October 16, 2007
Part B Customer Service Frequently Asked Questions
Q. Has the covered diagnosis changed for lab services (i.e. CPT 85610)? We are receiving CO-50 denials, when the diagnosis submitted is listed as a covered indication in the NCD.
A . Certain laboratory codes were not denied per a coverage determination policy. It has come to our attention that due to a system editing problem, laboratory codes were being denied in error with Remarks Code CO-50 (These are non-covered services because this is not deemed a “medical necessity” by the payer). The problem has been fixed. We will do a mass adjustment for the codes previously denied in error. No further action is needed by the provider.
Q. I have been trying to submit the quality measure codes. I know that these codes will be denied as not being payable. I am seeing some of these codes on a separate remittance, denied as a missing, incomplete, or invalid procedure. There may be only one or two codes showing up on one remittance for a patient when I have filed perhaps six on that same patient. I don't know if this means there was something wrong with those codes as the claim was separated or if the codes were okay. Can you please advise?
A . Previously, CIGNA Government Services identified several PQRI (Physician Quality Reporting Initiative) codes that were inadvertently omitted from the Type of Service Table, which caused claims to split on a separate remittance notice. Shortly thereafter, the Type of Service Table was updated to include the appropriate codes. The PQRI Project has been implemented by the Reopenings Team for providers impacted by this issue. It is not necessary for providers to notify us of the affected PQRI codes, as we have identified the providers involved and will handle their claims accordingly. The PQRI Project began in August and we anticipate will be completed on or before December 31, 2007 .
Q. Can you please provide me with a listing of Opt-Out Medicare Providers?
A . A current listing of Medicare opt-out providers is now available on our web site, under the Part B Provider Enrollment section. You can access this information at http://www.cignagovernmentservices.com/partb/enrollment/index.html. Please click on the link for “Report of Providers Opted Out of Medicare”.
Q. Our claims are being denied for missing or incomplete provider numbers. Where can I check to ensure our NPI matches our provider number (PTAN)?
A . Certain information you enter into the National Plan and Provider Enumeration System (NPPES) in order to obtain and maintain your National Provider Identifier (NPI) is used by Medicare in processing claims. If the information you entered in NPPES is not correct, your claims may reject. It is important to verify that information is entered correctly. Once the NPI application information has been submitted and the NPI assigned, NPPES will send the health care provider a notification that includes their NPI.
Medicare Learning Network (MLN) Matters article, SE0725 addresses information regarding the NPPES errors and using the NPI on Medicare claims. You can view this article on the Centers for Medicare & Medicaid Services (CMS) web site at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf.
Also, you may wish to contact Customer Service to verify that your NPI information is being cross-walked correctly in our system.
Q. What is required to change our address? Can I change our address through your web site? Do I have to complete a CMS form? Can I send the change of address form from the Post Office?
A. An address change requires submitting the appropriate CMS-855 Medicare enrollment application. The instructions included with each form provide the best guidance on what is needed to complete an address change. At this time this process is not available on-line.
Providers will need to have a National Provider Identifier (NPI) and may need to complete an Electronic Funds Transfer Authorization Agreement (CMS-588) with the address change. You may obtain the current versions of the CMS 855 forms through the Centers for Medicare & Medicaid Services website at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp. From this page, under “Select from the Following Options,”
- Select “Show only (select one or more options):”
- Select “Show only items containing the following word”
- Type “855” in the box
- Click the “Show Items” button
- Select the proper CMS-855 form
Providers will receive a courtesy letter within fifteen days, acknowledging receipt of the application. If the application is complete and accurate it is processed timely. However, if additional information is required to process an application, Provider Enrollment will send another detailing the additional items required.
Additional information and guidelines can be found on our web site at http://www.cignagovernmentservices.com/partb/enrollment/index.html.
Q. Your IVR system asked for a PTAN. What is a PTAN?
A. The PTAN is your Provider Transaction Access Number. This number was previously referred to as your Medicare Provider Identification Number (PIN) or legacy number. Only the title of the number has changed; the number still serves the same purpose.
Q. The only HMO directory I can find online was last updated in January 2005. When will it be updated so we can get current information?
A. There are web sites available that will give information on the Medicare Advantage Plans, based on the plan's identification number given on our Interactive Voice Response (IVR), including address and the type of plan. These listings are currently updated and maintained by the CMS. Please refer to the CMS links below for the current listings of Medicare Advantage Plans:
http://www.cms.hhs.gov/HealthPlansGenInfo/
http://www.cms.hhs.gov/healthplansgeninfo/downloads/claims_processing_20060120.pdf.
Q. How do I locate the old Medicare Part B Fee Schedule (allowance Limits) for drugs (i.e. first quarter of 2006) on your new web site?
A. The drug payment allowance limit for the Medicare Part B drugs is limited to the most recent quarters on the CIGNA Government Services web site. However, archived payment allowance limits for the Medicare Part B drugs, such as 2006, can be found on the CMS web site at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage.
Q. When two specialists from the same group bill a hospital E&M visit on the same day we are experiencing denials. Why are our claims being denied?
A. The Centers for Medicare & Medicaid Services (CMS) published evaluation and management guidelines in Chapter 12 of the Medicare Claims Processing Manual. The information below addresses hospital visits on the same day. The following excerpts are taken from Section 30.6.9 (http://www.cms.hhs.gov/Manuals/IOM/list.asp):
Two Hospital Visits Same Day
Carriers pay a physician for only one hospital visit per day for the same patient, whether the problems seen during the encounters are related or not. The inpatient hospital visit descriptors contain the phrase “per day” which means that the code and the payment established for the code represent all services provided on that date. The physician should select a code that reflects all services provided during the date of the service.
Hospital Visits Same Day But by Different Physicians
In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, carriers do not pay physician B for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.
If the physicians are each responsible for a different aspect of the patient’s care, pay both visits if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty.
Q. Where can I find a listing of diagnosis codes covered by Medicare?
A. Procedures or services affiliated with a CIGNA Government Services (CGS) Local Coverage Determination (LCD) Policy will have a specific listing of covered indications that are considered acceptable evidence of medical necessity. These LCDs can be found on our website at http://www.cignagovernmentservices.com/partb/index.html.
Procedures or services affiliated with a National Coverage Determination (NCD) Policy established by CMS may also have a specific listing of covered indications that are considered acceptable evidence of medical necessity (e.g. Laboratory NCDs). The CMS NCD policies can be found on their website at http://www.cms.hhs.gov/center/coverage.asp.
There is not a listing of covered diagnosis codes published specifically for Medicare use. However, in the absence of a local or national coverage determination, Medicare will consider procedures or services that document valid indications which supports medical necessity.
