- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
National Government Services has noticed that when a claim RTPs for additional information to be added to the Remarks Field (FL 80, or electronic equivalent) concerning certain drugs and high cost items, some providers attempt to provide more information than is required. Please review this article to better understand specifically what is required under these circumstances.
Additional Information May Be Requested
Medicare and NGS require that when additional information is required for accurate claims processing, the provider must supply all information requested or risk not having the service(s) paid. Providers should note that certain drugs and biologicals, as well as additional items that are typically high cost, may require additional information in order to properly price and process the claim.
When a service is covered by an LCD, the claim must include sufficient information to ensure that the service was provided in accordance with the LCD. For example, when the LCD provides coverage for a specific item or service after certain measures have been tried (such as prior chemotherapy drugs used) then the claim should include information (in the remarks section) specific to the previous medications/services used. One important item to include in the remarks section of the claims is the date of services and/or DCN for a previous claim for that patient and item; this information allows NGS to look for previous claim results.
NGS provides basic coverage guidelines in the Medical Policy, “Article For Drugs and Biologicals, Coding Article (A52855)” including that for claims submitted to the Part A MAC, the provider should list the appropriate HCPCS/CPT code to indicate the specific drug/service provided.
Note: Some drugs and high cost items require additional information such as prior treatments received. When additional information is necessary, NGS will return the claim to the provider along with a request for specific information.
FISS DDE information: The FISS Remarks Field (MAP1714) on claim page 04 is a 78 position alphanumeric field with ten lines available. Providers may utilize the <F6/PF6> key to scroll forward for two additional pages of remarks space, if needed. Thus, there are 10 lines per each of 3 pages available. Therefore, 78 spaces x 10 lines per page is 780 x 3 = 2340 spaces.
Note: The FISS system does not currently allow looking up the claims history for specific items and services. However, if the item/service has previously been paid for a beneficiary and date of service is provided in the remarks, the nurse will check for the claim in history.
Related Content
- Article For Drugs and Biologicals, Coding Article (A52855)
- Medical Policy Local Coverage Determinations and Medical Policy Articles – Check for specific coverage requirements for certain drugs and biologicals
Revised 5/30/2023