General Information: Incomplete Information Provided

When calling the Provider Contact Center (PCC), it is important that you have information needed to authenticate yourself, as this is a requirement of the Centers for Medicare & Medicaid Services (CMS). The authentication information must be entered into our Computer Telephony Integration (CTI) System using your telephone keypad.

The data elements required to do this include:

• Your National Provider Identifier (NPI);
• Your Provider Transaction Access Number (PTAN);
  • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
• The last 5-digits of your tax identification number (TIN).

If your inquiry is specific to a Medicare patient, the following beneficiary information also needs to be authenticated:

• The patient's Medicare Beneficiary Identifier (MBI)
• First initial
• Last name (first 6 letters); and
• Date of birth

We cannot assist you with inquiries without these data elements.

Refer to Save Time When Calling the Provider Contact Center (cgsmedicare.com) for additional information.

Claim Denials: Contractual Obligation (CO) Not Met

Services denied with a Contractual Obligation (CO) group code may not be billed to the patient.

• For a comprehensive listing of group and remark codes, refer to the X12 web site.

Rely on the CGS web site search engine to locate articles to address a number of issues.

Claim Status: Not Classified

Check the status of ALL claims BEFORE resubmitting them!

• Use myCGS to check the status of claims. Navigation steps are in the Claims section of the myCGS User Manual.
• The Interactive Voice Response (IVR) is another option.
  • Select option to check for additional claims with same date of service to locate the claim originally paid.

General Information: Misrouted Telephone Call/Written Correspondence

Check the J15 Part B Contact Information page to locate the correct phone/fax numbers and mailing/web addresses.

Claim Denials: Coding Errors/Modifiers

Call center staff cannot choose modifiers for you, as they do not have access to your medical records to ensure correct documentation is present.

• Utilize the Modifier Finder Tool for help with correctly selecting and using modifiers.
• Please be sure the documentation in the patient's medical record supports the use of any modifier added to a claim.

Claim Status: Payment Explanation/Calculation

CMS determines the amount allowed for all services paid from the Medicare Physician Fee Schedule (MPFS.) The formula used for the MPFS includes the following factors:

• Work, Practice Expense (PE), and Malpractice (MP) Relative Value Units (RVUs)
• Work, PE, and MP Geographic Practice Cost Indices (GPCIs)
• Conversion Factor (CF)

Refer to the How to Use the MPFS Look-Up Tool MLN Booklet for additional information and a reference to the CMS Physician Fee Schedule Search Tool.

To find the CGS Jurisdiction 15 (J15) allowed amount of specific codes, refer to the CGS Part B Physician Fee Schedule Database. Select your state (KY or OH) and the year from the drop-down boxes. You may search for up to five specific codes or view the entire MPFS.

• The amount located under the "Par" column is the allowed amount for a participating provider.
• The amount in the "Non-Par" column is the amount allowed for a non-participating provider.
  • The Non-Par amount is 5% less than the Par amount.
• Non-Par providers are limited in the amount they may charge for services, which is identified in the "Limit Charge" column.
• The allowed amount noted with a '#' sign is reduced due to the Site of Service reduction.

Providers who render services in a facility setting do not incur the cost of overhead that they would in an office setting, therefore, the reimbursement is reduced.

Provider Enrollment: Not Classified

When submitting inquiries, it is important that you include information needed to authenticate yourself, as this is a requirement of the Centers for Medicare & Medicaid Services (CMS). The data elements required to do this include:

• Your National Provider Identifier (NPI).
• Your Provider Transaction Access Number (PTAN).
  • Be sure to use the Group PTAN (when applicable). Individual PTANs are not used in the privacy verification process when a Group PTAN is assigned to the provider.
• The last 5-digits of your tax identification number (TIN).

Everything regarding credentialing is available to you on Provider Enrollment webpage!

• Use the Provider Enrollment Interactive Help Tool for guidance on which CMS-855 enrollment application to complete and what additional documentation to include
• Only delegated and authorized officials may receive a status of a provider enrollment application
  • Please be sure to identify anyone who is privy to this information on your application
  • THE best way to check the status of an application is to use the Provider Enrollment Application Status Check Tool!
    • You can search for applications by the CGS Reference Number from your acknowledgement letter, NPI, PTAN or Web Tracking ID from your PECOS on-line submission.
• Also, check out the most common provider enrollment application issues we see with those submitted via Internet-based PECOS and on the paper CMS-855

Claim Denials: Medicare Secondary Payer (MSP)

When Medicare is secondary, the primary payer MUST be billed first.

• Check this article for steps to help you with MSP claims.
• Refer to the MSP Job Aid to determine how a patient's record "should" appear.
  • If the patient's record is different than what the flowchart suggests, please contact the MSP Contractor (formerly known as the Benefits Coordination and Recovery Center (BCRC).)
• Verify patient eligibility to determine whether there is a payer primary to Medicare.
  • Check the Eligibility tab/MSP sub-tab in myCGS. Navigation steps are available under the Eligibility section of the myCGS User Manual.
• The Interactive Voice Response (IVR) is also a resource.
• Need help determining the claim payment calculations? Check out the Medicare Secondary Payer Tool!

Claim Denials: Claim Overlap

Medicare often receives multiple claims for the same patient with the same or similar dates of service. An overlap occurs when the date of service or billing period of one claim seems to conflict with the date on another claim, indicating that one of the claims may be incorrect.

• Verify patient status using the Eligibility tab in myCGS. Refer to the Eligibility section of the myCGS User Manual for navigation steps
  • The INPATIENT sub-tab allows you to enter a date span to determine whether patient was admitted to a hospital or skilled nursing facility (SNF)
  • The HOSPICE/HOME HEALTH sub-tab provides information on each election period (Hospice) and episode start and end dates (Home Health) based on the date span entered
  • You can also obtain the National Provider Identifier (NPI) of the billing provider for inpatient and SNF stays. Including Qualified Medicare Beneficiary (QMB) dual-eligible patients.

NOTE: Information on inpatient status is available only after Part A and/or Home Health and Hospice claims have been submitted and captured by the Common Working File (CWF)

NOTE: Be sure to enter a date of service span on the Eligibility Inquiry page in order for myCGS to correctly populate information on these tabs.

• Verify the place of service code submitted on claims, as this could generate rejections (e.g., submitting place of service Office (11) when patient is inpatient hospital (21).

Global Surgery guidelines may also cause overlap issues.

• Access the CMS Medicare Physician Fee Schedule Database (MPFSDB) Look-up Tool to determine the number of post-op days assigned to surgical procedures
• Use the correct global surgery modifiers when it is appropriate to bypass edits in the processing system
  • The Modifier Finder Tool can help you determine whether CPT modifier 24, 25, or 57 (for E/M services) is appropriate; or if CPT modifier 78 or 79 (for procedures) will help.

NOTE: The medical record must support the use of any modifier.

Claim Denials: Duplicate

Duplicate claims must be avoided:

• Check the status of ALL claims before resubmitting
  • Refer to the Claims section of the myCGS User Manual for navigation steps for using myCGS to check claim status
  • The Interactive Voice Response (IVR) is another option
    • Select option to check for additional claims with same date of service to locate the claim originally paid
• Submit multiple same services provided on same date on ONE claim
• Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • Refer to the Modifier Finder Tool for help
• When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
  • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
• It is also possible that a lab or radiology service has been paid by another contractor to a different provider
  • Be sure to consider services provided by other providers. Review the patient's medical records in full.