Q.

What is my UPIN?

A.

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: (877) 591-1587 Toll Free

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

A physician who DOES NOT HAVE a Medicare issued PIN and wants only a UPIN must submit an 855 (Blue) application along with their California License Number and their 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.

Which modifier would I use for an office visit and a flu shot on the same visit?

A.

A modifier 25 may be used for a significant separately identifiable Evaluation and Management service on the same day as another service by the same doctor.

Q.

I haven’t received payment, but I received a denial for a duplicate, why?

A.

Some claims that we receive are duplicates of claims that have already processed or, the original claim is still pending/processing. When a request is submitted more than once for:

• the same patient;
• the same Medicare number;
• the same date of service;
• the same service;
• the same quantity billed;
• the same billed amount; and
• the same rendering/billing provider the original (first claim that came in) will continue to process and all others will deny as a duplicate.

Most Medicare claims are processed, with Remittance Advice Notices, well within 30 days of the day we receive them (although some claims will take longer, especially if necessary information is lacking). You should allow at least 30 days before you inquire about an unpaid claim. Then, if a claim is still outstanding (and you have not received a request for additional information) call our Medicare Provider Line and follow the ARU instructions. If you are unable to retrieve claim status with the ARU system, ask one of our Customer Representatives about the claim’s status.

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

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

Q.

I’ve used the ARU; it told me you were not working on the claim at this time, could you double-check this for me?

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 is the correct information (example: the date of service, year, etc.). 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(s) 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.

I misplaced the EOMB, can I get a duplicate remittance notice ?

A.

You may obtain duplicate copies of a Medicare remittance notice through our Automated Response Unit (ARU). The information that you need 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.

The claim denied for ICD-9; it needs to be billed at the diagnosis level. What does that mean?

A.

A diagnosis code may be 3, 4 or 5 digits long depending on the highest digit in their classification. HCFA requires that a diagnosis code is carried to the highest level of specificity, however not beyond the highest level. That is, be careful not to add a digit to the end of an ICD-9 code thinking it needs to go to a higher level when it does not, thereby making it an invalid diagnosis. Remember that each digit within the sub-classification has a specific meaning. Providers should consult their most current ICD-9 book for the correct codes.

Q.

Why did this claim deny stating beneficiary is not eligible?

A.

Eligibility information is received from the Social Security Administration. Privacy Act guidelines apply when releasing eligibility information.

Eligibility information may be released to the beneficiary or the representative listed on our file.

Specific eligibility information may not be released to providers, unless the beneficiary gives us permission. The provider may be told that the beneficiary was or was not eligible for a specific date of service if the claim is showing on our file.

If the provider is inquiring about eligibility in general, not a specific date of service, refer them to the beneficiary. If the beneficiary is inquiring and there is change or problem with their eligibility, refer them to Social Security Administration.

All changes or eligibility problems need to be reported to Social Security Administration by the beneficiary or the beneficiary’s legal representative. Medicare carriers are prohibited from making changes or revisions to the beneficiary's eligibility.

Q.

May I have the bulletin for the modifier for bundled procedures?

A.

The Correct Coding Initiative (CCI) Overview was published in Medicare Bulletin 99-4, Pages 60-64. A listing of applicable modifiers is available on page 62.

Q.

When did my last check clear, and what was 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 ARU does not limit the number of Inquiries made. You may research unlimited PINs, claims, etc. on the ARU.

Also, when speaking to a Customer Service Representative you will be asked for 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, Issue Date, Total Amount, and the date the check was cashed. 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.

What HMO coverage does this patient have?

A.

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 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 beneficiary's 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 supplier submits 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.