National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Revision to Medicare Publication 100-09, Chapter 3 – Provider Inquiries, and Chapter 6 - Provider Customer Service Program Updates (MM5597-R)

Note: This article was revised on July 16, 2007, to reflect changes that CMS made to CR5597. The transmittal number, CR release date, and the Web address for accessing CR5597 were changed. All other information remains the same.

Provider Types Affected
All physicians, suppliers, and providers who submit written inquiries to, or contact the toll-free lines at, their Medicare contractors [fiscal intermediaries (FI), carriers, Part A/B Medicare Administrative Contractors (A/B MAC), DME Medicare Administrative Contractors (DME/MAC), and/or regional home health intermediaries (RHHI)]

Provider Action Needed
CR5597 contains a number of revisions to the Medicare Contractor Beneficiary and Provider Communications Manual, including changes for authenticating providers who make inquiries of Medicare contractors. Due to the Medicare fee-for-service contingency plan for the National Provider Identifier (NPI), the NPI will not be a required authentication element for general provider telephone and written inquiries until the date that the Centers for Medicare & Medicaid Services (CMS) requires it to be on all claim transactions. In this contingency environment, the provider transaction access number (PTAN) is your current legacy provider identification number. Your PTAN, which may be referred to as your legacy number by some Medicare fee-for-service provider contact centers (PCC), will be the required authentication element for all inquiries to Interactive Voice Response (IVR) systems, customer service representatives (CSR), and written inquiry units.

While the authentication rules are part of CR5597, for complete details about these rules under the Medicare NPI contingency plan, see MLN Matters article SE0721, which you will find at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0721.pdf on the CMS Web site.

The remainder of this article provides information on the highlights of changes announced in CR5597.

Background
CR5597 modifies Medicare Contractor Beneficiary and Provider Communications Manual, Publication 100-09. These changes are summarized as follows:

Overlapping Claims—New Rules

• Medicare often receives multiple claims for the same beneficiary 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.
• When an inquiry regarding an overlapping claim is received, only the Medicare contractor initially contacted by the provider can authenticate the provider. The provider will be authenticated by verifying the name, PTAN/ legacy number or NPI, beneficiary name, Health Insurance Claim Number (HICN), and date of service for post-claim information, or date of birth for preclaim information. Authentication does not need to be repeated when the second contractor is contacted.
• Contractors shall release overlapping claim information whether a provider inquires about a claim that was rejected for overlapping information, or if the provider found overlapping information when checking eligibility for a new admittance.
• For specific information regarding the resolution of claims rejected by Medicare’s Common Working File (CWF) system, refer to the Medicare Claims Processing Manual, Chapter 27, §50 at http://www.cms.hhs.gov/manuals/downloads/clm104c27.pdf on the CMS Web site.

Information Available on the IVR

• USE THE IVR whenever possible . Providers should be aware that if a request for claim status or eligibility is received by a CSR or written inquiry correspondent and the requested information is available on the IVR, the CSR/correspondent will probably encourage you to use the self-service options that are available.
• If at any time during a telephone inquiry, you request information that can be found on the IVR the CSR will most likely refer you back to the IVR.

Information Available on the Remittance Advice (RA)

• USE THE RA whenever possible . If a CSR or written inquiry correspondent receives an inquiry about information that is available on an RA, the CSR/correspondent will discuss with the inquirer how to read the RA in order to independently find the needed information. The CSR/ correspondent will inform the inquirer that the RA is necessary in order to answer any specific questions for which the answers are available on the RA. Providers should also be aware that any billing staff or representatives that make inquiries on his/her behalf will need to have a copy of the RA.
• To make your job easier you may use the Medicare Remit Easy Print (MREP) software. Information about MREP is available at: http://www.cms.hhs.gov/AccesstoDataApplication/02_MedicareRemitEasyPrint.asp on the CMS Web site.
• Providers may also take advantage of national training materials available to educate themselves and their representatives about reading an RA. The national training materials include the MLN product, Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers which is available at http://www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf on the CMS Web site.
• Also available is a Web site that serves as a resource allowing providers to check the definitions of Claim Adjustment Reason Codes and Remittance Advice Remark Codes. This information is available at http://www.wpc-edi.com/products/codelists/alertservice on the Washington Publishing Company Web site.
• There is a Web-based training course, Understanding the Remittance Advice for Professional Providers, which is available at: http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=5 on the CMS Web site. The course provides continuing education credits and contains general information about RAs, instructions to help interpret the RA received from Medicare and reconcile it against submitted claims, instructions for reading Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices, and an overview of the MREP software that Medicare provides free to providers for viewing ERAs.

Authentication of Beneficiary Elements—additions to current rules
CR5597 contains, within its attachments, a detailed table showing the data elements that are released in response to provider inquiries for beneficiary information. A key new provision allows Medicare contractors to release abdominal aortic aneurysm screening information to providers. CR5597 is available at http://www.cms.hhs.gov/Transmittals/downloads/R20COM.pdf on the CMS Web site.

Additional Key Points of CR5597

• Medicare’s CSRs have the discretion to end a provider telephone inquiry if the caller places them on hold for two minutes or longer. Where possible, the CSR will give prior notice that a disconnection may occur.
  
• If a provider requests a copy of the Report of Contact made during a telephone response to a written inquiry, Medicare contractors will send you a letter detailing the discussion. This letter may be sent to you by e-mail or fax, if you request, unless the details include specific beneficiary or claim related information.
  
• When your Medicare contractor schedules a training event for which there is a charge for attendance and you register and pay, but are unable to attend, you may be entitled to a refund of some or all of your payment. But, to receive such a refund, you must notify the contractor before the event.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5597) issued to your Medicare carrier, FI, A/B MAC, DME MAC, or RHHI. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R20COM.pdf on the CMS Web site.

If you have questions, please contact your Medicare carrier, FI or A/B MAC, DME MAC, or RHHI at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5597 Revised
Related Change Request (CR) #: 5597
Related CR Release Date: July 13, 2007
Effective Date: May 23, 2007
Related CR Transmittal #: R20COM
Implementation Date: July 30, 2007