Q.

Claim Information not on ARU ­ I went through the ARU, why doesn’t it give me any information on my claim?

A.

Claim status may be obtained through the Automated Response Unit (ARU). The Automated Response Unit will have information on claim(s) that are being processed, duplicate claim(s) and denied claim(s). If the ARU is stating that we are not working on a claim at this time, verify that the information you are keying into the ARU you is the correct information (example: the date of service, year, etc.).

The ARU will retrieve the information based on what is keyed into your telephone keypad. Make sure that you have the correct:

• Date of Service,
• Medicare claim number and,
• Provider Identification Number (PIN).

Also, verify that the claim was submitted with the correct date of service, correct patient’s Medicare number and the correct Provider Identification Number (PIN). There is no limit to the number of transactions that you could verify through the ARU.

If you have gone through the ARU and have not been able to get the information that you are requesting, our Customer Service Representative could verify the information for you. There is a limit to the number of transactions that a Customer Service Representative could help you with.

Q.

Claim Pending ­ Why is my claim still processing and when will it finish?

A.

Medicare carriers are required by law to withhold payment to providers and suppliers after claims have completed processing for a minimum number of days. This minimum number of days is called the "payment floor".

The payment floor for paper claims is 27 days. However, for electronic claims, the payment floor is reduced to only 13 days. This reduction is to encourage providers and suppliers to use electronic claim submission. Paper claims are paid no sooner than the 28^th day after the claim is received, and electronic claims are paid no sooner that the 14^th day following the receipt of the claim.

Clean claims are usually paid immediately after the payment floor time period has passed. A claim is considered "clean" when it does not require manual intervention, and it contains all of the required information necessary to issue a payment decision and Medicare Remittance Notice or Summary Notice. Clean claims allow the Medicare carrier to process the claim without having to ask the physician, supplier, beneficiary, or a third party for additional information. Claims, which are not considered "clean", and claims involving unique circumstances, may be subject to longer processing periods while Medicare researches for more information.

"Clean" claims, which have not been paid by the 30th day after the date of receipt, are subject to payment of interest. Interest will be applied starting on the 31^st day.

Q.

Individual Provider Information ­ Is my pin linked to the group or what is the Dr’s. upin?

A.

Is my PIN linked to the group?

You may obtain this information by speaking with one of our Customer Service Representatives. You will be asked to provide the name and provider identification number of the individual provider and/or the group you are affiliated with.

Up to 5 group names may be given, per call, that an individual is affiliated with or 5 names of individual providers that are affiliated with a group.

What is the Dr’s UPIN?

The UPIN is for Unique Provider Identification Number. You may locate in the Nationwide UPIN Directory on the web site at www.cpg.mcw.edu/www/upin.html.

To retrieve or verify a Unique Provider Identification Number (UPIN), over the telephone, you must provide the Customer Service Representative with your 9 digit Provider Identification Number (PIN) issued by Medicare.

N. California Provider Lines: 1 (877) 591-1587 Toll Free

S. California Provider Lines: (213) 742 - 3996

If you do NOT HAVE a PIN, issued by Medicare, and want a UPIN only, you must submit an 855 (Blue) application along with your California License and Social Security Number to:

N. California
The Medicare Certification Department
PO Box 602
Marysville, CA. 95901-0602

S. California
The Medicare Certification Department
PO Box 6056
Los Angeles, CA. 90060-0560

Q.

Can you correct my claim? I want to change or add a modifier.

A.

Each claim received by Medicare is processed on a claim by claim bases. However, once a claim has been file with Medicare, Medicare will either deem the claim unprocessable, deny or reduction of payment claim, or pay the claim.

For a modifier an unprocessable claim(s) is a claim that has been submitted with a missing, incomplete or invalid modifier. The submitter of the claim will be notified of the error(s). No appeal rights are allowed on this claim(s) because no "initial determination" can be made rendering the claim unprocessable. However, once the submitter has corrected the modifier, the claim then can be resubmitted or retransmitted to be considered for payment.

For a modifier to be denied or have a reduction in payment a review of an initial claim determination may be requested by telephone or by written correspondence.

General Guidelines for Written Correspondence Review ­

• A cover letter explaining precisely why the modifier needs to be reviewed, why it was felt the modifier in question was incorrectly processed, and the action desired to be completed.
• Include your provider number, provider name, and beneficiary Health Insurance Claim Number.
• An identification of the claim(s) in question. (Copies of Medicare Remittance Notice forms with the affected claim(s) highlighted are best.)
• Any documents that will substantiate the reason for the review that were not submitted with the original claim(s).

General Guidelines for Telephone Review ­

• Your name, the provider’s name, beneficiary Health Insurance Claim Number, and name of the beneficiary will be requested.
• An identification of the claim(s) in question. Why the modifier needs to be reviewed, why it was felt the modifier in question was incorrectly processed, and the action desired to be completed.
• If the claim denied more than six (6) months ago and the time-limit has been exceeded, Medicare cannot review it over the telephone.
• Medicare will only review claim(s) for three (3) patients per call.

Q.

Check Status ­ When did the last check cash and what is the check number?

A.

Information about your last three checks can be found on the Automated Response Unit (ARU). You will need to know your Provider Identification Number (PIN). The ARU will be able to tell you the last three Check Numbers, Issue Dates, Total Amounts, and status of each check. The cashed date can not be obtained through the ARU; you would need to call our provider line number and speak to a Customer Service Representative for cashed date information.The ARU does not limit the number of Inquiries made. You may research unlimited PINs, claims, etc. on the ARU.

This information can also be obtained by speaking to our Customer Service Representative. When speaking to a Customer Service Representative you will be asked for the patients Medicare Claim number, date of service and your Provider Identification Number (PIN) and the office you are calling from. The Customer Service Representative will be able to tell you the Check Number and the date the check cleared our bank. You will be limited to five transactions per call.

Up to six months of check information is retained on our file. If the check cleared prior to six months ago, the information cannot be obtained over the phone.

Q.

Facsimile Remittance Request ­ I lost or never received the RA, can you send me another one?

A.

You may obtain duplicate copies of a Medicare remittance notice through our Automated Response Unit (ARU). The information that you will to request a duplicate notice is your Provider Identification Number (PIN) and the patient(s) Medicare number (Health Insurance Claim Number) and the date of service or the Internal Control Number. There is no limit to the number of patient(s) that you could request duplicate statements for through the ARU.

You could also obtain a duplicate by speaking to a Customer Service Representative, you will need the patient(s) Medicare number, Provider Identification Number (PIN) and the date of service or Internal Control Number. You will be limited to five transactions per call.

Q.

Reopening/Limiting Charge ­ Can I bill over the allowed amount?

A.

The limiting charge provision applies only to non-assigned claims. The submission of a non-assigned claim with a billed charge that exceeds the Medicare limiting charge amount is a violation of the charge limit. The maximum amount that a non-participating physician, practitioner, or supplier can charge a Medicare beneficiary for a non-assigned service is 115% of the Medicare allowed amount. The Medicare limiting charge can be calculated by multiplying the amount under the "ALLOWED" field on your Medicare Remittance Notice by 115%. If the charges are billed as assigned, you can collect in total, no more than the Medicare approved amount for the service(s).

Q.

All Other HMO ­ I want to know who the correct payer is and/or who was the claim transferred to?

A.

This information can be obtained from the beneficiary or by requesting a copy of their HMO eligibility card. If the beneficiary does not recall the HMO or is unable to provide you with the HMO information, you may obtain the information by calling a Medicare Representative at our toll free number 877-591-1587.

Many beneficiaries receive Medicare Part B benefits through their voluntary enrollment in a health maintenance organization (HMO). These HMO plans are under contract with the Federal government to both furnish Medicare benefits for their beneficiary enrollees.

Physicians and suppliers should periodically verify beneficiary Medicare coverage. Beneficiaries may be in or out of HMO plans often. Effective communication with the beneficiary and the HMO plans regarding coverage requirements and eligibility is essential.

Changes in a beneficiary’s eligibility can only be made by the beneficiary (or the beneficiary’s legal representative) through the Social Security Administration. Medicare carriers are prohibited from making changes or revisions to a beneficiaries’ eligibility, and must protect eligibility information under the Federal Privacy Act. Currently, information regarding beneficiary eligibility is only available to physicians and suppliers from the beneficiaries themselves. Beneficiaries with eligibility problems should be encouraged to contact the HMO or their local Social Security Administration office.

However, when a physician or suppliers submit a claim(s) to a Medicare carrier and the claim(s) denies with the message: "The claim\service has been transferred to the proper payer\processor for processing. Claim\service not covered by this payer\processor". The physician or supplier may ask the Medicare carrier who is the correct payer\processor for this denied claim.

Q.

Diagnosis ­ I received a denial on the Remittance Advice, what information is incorrect or missing?

A.