4/3/2025 J6/JK Part A and FQHC POE Advisory Group Meeting

Meeting Minutes

Meeting Time: 10:30-12:30 a.m. ET

Member Attendees: Carol Baron, Todd Bergstrom, Kimberly Bischel, RaeAnn Couture, Jennifer Crocker, Dolores DiRe, Amy Fanelli, Matthew Felton, Melisa Garcia, Sherri Hampton, Sam Hollis, Nadia Khalid, Christine Leibold, Vera Loftin, Sara Luther, Karen Matarazzo, Heather McCarthy, Mara Nieves, Catherine Nolin, Larisa Orlando, Anna Santoro, Liz Saulnier and Beth Zavattero

National Government Services Associates: Madison Armstrong, Connie Arszman, Brandie Biszantz, Stefanie Boucher, Charity Bright, Laura Brown, Julie Chang, Emily Dexter, Emma Eno, Alicia Forbes, Emily Fox-Squairs, Andrea Freibauer, Jeanine Gombos, Alison Hamilton, Christine Janiszcak, Nathan Kennedy, Laura Kiker, Christine Klimek, Raeann Lawson, Kathy Mersch, Cheryl Papalia, Kelly Rasmussen, Jean Roberts, Nena Rodrigues, Sydney Sabo, Sonja Schute, Nicole Schwanger, Brittany Small, Susan Stafford, Michelle Vannatter-Johnson, Mary Vier, Patricia Walker, Christine Warshel, Auburn Wheeler and Denise Winsock (CGS DME).

Agenda

1. Welcome, Introductions and Approval of Minutes from Previous Meeting
2. Updates
3. Review of Educational Material
4. POE AG Member Suggestions for Education and Open Forum
5. Upcoming Events and Additional Education
6. 2025 Part A and FQHC POE AG Meeting Schedule

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I. Welcome, Introductions and Approval of Minutes from Previous Meeting

Jean Roberts and Christine Janiszcak, POE Consultant, NGS

Jean and Christine welcomed everyone to the meeting. Jean made the following announcements:

• If you joined the Teams meeting with just your phone number showing, please type your name and number in the chat so we can identify you for the minutes.
• If you do not have your microphone on mute, please place it on mute unless you are speaking.
• We sent out a link to the agenda and meeting material. In the agenda, we included hyperlinks to various documents and spelled out the links (and provided bread crumb trails when possible) since attendees mentioned the links did not work from a PDF document. If this new process works, please let us know and we will do this going forward.
• We placed the agenda in PowerPoint format to make it easier to show it on the Teams screen.

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II. Updates

Denise Winsock, Provider Relations Senior Analyst, CGS – DME MAC JB

Denise explained she does not have significant updates to provide regarding DME. She reviewed her handout including resources for treating practitioners and prescribers of DMEPOS which are on the web page Treating Practitioners and Prescribers DMEPOS Education including:

• MLN® Fact Sheet: Collaborative Patient Care is a Provider Partnership
• Dear Physician Letters (letters written by the DME MAC medical directors and their physicians/practitioners which summarize coverage and documentation requirements)
• Local Coverage Determinations (LCDs and related articles)
• MLN® Fact Sheet: Medical Record Maintenance & Access Requirements
• Medicare Minute MD (short videos created by the medical directors)
• Physician's Corner
• Collaborative webinars (DME MAC POE team collaborates with A/B MACS to enlist support of prescribing practitioners in reducing error rates related to orders and medical records in the areas where they prescribe).
• "Practitioners Are You Ordering…" (variety of articles listed by topic and publication date)

Denise mentioned a collaborative webinar will be conducted on 5/6/2025 which will be posted on the A/B MAC’s websites. She asked for any questions and received none.

Stephanie Boucher, Lead of OPD Program, NGS

Stephanie reviewed her PA handout, shared the timeliness change that was implemented 1/1/2025, reviewed updates on exemption cycles and reviewed claim trends. Some highlights included:

• Effective 1/1/2025, the standard timeframe to review and communicate a decision for all initial and resubmitted requests is seven calendar days from the date of receipt. Substantiated expedited requests will be reviewed with decisions communicated within two business days of receipt of the expedited request.
• There is a chart in the handout that summarizes clinical decisions for JK and J6.  The PA team has observed improvement in the affirmation rates for both jurisdictions, which reflects our ongoing outreach and educational efforts. The PA team increased these efforts to more than double from October of 2024 to February of 2025. These efforts are aimed at ensuring compliance, ensuring clarity regarding our policies, avoiding recurring errors/submissions as well as on decreasing the need for providers to resubmit PA requests.
• The exemption cycle runs from January through December. Providers under exemption do not need to submit PA requests and, therefore, UTNs on claims are not required. Any requests submitted to us by an exempt provider will be rejected. For continued evaluation of claim approval rates for current exempt providers, we will issue ADRs on or by 8/1/2025 using the FISS DDE. It is important to respond to these requests timely and accurately to ensure you retain your exemption status. Providers will be sent written notices by 11/2/2025 for continued exemption or withdrawal from exemption starting January 2026. Our provider counts for exempt providers doubled for JK and J6 due to our education.

Stephanie reminded members about the requirement for Botox codes to be paired. She reviewed upcoming PA webinars and Let’s Chat sessions. She then asked for any questions and received none.

Christine Klimek, Manager, A&R, NGS

Christine provided the following updates and asked attendees to share them with their finance staff. 

Cost Report Filing

The cost reports for FYE 12/31/2024 are due 6/2/2025. Please file cost reports early when possible. Filing late can result in payment suspension, and we do not release that suspension until we receive and accept the cost report. The acceptance review process can take up to 30 days but tends to take the full 30 days during this round since it’s our busiest round for cost report receipts annually. For cost report filing questions, JK providers contact: JK_Cost_Report_Filing@anthem.com and J6 providers contact: J6_Cost_Report_Filing@anthem.com. The best option for submitting cost reports is CMS’ MCReF. It performs a series of edits upon submission and filings in MCReF that may result in automatic acceptance.  If you’re unable to use MCReF, you must mail us your cost report with files on electronic media. If you are mailing it, please do so before the due date to avoid delays that can cause it to be late.

COMING SOON: One-Click Provider Statistical and Reimbursement Report (PS&R) Summary Download

This upcoming functionality in MCReF is intended to cover most users’ everyday needs for PS&R, including providing the necessary input for generating and filing the Medicare cost report. Summary PS&R reports will be available for download in the MCReF dashboard for all providers and FYEs within the last three years, except for FYEs not finalized.  Once generated, these reports will be periodically refreshed after the PS&R receives updated paid claims for the provider and FYE. They are equivalent to the reports that can be generated in the PS&R system, which is still available if users want to request PS&R reports on their own.

Christine then asked for any questions and received none.

Charity Bright, Agile Product Owner NGSConnex, NGS

Charity reviewed her handout and provided an update and additional information on NGSConnex.

She explained there is an update going into production on (4/4/2025) to allow you to view the reason for Medicare inactivity. Previously, when you did an eligibility lookup, we provided the Medicare beginning and ending inactive dates but did not provide the reason for the inactivity. CMS has now allowed us to provide this information. if the patient’s Medicare coverage indicates an inactive period, you will also see the reason. These reasons could include that the person was incarcerated, deported or not lawfully present in the United States. We will provide the most current period of inactive coverage dates, and we have created a section with historical inactive Medicare coverage information you can view.

Charity advised the members how to prevent account suspensions which included logging in at least once every 30 days (including going through the multi-factor authentication and logging into the portal) and changing the password once every 60 days. She walked through the steps on how to unsuspend a suspended account. She explained that sometimes the email with the security code may go to your spam email folder so providers should check there if they do not receive that email.

Charity asked if anyone had questions and received the following:

• One member asked if the period of inactivity for incarceration would show long sentences, such as a 20-year long incarceration sentence. Charity advised yes, it would show the incarceration period’s beginning date and ending date.
• One member wanted to know if, in the future, for MSP patients, the NGSConnex system can provide the type of insurance in which the patient is enrolled (examples: type A, J or K) because this information is not currently provided. Charity explained the information we provide is limited to what is available in CMS’ HETS. She will discuss this with CMS and suggest this as an improvement.

Alison Hamilton, Clinical Review Nurse Senior, Clinical Operations, NGS

Alison reviewed the Medical Review and Case Management handout. She first focused on providing information to help providers understand their responsibility in the TPE process. She explained:

• TPE initiatives are on CMS’ TPE web page.
• TPE is intended to increase accuracy.  
• Your success depends on your involvement.
• Once you receive a TPE notification letter, respond with contact information and update us when staffing changes occur.
• Initiate internal dialogue in your facility to ensure all pertinent departments are involved and aware of the review.
• Familiarize yourself with the edits you are placed on and with CMS’ resources.
• Read all communication from us thoroughly.  
• Ensure you/your team gains access to appropriate systems (FISS DDE and NGSConnex); do not rely on the mail.
• Reach out early during the review process if you are seeing denied claims and are unaware of the reason, don't wait for the post-probe education.
• Request and prepare for the education session in advance and ensure appropriate staff are available.
• Internally share and discuss your self-researched denial rationales in preparation of your education call; be ready with questions.
• Monitor your appeal deadline; do not wait for education to submit your appeals.

Alison provided tips on conducting denial rationale research including where to find information in FISS DDE and in NGSConnex. She provided links to information on our website.

Alison mentioned new edits for IRF claims with a diagnosis of malaise, the drug Prolia and the 2025 therapy exception.

Alison added the Case Management Team is available for questions/concerns related to Medical Reviews and/or Comparative Billing Reports at: JKACaseManagement@elevancehealth.com or  J6ACaseManagement@elevancehealth.com. 

She then asked for any questions. One member responded that their hospital has several NPIs but share a PTAN so when they try to bring up ADRs, they receive the same information for every NPI rather than separate information for the different NPIs. Alison asked the provider to email her so she can discuss the issue with Charity and try to assist her. 

Susan Stafford, POE Consultant, NGS

Susan reviewed her handout and provided the following information about provider enrollment:

• The CMS 855A (version 9/24) was added back in November 2024. They added the medical records correspondence address. If you haven't updated your enrollment, make sure that section is exactly where your facility can be reached for a medical record review. It will be under section 2D in the paper application or in the correspondence address/mailing address section in the PECOS.
• The main reason for the update to the CMS 855A was to add the new attachment 1 for SNFs (off-cycle for SNF due 5/1/2025). The flowcharts for SNF attachment 1:
  • A chart identifying entities in Section A of the Organizations section of the attachment; shows their relationships with the SNFs and each other (chart will include the SNF’s organizational ADP)
  • A chart identifying the organizational structures of all its owners, including owners not in the SNF attachment (e.g., less than 5% direct or indirect owners of corporations)
  • A chart outlining the organizational structures of each ADP of the facility. Must include a written description of the relationship of each ADP to the facility and to all the SNF’s other ADPs
  • At least one of these charts must also identify the SNF’s ultimate parent company and the entities between the SNF and the parent in the organizational arrangement
  • Institutional Providers: Revised CMS-855A Version (09/24) Medicare Enrollment Application
• We have some notifications and reminders:
  • Enrollment: Inactivity Information
  • Provider Enrollment Application Fee Amount for CY 2025
  • Provider Enrollment: Verify Bank Account Information to Prevent Interruption in Medicare Payment
  • Provider Enrollment: Top Reasons Behind Delays in Processing the Application
  • Safeguard Your Finances: Know Your Provider Enrollment Revalidation
  • Updated contact information for CMS’ External User Services (EUS):  
    • Address: Mail Stop DO-01-50, 7500 Security Blvd, Baltimore, MD 21244-1850
    • Website: https://eus.cms.gov   
    • Email: EUS_Support@cms.hhs.gov
  • Identify & Access (I&A) System Quick Reference Guide – updated   

Susan then asked for any questions and received none.

Laura Brown, POE Consultant, NGS

Laura reviewed her handout and provided the following information regarding the CERT program:

• Internal error rates for the November 2025 reporting period (claims received 7/1/2023 to 6/30/2024) for JK and J6 and the top CERT denial error codes and counts for JK and J6
• The three top CERT errors remained the same during the Nov 2025 report period for JK and J6 (insufficient documentation, incorrect coding and not medical necessary)
• Resources for finding CERT reports
• A review of the November 2024 report, which included high-level performance results.
• CERT contact information (distributed previously as well)
• CERT contractor has two e-mail addresses (one for general questions and another for medical records/passwords)

Laura asked for any questions and received none.

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III. Review of Education Materials

Jean Roberts and Christine Janiszcak, POE Consultants, NGS

Christine advised the members about the upcoming Virtual Summit we are conducting from 6/10/2025 to 6/12/2025 for our Part A providers (including FQHCs/RHCs). She explained:

• We will be advertising the event soon so watch for an announcement within about a week.
• We have been and will continue to create the materials for this event.  
• On each day, we will offer four sessions for a total of 12 sessions.  
• The theme is “Turning Insight Into Action” and we have invited various NGS departments (Provider Contact Center, Medical Review, Appeals and more) to partner with us to provide education to providers from their point of view including hot topics of which they are aware.
• This Summit replaces the two Virtual Conferences we typically conduct in the Spring and Fall.
• Please register for the webinars and we will ask for feedback in the August POE AG meeting.

Jean mentioned we posted an article, Medicare Change of Status Notice, to our website at the end of January. The article is about the MCSN which is a CMS required notice (Form CMS-10868) for eligible inpatients. It is used when an eligible Medicare beneficiary, after formally being admitted as an inpatient, is reclassified from an inpatient to an outpatient receiving observation care. The notice must be issued while the beneficiary is still an inpatient. Jean asked members to review the article.

Jean also announced there is a new National AB MAC Ambulance Provider/Supplier Coalition. We will conduct a meeting on 5/22/2025, 2-4 p.m. ET.  Update: You can register for the meeting here. Jean added that we recently posted a Hospital-Based Ambulance Billing guide on our website. 

Jean reviewed the POE tracker and explained:

• We are conducting two ACH webinars in April; Part 1 on 4/17 and Part 2 on 4/24. In Part 2, we will review HCOs, a topic members suggested.
• We received a suggestion to repeat PHP education, so we conducted a webinar on PHP coverage (3/25) and a webinar on PHP billing (3/27).
• We have a new suggestion to conduct education on vaccine billing for FQHCs.  Mimi Vier will include this subject in her next FQHC billing webinar, so watch our events.  Mimi will be conducting several Let’s Chat webinars on FQHC billing from now through July and may also add more of these sessions in the future.  Interested FQHCs may review the events page to register.  During the Let’s Chat webinars, Mimi will address incoming FQHC questions, but providers can also pre-submit questions for these webinars.

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IV. POE AG Member Suggestions for Education and Open Forum

Jean Roberts, POE Consultant, NGS

Jean asked the members to advise us of areas of education they are interested in, such as a specific topic or a global item. She explained we would appreciate receiving all suggestions since the primary purpose of meeting with the POE AG members is to solicit feedback and suggestions so we can craft education that meets their needs.

One member asked if they could meet with their staff and email the information to us. Jean provided the email NGSPartAPOE@elevancehealth.com.

Another member suggested the topics of IME payments on MSP claims and split shared services. Regarding education on IME claims, Christine advised the member that when a hospital is submitting an inpatient claim requesting IME, they should submit it as a Medicare primary claim even if there is a payer primary to the MAO plan in which the beneficiary is enrolled.  She referred the member to an article on our website Billing for Beneficiaries Enrolled in Medicare Advantage Organization Plans. Christine added that if this is not the educational topic she is suggesting, to let her know. The member will discuss the article with their facility and let us know. Jean added that split shared services is a topic handled by the Part B POE staff and directed the member to our Part B website.

One member mentioned she has two questions, one about an LCD regarding outpatient physical and occupational therapy and another about a policy article on speech language pathology.  She explained she has attempted to find answers/resolve the issues; but it has been more than 45 days, and both have not been resolved. Jean advised the member about the usual process for researching questions via our website and/or for contacting our PCC but asked the member to email the inquiries to our Part A POE mailbox, NGSPartAPOE@elevancehealth.com, and include any activity numbers she was provided by our PCC. Jean also explained to the member that when medical policy is developing an article, they hold meetings on draft LCDs and providers can provide input. She also mentioned that if a provider is asking for a change to an LCD, we have a process to follow for these requests on our website under Medical Policy.

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V. Upcoming Events and Additional Education

Jean Roberts, POE Consultant, NGS 

Jean advised the members to continue to check our Events Page for educational events.

She explained she provided links to helpful articles in the agenda and briefly reviewed the following:

• CY 2025 Telehealth Update
• NGS Part A TOP Claim Errors – RTPs, Rejects and Denials, refreshed every three months
• Medical Documentation Signature Requirements
• Signature Requirements
• Documentation Submission Responsibilities
• News articles:
  • NGS Quarterly Credit Balance Reports No Longer Required  
  • Medicare Advantage Information For Part A and Part B Not Offered on IVR Beginning 3/14/2025
  • April 2025 EDI Front End Quarterly Release
  • Fiscal Intermediary Standard System Direct Data Entry Screen Changes – April 2025
• CMS Provider Compliance Fast Facts

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VI. 2025 Part A and FQHC POE AG Meeting Schedule 

Jean Roberts, POE Consultant, NGS

Jean indicated the next meetings will be on 8/7/2025 and 12/4/2025 in Teams, 10:30 a.m. - 12:30p.m. ET.  She thanked everyone for attending this meeting, reminded everyone to meet with their staff to determine education topics and to email suggestions to us at NGSPartAPOE@elevancehealth.com.

Note: During the meeting, an artificial intelligence (AI) notetaker appeared in the chat box to be taking meeting notes. Jean advised attendees not to use this type of program during our POE AG meetings and reminded everyone that recording any of our meetings or events is not permitted.

Meeting adjourned