FAQs

All MSP claims must be filed electronically. The HIPAA compliant ANSI X12 format allows the primary EOB information to be entered electronically. The primary EOB should be kept on file in your office. MSP claims are considered “initial” claims to Medicare and must be filed electronically. For more information on where to enter the primary EOB information contact your software vendor.

Reviewed: 10/05/22

MAP1755 of the eligibility file contains the remaining dollar amount of the therapy cap yet to be met based on claims processing. Providers can access beneficiary eligibility files through the FISS/DDE Provider Online System.

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Reviewed: 10/05/22

If you are trying to work a claim that has been returned (TB9997) or adjust a previously processed claim and you are unable to retrieve/select it, you can go back to the Main Menu and choose Option 01 – Inquiries. Once you are on the Inquiries menu, select Submenu 12 for Claims. From the Claim Inquiry screen you can enter your claim information to determine what location the claim may be in. If your claim is in an 'S' location, it cannot be worked by the provider. In addition, you should go back and validate that you are using the correct beneficiary/claim information, e.g., HICN, DCN, etc. Make sure that you are using the correct type of bill, you may have to change the type of bill to be able to access the claim.

Reviewed: 10/05/22

Laboratory, diagnostic, and therapeutic procedures - MD order and progress notes showing medical necessity are needed.

  • Requisition forms or MD order form needed with MD signature.
  • Illegible MD signatures
    • Signature key or attestation statement is needed if MD signature illegible - by MD or Compliance Officer with typed name and MD signature
    • Alert treating physicians and medical records staff
  • Progress note by ordering physician is needed also to show the medical necessity of the services ordered. MD signature also needed with progress note.
    • Signature key or attestation statement is needed if MD signature illegible - by MD or Compliance Officer with typed name and MD signature
  • Providers with electronic ordering or progress notes systems
    • Print of screen showing electronic order or progress note (Include notation such as “Electronically signed by”.)
    • One copy per provider of the protocol that describes that the system is entered by the MD with a unique ID and password or audit trail showing MD entered system with unique ID and password
      • Alert medical records staff
  • For verification of illegible signature - Signature attestation example: “I, _[print full name of the physician/practitioner]_, hereby attest that the medical record entry for _[date of service]_ accurately reflects signatures/notations that I made in my capacity as __[insert provider credentials, e.g., M.D.]_ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.” M.D. Signature.

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Reviewed: 10/05/22

Comments can be entered in multiple places, Loop 2300 NTE, Loop 2400 NTE or loop 2400/SV101-7. For faster claims processing, enter comments in loop 2400/SV101-7.

For additional information, visit Medicare Part B CMS-1500 Crosswalk for 5010 Electronic Claims.

Reviewed: 10/05/22

A claim which has been denied at the claim level cannot be accessed in the DDE adjustment menu and must be appealed. If you are adjusting a partially denied claim you must use a D1 condition code and an LN adjustment reason code on the adjusted claim. Also include remarks clarifying what is being changed from the previous submission.

Reviewed: 10/05/22
  • Complete the Part A Logon Request Form within the EDI Guided Enrollment
  • Select Change Name as the action type
  • Complete the form in its entirety including the log on ID

Please Note: The name associated with a Logon ID cannot be changed to reassign to a different employee.

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Reviewed: 10/05/22

The FISS/DDE Provider Online System functions allow providers to view ADRs online. If a provider is set up to submit claim attachments electronically, the provider will not receive a hard-copy ADR for therapy and ambulance services that are pending in status locations SB6099 or SB6098; they must use the FISS/DDE Provider Online System to identify claims and view the ADR for which National Government Services requires documentation. Providers will not receive hard-copy ADRs for claims pending in status locations SB6099 or SB6098. Providers who cannot submit electronic attachments will see all claims requiring medical documentation in status/location SB6001.

Reviewed: 10/05/22

To avoid denials on claims for postoperative management, submit claims with the original surgical date of service with number of service = 1. 

  • Only comment the date span of assumed care. 
  • Be sure it is after the surgery and that the correct year(s) is included. 

Visit Global Surgery for more detailed information on submitting postoperative claims. 

Note: 2019 and 2021 are not leap years so February only has 28 days. 

Reviewed: 10/05/22

To avoid incorrect payments or denials, use the following format: MM/DD/YY or MM/DD/YYYY.

For additional information and guidance visit Global Surgery.

Reviewed: 10/05/22

Yes, to avoid the claim being denied, base and mileage codes for the same trip must have the same ZIP code, including any four-digit extension on the ZIP code.

For additional information and guidance view our Ambulance Billing Guide

Reviewed: 10/05/22

You will want to be sure to submit the drug name and total dosage given in Item 19 of the CMS-1500 or the electronic claim equivalent (Loop 2400/SV101-7) for the applicable line only; adding comments in multiple places can lead to incorrect processing. 

Reviewed: 10/05/22

When billing unlisted codes, the unit of service equals one (1) and the following details must be entered into in Item 19 of the CMS-1500 or the electronic claim equivalent (Loop 2400/SV101-7):

  • Name of the drug
  • Dose administered (mg, cc, etc.)
  • Route of administration (IV, IM, SC, PO, etc.)
  • The invoice price (for new drugs if the WAC is unavailable, or for compounded drugs)

For additional information and guidance visit Drugs and Biologicals – Coverage and Billing

Reviewed: 10/05/22

It is important to ensure the name is submitted exactly how it appears on their Medicare card. 

  • Be sure not to submit any invalid characters in the name field as it may cause the claim to deny.

For additional information, visit CMS-1500 Claim Form Completion Instructions.

Reviewed: 10/05/22

To prevent monthly ESRD CPT codes 90951-90966 from denying, submit only one code per month with a quantity billed amount of 1.

For additional guidance and information visit Physician Dialysis Services.

Reviewed: 10/05/22

Any of the ICD-10-CM diagnosis codes listed under screening Pap tests must point to the claim detail line.

For additional guidance and information visit Screening Pap Tests.

Reviewed: 10/05/22

CMS developed MUEs in 2007 to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum UOS that a provider would report under most circumstances for one beneficiary on one DOS; not all HCPCS/CPT codes have a MUE.

View CMS’ Medically Unlikely Edits web page for additional information and access the MUE table; to view a full listing of all HCPCS/CPT codes subject to MUE.

Reviewed: 10/05/22

Claims submitted via paper for beneficiaries with Medicare as a secondary payer need to include a clear copy of the primary payers EOB for each claim submitted.

Visit Prepare and Submit an MSP Claim for additional information and guidance.

Reviewed: 10/05/22

National Government Services accepts documentation by NGSConnex, mail, esMD, CD/DVD and fax.

Visit Methods for Submitting an ADR for additional information and guidance. 

Reviewed: 10/05/22

No, CMS-1500 claim filing instructions, found in CMS Internet-Only-Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 26 Section 10.3 Item 12, indicate the patient or authorized representative must sign and enter the date unless the signature is on file. Signature on file is obtained when a beneficiary signs a specific signature card indicating they are providing their authorization to the provider to file claims on their behalf.

Reviewed: 10/05/22

When a Medicare claim is truly not related to liability, no fault, or workers compensation:

The provider must enter a comment in the first line of the Remarks field to allow the claim to process as Medicare primary. Providers can use a comment such as “not related to liability”, “not related to no fault”, or “not workers’ compensation”.  

Reviewed: 11/01/22

Contact the EDI Help Desk and follow the prompts.

  • J6: 877-273-4334
  • JK : 888-379-9132
Option: Select If: Additional Selections/Information:
Press 1 You want to check the status of your EDI enrollment forms
  • Provide the Packet ID (PID), PTAN and NPI
  • Status of enrollment forms* will be available 24 hours after online submission
Press 2 To hear the latest EDI news N/A
Press 3 You want to receive a password reset or account unlock
  • Press 1 for Part A
  • Press 2 for Part B
Press 4 For all other inquiries
  • Press 1 for Part A
  • Press 2 for Part B

 

Reviewed: 10/05/22