Palmetto GBA and the Jurisdiction 11 World
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1 Palmetto GBA and the Jurisdiction 11 World 1
2 Disclaimer This presentation was current at the time it was published or uploaded onto the Palmetto GBA Web site. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. 2
3 Palmetto GBA and the Jurisdiction 11 World 3
4 The Providers First Point of Contact 4
5 Provider Contact Center (PCC) The PCC Should be Utilized as the First Point of Contact to Assist with Provider Issues Per the Centers for Medicare & Medicaid Services (CMS) guidelines a provider must call the PCC first for Assistance Tracked Calls Ensures Timely and Appropriate Answers The PCC Will be Able to Assist Providers with the Best Methodology for Contacting Other Areas at Palmetto GBA if Needed 5
6 PCC Contact the PCC for referral information including: Social Security Information Coordination of Benefits Contractor Claim denials with unclear reason code explanations and general questions 6
7 Tier Process Tier Process Allows us to Better Serve Our Customers Tier 1: Handles All Basic Telephone Inquiries Covering a Broad Range of Questions that Cannot be Answered by the Interactive Voice Response (IVR) Unit Tier 2: Handles Telephone and Written Inquiries that are More Complex and May Require Research Tier 3: Handles all Complex Inquiries 7
8 Provider Outreach and Education 8
9 Provider Outreach and Education (POE) Educate Providers: To Ensure Understanding and Compliance with Medicare s Operational Processes, Policies, and Claim Submission Procedures that are Governed by Federal Law, CMS Directives, and Contractor- Level Guidance Develop and Update Educational Materials 9
10 POE Focus Provide Helpful Information and Resources Enable Providers to File Claims Correctly Provide Appropriate Resources if Claims are Returned To Provider (RTP) Provide Education Utilizing Many Avenues to Reach All Providers 10
11 Palmetto GBA Web site Resources Include: Monthly Medicare Advisories Current Articles Workshop Information Workshop Hand-outs Job Aids Online Webinars and Teleconferences Self Service Tools 11
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13 Provider Self Service Tools Claim Submission Error Help EDI System Status Medicare Secondary Payer (MSP) New to Medicare? Provider Enrollment Application Provider Enrollment Application Status Tools and Calculators 13
14 14
15 Claims Processing Issues Log (CPIL) Located Under Top Links Updated on a Weekly Basis to Ensure Accurate Information Outlines the Issues/ Impact to Providers and Status Updates on the Issue Check the CPIL Often for Updates Before Contacting the Provider Contact Center 15
16 Online Provider Services (OPS) Palmetto GBA shares CMS s vision to offer Online Provider Services to the provider community through the deployment of Internet-based, provider self-service secure applications Palmetto GBA s goal is to give the provider secure and fast access to their Medicare information seamlessly via our Web site through the OPS application 16
17 Who Can Enroll in OPS? All Palmetto GBA Providers that Have a Signed Electronic Data Interchange (EDI) Enrollment Agreement on File with Palmetto GBA The EDI Enrollment Agreement: Located in the EDI Enrollment Area of the Palmetto GBA J11 A Web site Click on EDI From the Left-Hand Menu and Click on the Enrollment Link to Enroll 17
18 Online Provider Services (OPS) The OPS Application Provides Real-Time Information Access Over the Web for the Following Online Services: Eligibility Claims Status Remittances Online Financial Information (payment floor and last 3 checks paid) 18
19 Frequently Asked Questions (FAQs) Select Resources, then FAQs from the Menu Data is Captured from a Data Analysis Report Updated Quarterly by the Provider Relations Research Specialists (PRRS) and the Provider Outreach and Education (POE) team Lists a Combination of Questions or Issues that are Brought Up Each Month by Our Providers 19
20 Job Aids Easy to Follow Instructions and Tips to Assist Providers in Billing Correctly Palmetto GBA Job Aids are Located on the Palmetto GBA Web site Learning and Education and then select Job Aid New Job Aids are Distributed via the Listserv CMS Offers Direct Access to Job Aids at: 20
21 Claims Submission Errors Help Provides Explanation and Suggestion for Correcting the Top Reason Code Errors by State and Provider Type Information is Generated by Monthly Data Analysis of the Primary Return To Provider (RTP) Claims for a Particular Month Self Service Tools 21
22 Listserv Updates Providers are Encouraged to Register for the Palmetto GBA Listserv Registering is Quick, Easy and Free! Provides Updates on New Policy Changes, CMS Coverage and Billing Updates 22
23 How to Register Select Updates Fill out Registration Create a Customized Profile Create a Unique Password and Username After Registering: Confirmation Sent 23
24 Educational Resources Workshops Handouts Medicare Advisory Training Online Learning Webinars via WebEx POE Advisory Group (POE-AG) Meetings Ask-the-Contractor Teleconferences (ACTs) Association Meetings 24
25 25
26 Educational Resources Link to Forms Allows Providers to Access Common Forms for Their Use Link to Information Regarding the Recovery Audit Contractor (RAC) Contact Us Tool 26
27 Contacting POE Request for Educational Assistance Complete the Provider Outreach & Education Request Form Click on Forms Fax a Completed Form to An Ombudsman will Contact Provider 27
28 Ask the Contractor Teleconference (ACT) Ask-the-Contractor Teleconference (ACT) Intended to Open the Communication Channels Between Providers and Palmetto GBA Teleconferences Will Now be Held Quarterly Allows Providers to Ask Questions Regarding Various Medicare Coverage and Billing Guidelines Led by POE Staff Questions Must be Submitted Within 5 Business Days Prior to the Call to be Included 28
29 Provider Outreach and Education Advisory Group Quarterly Provider Outreach and Education Advisory Group (POE AG) Meetings Provides Feedback Regarding Provider Education and Training Topics as well as Locations for Educational Forums One Meeting will be Held Each Quarter via Teleconference for All J11 A Providers 29
30 Onsite Training Training Must be for More than One Provider Indicated by a Medicare Provider Number Provider and Ombudsman Must Agree Upon a Date that Will Not Interfere with Any Other Scheduled Educational Events Provider Must Submit a Completed POE Request Form on the Palmetto GBA Web site via Fax 30
31 Impact and Key Date Minimal Impact for West Virginia Part A Your Implementation Date is: May 16,
32 The Palmetto GBA Plan: Maintain Continuity of Services Minimize Disruption to Every-Day Interactions Tenured Staff Throughout Operation Use Our Experience with West Virginia Part B Providers and with the J11 MAC Implementation to Serve You Better! 32
33 Who is Palmetto GBA? Subsidiary of BlueCross Blue Shield of SC Medicare Contractor for 45 Years Headquarters are Located in Columbia, SC 33
34 Who is Palmetto GBA? Additional Offices are Located in Augusta, GA; Columbus OH; Camden, SC; Wheelersburg, OH Associates ISO-9001:2000 Certified 34
35 Who is Palmetto GBA? Doing Work in West Virginia Already! Carrier Since 1966 NGS is Our Key Business Partner on J11: Part A EDI Audit and Reimbursement 35
36 How to Get Ready Stay Connected to Your Current Contractor! Sign up for Palmetto GBA Jurisdiction 11 Part A Listserv ( s) for Implementation Updates at Attend Palmetto GBA Ask the Contractor Teleconferences (ACT) 36
37 What to Expect Dark days Pay Forward; Use Correct Payer ID Cash flow *New Contractor Payer ID Confusion Implementation Hotline
38 What WILL Change Electronic Funds Transfer (EFT) Agreement *New Web site: *Contact Us 38
39 Numbers that WILL Change Provider Contact Center Phone Numbers *New IVR LINE Self Service No CSR Transfer *New CSR LINE :00 a.m. 4:30 p.m. ET 39
40 Local Coverage Determinations (LCDs) Criteria for selecting LCDs: Priority to existing policies in multiple states Compatible Part A and B policies All or nothing - No revisions Clinically relevant Appropriate for all J11 states 40
41 LCD Selection Results 509 active policies considered CMS final approval 52 approved Part A policies 41
42 What WILL Change On Cutover Date *New Health Insurance Query Access (HIQA) or Health Insurance Query for HHAs (HIQH) Contractor Number Enter Contractor ID number in the INTER NO field to access the HIQA and HIQH screens. 42
43 What Will NOT Change FISS System Used to Process Claims CMS Guidance: Applies to All Fee-For- Service (FFS) Contractors Direct Data Entry (DDE) ID RAC - Connoley ZPIC - Advance Med 43
44 Hospital Association West Virginia Hospital Association Early meetings Close Contact Weekly Updates 44
45 Preparing Your Facility Look for the Implementation Guide for West Virginia Part A: Soon to be Released at CMS Article: Preparing for the Transition from an FI/Carrier to a Medicare Administrative Contractor (MAC) : SE
46 We Are Ready! We Look Forward to Serving Our West Virginia Part A Providers with Dedication to Outstanding Customer Service and Excellence as the J11 MAC! 46
47 QUESTIONS? 47
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