these updates will be listed on our website. If changes are needed, we encourage providers to submit updates to their local MAC.

Answer: If your claim is denied you may file a first level of appeal to have the decision of your claim redetermined. At this time, you should submit any supportive documents that may support your claim. All documents received will be taken into consideration, but please note that does not mean that your claim will be paid. Question: Is there a specific Remittance Remark code that is used to identify claims that cannot be appealed? Answer: Claims that have been rejected as unprocessable with remark code MA cannot be appealed.

Question: When it comes to appeals, what is the difference between a rejection and a denial? Can you provide us with an example?

Answer: When incorrect information such as an invalid PTAN or procedure code is submitted, a rejection will occur because this information cannot be processed, and unprocessable claims cannot be appealed.

They must be corrected and resubmitted. On the other hand, if all Medicare requirements aren't met during the review of a claim if required documentation is missing, for example , then this will result in a denial that can be appealed. Question: Is the appeal process for Railroad Medicare the same as the appeals process with our local Medicare contractors? Answer: Yes, it is the same process.

Question: Is there a way to check the status of an appeal on the Railroad Medicare website? Or will I need to call to check on the status of my request?

Answer: You can check the status of an appeal by using the Railroad Medicare Redetermination Status Tool on our website. Question: Where can I find all the timelines for reconsideration and appeals?

Answer: If you are looking for additional information about Appeals, please see our website , and look for our Appeals page. You can find that page by using our Topics tab in the main toolbar on our homepage. When you open the Topics page, you will see Appeals is the very first subtopic link on that page. When you open the Appeals page, you will find information about filing Appeals, Appeals timeliness, checking the status of your Appeals, and we do have information about the different levels of Appeals, as well.

But remember, the only level of appeal you would file to Railroad Medicare will be the First Level or Redetermination. That module takes you through the different steps and levels of Appeals and gives you more information about filing appeals to Palmetto GBA as well.

Question: How do the five levels of appeals work? Answer: If you access our Appeals page via the Topics tab on our website , you will see a heading titled Appeal Timeliness. If you access this resource, a breakdown of each of the five levels of appeals is listed there. Addendum: Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and suppliers — or their respective appointed representatives — has the right to appeal the Medicare coverage and payment decision.

An appeal must start at the first level, redetermination, and can then proceed in order through each additional level. Each level of appeal has specific filing and decision timeframes and levels three and five have a dollar amount that must remain in dispute to qualify. Answer: Your appeal rights are based on the date of the claim determination. So, if you have an older date of service that has been chosen for medical review, your appeal right will be based on the date of the determination medical review makes on that claim, not the date of service.

You will need to register a separate account for Railroad Medicare in eServices. When you register, there is a line of business drop-down box and you will see a choice for Railroad Medicare Part B— All States. That is what you should choose when setting up an account for Railroad Medicare. Addendum: For more information about registering an eServices portal account for Railroad Medicare, see our eServices Portal resources. Question: I bill for two different entities.

Can I link those two eServices accounts into one account? Once you link those accounts together, you will have a default User ID that you can use to log into. There are step-by-step instructions for linking accounts in our eServices User Manual in section Question: How can I find out who is the admin for our organization?

If you are signed into your account, you can find a list of your account admins, up to three, on the MyAccount tab.

Answer: eDelivery preferences are controlled by the administrator of the eServices account. On the Admin tab, there is a subtab for eDelivery Preferences. On that eDelivery Preferences subtab, there will be a list of all of the different types of documents that are available to be received via eDelivery for Railroad Medicare.

If you choose eDelivery, there is also an option to click a box that is labeled User Pref Email Notification, and what that will do is also allow you to get an email directly when there is a letter of that type that has been delivered to your eServices inbox.

In particular: Beginning in the s, there was an increase in waiver activity, and waivers became broader in scope. Under different administrations in the past, waivers have been used to expand coverage, modify delivery systems, and restructure financing and other program elements. The Biden Administration has signaled a shift in policy to emphasize waivers that expand, rather than restrict, Medicaid coverage and access to care though still within the limits of budget neutrality.

Waivers with Eligibility Changes back to top. Waivers with Benefit Changes back to top. All Approved Waivers by Topic back to top.

All Pending Waivers by Topic back to top. Section Waiver Tracker Work Requirements.

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