General

Published 04/22/2026

1. Question: Where should an independent RHC send a bill for the total component (technical and professional components) of an electrocardiogram (EKG)?

Answer: The professional component is included in the all-inclusive rate and is not separately payable.

  • Independent (freestanding) RHCs: The technical component of an EKG performed is billed under the practitioner's ID to Part B, on the CMS-1500 claim form, with appropriate place of service
  • Provider based RHCs: The technical component of the EKG performed is billed by the base-provider on the UB-04 claim form

References

2. Question: When we file a redetermination for an overpayment is recoupment stopped?

Answer: You may stop recoupment at two points:

  • When a valid and timely request for a redetermination (i.e., within 30 days from the date of the overpayment letter) is received. Recoupment stops or is delayed pending results of the appeal
  • When receipt of an unfavorable or partially favorable redetermination decision and there is notification that the qualified independent contractor received a valid and timely request for reconsideration within 60 days of the redetermination

Note: Interest continues to accrue even when recoupment stops.

Reference: I Received a Demand Letter for an Overpayment.
 

3. Question: If a surgery date is changed or cancelled, can we request a prior authorization extension of the 120 days?

Answer: No, a new Prior Authorization Request (PAR) would be required. PAR decisions and Unique Tracking Number (UTN) for these services are valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on January 1, 2021, the PAR will be valid for dates of service through April 30, 2021. Otherwise, the provider will need to submit a new PAR to obtain a new UTN timeframe that includes the dates of service.

Reference: Prior Authorization (PA) Program for Certain Hospital Outpatient (PDF).
 

4. Question: If there is an approved UTN for a certain date of service (but never billed), but the procedure got rescheduled, do I need to do a new PAR? The rescheduled date is within the 120-day period.

Answer: If the procedures Date of Service (DOS) has been rescheduled and the same procedure that was affirmed still falls within the 120-day timeframe of the UTN, nothing additional is required.

Note: If the UTN has not been used and is still valid then it can be used.

Reference: Prior Authorization (PA) Program for Certain Hospital Outpatient (cms.gov).
 

5. Question: If I provide a service under arrangement to a SNF that is subject to SNF consolidated billing, what rate do we charge the SNF for that service?

Answer: The SNF and the provider/supplier agree to contractual terms prior to providing services. As part of this agreement, the SNF and the supplier (could be an ambulance) negotiate the terms and amount of payment. According to the CMS Publication 100-04, Claims Processing Manual, Chapter 6, Section 10.4.1 (PDF), “Medicare does not prescribe the actual terms of the SNF’s relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement.”
 

6. Question: Can I submit a no-pay claim (210) and a Part B ancillary claim (22X) at the same time?

Answer: No. The 210 Medicare claim must be finalized before the 22X claim can be submitted.

References

7. Question: Do the botulinum toxin J-codes require prior authorization when they are used for injection procedures other than 64612 and 64615?

Answer: No. Prior authorization is only required when one of the required Botulinum Toxin codes (J0585, J0586, J0587 or J0588) is used in conjunction with one of the required CPT injection codes (64612, injection of chemical for destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face).

Use of these Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.

References

8. Question: How do I adjust a claim that has medically denied lines?

Answer: All lines that were medically denied must be left in non-covered. These lines cannot be removed from the claim or moved to covered. An appeal must be submitted to adjust these lines. It is not sufficient to just enter comments, "Not adjusting medically denied lines." The lines must be submitting in non-covered exactly as they were on the original claim. If there is a GZ Modifier on any line on the original claim, it must be present with charges in non-covered on new claim also.

Reference: Appeals and Clerical Error Reopenings Module.
 

9. Question: What happens if someone ignores a demand letter request regarding Part A overpayment?

Answer: When Medicare is notified of a settlement, judgment, award, or other payment, including ORM, the recovery contractor will perform a search of Medicare paid claims history. When the most recent search is completed and related claims are identified, the recovery contractor will issue a demand letter advising the debtor of the amount of money owed to the Medicare program and how to resolve the debt by repayment. The demand letter also includes information on administrative appeal rights. Reimbursing Medicare. 

Assessment of Interest and Failure to Respond
Interest accrues from the date of the demand letter but is only assessed if the debt is not repaid or otherwise resolved within the time period specified in the recovery demand letter. Interest is due and payable for each full 30-day period, the debt remains unresolved; payments are applied to interest first and then to the principal. Interest is assessed on unpaid debts even if a debtor is pursuing an appeal or a beneficiary is requesting a waiver of recovery; the only way to avoid the interest assessment is to repay the demanded amount within the specified time frame. If the waiver of recovery or appeal is granted, the debtor will receive a refund.

Failure to respond within the specified time frame may result in the initiation of additional recovery procedures, including the referral of the debt to the Department of Justice for legal action and/or the Department of the Treasury for further collection actions. Reimbursing Medicare.

For a more detailed breakdown of this process, please review the information below:

  • If there is no response after 30 days, one 30-day period of interest is accrued, and a second demand letter is sent out
  • If there is no response to the second demand letter, a third demand letter will be sent with current interest calculations. The third demand letter will also include the intent to refer debt to the Department of Treasury's Debt Collection Center for cross-servicing and offset of Federal payments and certain eligible State payments information.
  • If there is no response on day 61, the matter will be referred to the Department of the Treasury Debt Collection Center. The provider will also remain on payment withholding at the contractor level.
    • The Debt Collection Center will use various tools to collect the debt, including offset, demand letters, phone calls, referral to a private collection agency and referral to the Department of the Justice for litigation. Other collection tools available, which may be used, include Federal salary offset, administrative wage garnishment and the offset of income tax returns through the Internal Revenue Service. If the debt is discharged, it may be reported to the IRS as potential taxable income. During the collection process, interest will continue to accrue on the debt, and the provider will remain legally responsible for any amount not satisfied through the collection efforts.

Reference: I Received a Demand Letter for an Overpayment.
 

10. Question: Can I get a letter indicating a patient’s Medicare Part A benefits are exhausted?

Answer: Medicare benefits exhaust letters are not issued. This information will appear on your remittance advice. Please review the example below for clarity:

  • Claim status code 432 — Date benefits exhausted
  • CARC 78 — Non-covered days/Room charge adjustment
  • RARC N374 — Primary Medicare Part A insurance has been exhausted, and a Medicare Part B Remittance Advice is required
  • RARC N587 — Policy benefits have been exhausted
  • CARC 119 — Benefit maximum for this time period or occurrence has been reached

References

11. Question: When is it proper to use pre-entitlement billing instructions and what are some billing tips?

Answer: Use pre-entitlement billing instructions for inpatient admissions when you:

  • Admit the patient before their Medicare Part A entitlement date
  • Discharge them after their Part A entitlement effective date

Billing and Claims Tips

  • Room and Board Revenue Codes = 010X – 016X • Admission Date = Patient’s formal inpatient admission date
  • Statement Covered Period "From" Date = Effective date of Part A entitlement
  • Statement Covered Period Through Date = End date of the inpatient stay
  • Covered Days with Value Code (VC) 80 = The number of days in the "Covered From" to "Covered Through" date range
  • Accommodation Days/Units = The number of days reported in VC 80
  • Only include room and board charges for the days the patient had Part A entitlement
  • Don’t bill the patient or anyone else for days of care before the patient’s Part A entitlement, except for days above the outlier threshold
  • Report all revenue codes from the admission date through the discharge, transfer or death date as covered charges
  • Include surgical procedure codes from the admission date to the discharge, transfer or death date
  • Include diagnosis codes from the admission date to the discharge, transfer or death date
  • Include Part A entitlement date, in the remarks

References

Note: If a beneficiary’s group health plan coverage terminates prior to their Medicare entitlement date, MSP rules do not apply. MSP status is determined by reason for Medicare entitlement (age, disability or ESRD) and requires overlapping coverage, without coverage on or after the entitlement date, the MSP provisions cannot be applied.

Last Reviewed: 04/21/2026

1. Question: Can we use hospice inpatient days as the three-day qualifying stay for SNF?

Answer: Section 1861(i) of the Act provides that to be covered under Part A, inpatient care in a SNF must be preceded by a qualifying hospital stay of at least three consecutive days (not including a day of discharge). Section 409.30(a) of 42 Code of Federal Regulations (CFR) further specifies that the stay must have been in a participating, or qualified hospital for medically necessary inpatient hospital care. There is no policy preventing a hospital stay covered under the hospice benefit from serving as the required Skilled Nursing Facility (SNF) three-day hospital stay.

Additional Resource: Skilled Nursing Facility Billing Reference.
 

2. Question: Can I submit a no-pay claim (210) and a Part B ancillary claim (22X) at the same time?

Answer: No. The 210 claims must be finalized before the 22X claim can be submitted.
 

3. Question: Can I appeal against a claim that was denied because it was submitted to Medicare untimely?

Answer: Denials for untimely filing are not appealable unless one of the exception situations described in the Centers for Medicare & Medicaid Services (CMS) Publication 100-04, Claims Processing Manual, Chapter 1, Section 70.7 — Exceptions Allowing Extension of Time Limit (PDF) applies to the claim in question.
 

4. Question: What actions do I need to take if I receive a favorable appeal decision from a higher level of appeal (e.g., administrative law judge)?

Answer: If you receive a favorable appeal decision beyond the first level of appeal (redetermination), the contractor that determined the appeal was favorable, will notify Palmetto GBA to reprocess your claim for payment.

Additional Resources

5. Question: How can I bill an MSP claim if there is an open worker's compensation, auto or liability file on the common working file, but the services provided are not related to the open file?

Answer: The original claim will reject if diagnosis code(s) on page 5 appears to be related. The provider will need to submit an adjustment with remarks specifying the services are unrelated. The processing unit will review comments and diagnosis codes reported on the claim when making their determination. Please call customer service if you need assistance in preparing the claim.

Additional Resources

6. Question: Can you tell me why my partial hospital discharge claim returned with reason code 38205?

Answer: Reason code 38205 occurs when a partial hospitalization discharge claim is received and there is no claim in history that contains a line-item date of service within seven days prior to the "from" date of the incoming claim. Partial hospitalization claims must be submitted in sequence with the most appropriate patient status code. For partial hospitalization discharge claims (XX4), the patient status code should be "01," discharge home. Reporting any other patient status code will cause the claim to be out of sequence and returned to you.

Additional Resources

7. Question: How do I view or print an ADR in FISS?

Answer: Access the claim summary inquiry screen in FISS (selection 12 on the inquiry menu) type a provider number or Medicare Beneficiary ID number and press enter. If the status / location is "S B6001" there is an ADR available on this claim.

  • Type "S" in the "SEL" field; press "Enter"
  • Go to page 6, hit F8 to view/print the ADR
  • Submit the printed ADR letter along with the documentation

Additional Resources

8. Question: Where do my ADR letters and medical review (MR) correspondence go?

Answer: In FISS, the address in the “other address” field is used for mailing MR correspondence and ADR letters. Unfortunately, Palmetto GBA cannot update or change the designation for mailing correspondence and ADRs to a different address. However, it is important to note that you can update the address listed in the “other address” field by completing a Medicare Enrollment Application (CMS-855A) (PDF).
 

9. Question: Can I get a letter indicating a patient’s benefits are exhausted?

Answer: We do not issue benefit exhaust letters. This information will appear on your remittance advice. We’ve included the link to the X12 Website which contains links to various code lists, including claim adjustment reason Codes (CARCs); remittance advice remark codes (RARCs); provider adjustment reason codes; claim status codes; and much more.

Examples of what you may see on the remittance advice:

  • Claim status code 432: Date benefits exhausted
  • CARC 78: Non-covered days, room charge adjustment
  • RARC N374: Primary Medicare Part A insurance has been exhausted, and Part B Remittance Advice is required
  • RARC N587: Policy benefits have been exhausted
  • CARC 119: Benefit maximum for this time period or occurrence has been reached

Additional Resource: Publication 100-04, Section 150.17 — Benefits Exhausted (PDF).
 

10. Question: The patient’s surgery is scheduled for seven days. Can I submit my Prior Authorization Request (PAR) now? 

Answer: A PAR should be submitted prior to scheduling the patient for the surgery. Providers should not schedule surgery until the affirmed decision letter and Unique Tracking Number (UTN) are received for a PAR. Once a PAR is received, a decision will be made within seven calendar days. Do not submit an expedited PAR unless the Beneficiary’s life or functional status is in jeopardy.
 

11. Question: Where can I locate information on Medicare’s Next Generation ACO Model waiver of the SNF three-day rule?

Answer: Three-Day Inpatient Hospital Stay Requirement for Care in a Skilled Nursing (PDF).
 

12. Question: I would have liked more information on when an audit is done in our own practice. And we need to correct coding to a higher-level E/M after six months have gone by. I seem to struggle with the correct process for this type of situation. It seems like no options work to fix the issue.

Answer: You can generally correct a Medicare claim to a higher-level E/M service more than six months after the original service date, provided the date of service is within the 12-month (one calendar year) timely filing limit for original claims. Corrected Claim Submission: If the date of service is within the 12-month window, you can submit a corrected claim to the MAC using the appropriate frequency code (often "7" for replacement of a prior claim = XX7). The corrected claim does not reset the original timely filing clock; it's still tied to the original date of service.

The CMS Medicare Claims Processing Manual outlines the specific reopening and adjustment rules.

Last Reviewed: 02/04/2026

1. Question: My claim is editing for reason code 38022. How do I resolve this issue?

Answer: Reason Code 38022 assigns when the discharge and admit dates do not match on both the inpatient hospital's claim and the skilled nursing facility's claim. Per guidance received from CMS, the only way to correct this issue is either the hospital can change their admission date to match the SNF's discharge date, or the SNF must change their discharge date to match the hospital's admit date. Once the dates on both claims match, the claim will no longer be assigned this reason code.
 

2. Question: I can't log into the Provider Enrollment, Chain, and Ownership System (PECOS). Who can assist me?

Answer: For technical issues within PECOS, please call the PECOS help desk. The External User Services (EUS) contact information hours of operation are Monday – Friday, 7 a.m. – 7 p.m. ET.

3. Question: Will my payment be recouped because of negative reimbursement?

Answer: When a claim has a negative reimbursement amount, it means the beneficiary’s coinsurance and/or deductible are more than the provider’s reimbursement amount. When this happens, the negative amount will be withheld from the provider on future remittance advice. Please review Palmetto GBA's Clarification of Negative Reimbursement article for more information.
 

4. Question: My claim is editing for reason code U5200. How do I resolve this issue?

Answer: Outpatient claims are reimbursed through the Part B Payment Perspective System. Therefore, the beneficiary must have Part B entitlement. Inpatient claims are reimbursed through the Part A Payment Perspective System. Therefore, the beneficiary must have Part A entitlement. If claims are submitted and the beneficiary does not have either Part A or Part B entitlement it can cause the claim to be rejected. It is the provider's responsibility to ensure that eligibility/entitlement is verified before providing services.
 

5. Question: Can I get a letter indicating a patient's Medicare Part A benefits are exhausted?

Answer: We do not issue benefit exhaust letters. This information will appear on your remittance advice. Examples of what you may see on the remittance advice for benefits exhaust are listed below:

  • Claim status code 432: Date benefits exhausted
  • CARC 78: Non-covered days/Room charge adjustment
  • RARC N374: Primary Medicare Part A insurance has been exhausted, and Part B Remittance Advice is required
  • RARC N587: Policy benefits have been exhausted
  • CARC 119: Benefit maximum for this time period or occurrence has been reached
     

6. Question: When there is a takeback on a remit, there are no patient names, only Medicare numbers. This makes it very difficult to determine which patient the takeback is for. Can this be modified in the future so that patient names are associated with takeback?

Answer: On Palmetto GBA’ s remittance advice (RA), patient names are not listed for a takeback or recoupment. Instead, you must use the invoice number provided in a separate overpayment demand letter to identify the specific patient. The RA primarily contains financial information, such as payment adjustments and recoupments, to adhere to privacy regulations. All MACs operate under strict privacy rules from the Centers for Medicare & Medicaid Services (CMS). They are required to protect beneficiary privacy and limit the disclosure of information. Please follow the steps below to identify the patient for recoupment:

  1. Review the overpayment demand letter: Before a takeback appears on your RA, Palmetto GBA will mail you a demand letter. This letter contains the specific invoice number(s) and lists the patient(s) and dates of service associated with the overpayment.
  2. Match the invoice number to the financial control number (FCN): When you see a recoupment on your RA, match the FCN on the remittance notice with the corresponding invoice number on your overpayment letter to correctly identify the patient account.
  3. Contact your software vendor if necessary: If your billing software does not correctly map the invoice number data from the electronic remittance file, you may need to contact your vendor for assistance.
     

7. Question: How long does it take to process an application?

Answer: Please refer to the article Provider Enrollment Application Processing Time, located on the Palmetto GBA website.
 

8. Question: I file the cost report for dialysis facilities. How do I obtain additional information that I need regarding dialysis?

Answer: When submitting a cost report to Palmetto GBA, there are only two acceptable ways of submission, either:

  • Through Medicare Cost Report Electronic Filing system (MCREF)
  • By mailing into Palmetto GBA's physical location in Camden

Ensure the Worksheet S (WS S) is signed and, if submitted through MCREF, that the checkbox in item 2 is selected. Additionally, if bad debts are being claimed when submitting an End Stage Renal Dialysis (ESRD) cost report, a bad debt log will always need to be submitted with the cost report. The electronic cost report (ECR) files should always be submitted with a full cost report, which consist of the renal Dialysis (RD) and Print Image (PI) file.

  • If submitting a No Utilization cost report, ensure the WS S is signed, and you send the letter on company letterhead. It must be stated that no covered services were furnished during the reporting period, and no claims for Medicare will be filed for this reporting period.
  • If submitting a Low Utilization cost report, the Medicare net reimbursement must be less than $200,000, a signed WS S must be submitted, along with a balance sheet with statement of revenues and expenses
     

9. Question: How can I become more knowledgeable about accurate billing and compliance?

Answer: Review these resources:

Last Reviewed: 03/18/2026

1. Question: Is a copy of the Additional Documentation Request (ADR) letter required with the provider’s ADR response?

Answer: Submitting a copy of the ADR is listed on the ADR document issued to the providers as information to submit. If the provider does not have a copy of the ADR, they can place a cover sheet with the claim number, as well as the date of service (DOS) with Part A Medical Review (MR).
 

2. Question: Can a provider submit a response for a past-due ADR?

Answer: The Centers for Medicare & Medicaid Services (CMS) contractors may accept late documentation if the provider can demonstrate good cause (natural disaster, business interruptions, extenuating circumstances, etc.). Providers typically have a maximum 120 days to submit their ADR response to MR from the denial date for records not received timely. Submit the late response to the department that initially requested the documentation, not to the Appeals Department. However, this is not the recommended approach, as providers should typically respond to ADR requests within 45 days.
 

3. Question: Should the providers complete the provider contact box for each ADR response?

Answer: Yes, the provider should provide their point of contact information with each ADR response. This is stated on the ADR letter sent to the provider. The MR team uses the updated contact information to reach out to the contact person listed on the form. This will occur during the review process if documentation is incomplete or clarification is needed. However, if the contact information needs to be changed/updated, please call the PCC to have the information reviewed and send it to MR for updates. It is a best practice to provide first and second choices, should the initial contact be out of the office when MR attempts to reach you.
 

4. Question: Can the provider be given the assigned medical reviewers’ information?

Answer: Claims are randomly assigned to our medical reviewers. While we have dedicated reviewers for each line of business, we cannot inform providers in advance who will review their claim. If documentation is incomplete or clarification is needed, the assigned reviewer will contact the point of contact person on file to resolve the issue.
 

5. Question: Who do I contact after receiving the Targeted Probe and Educate (TPE) Final Results?

Answer: The Senior Provider Education Consultant for Medicare Part A will contact you within two weeks of receiving your TPE Final Results Letter. If you are moving on to a subsequent round, you’ll have 45–56 days before it begins, starting from the date of your education session. The Senior Provider Education Consultant will make a maximum of three attempts to contact the designated individual(s) for your office. If these attempts are unsuccessful, it will be your responsibility to initiate contact with the Senior Provider Education Consultant regarding your Medicare Part A education session. If this occurs, you will move on to a subsequent round, and the 45- to 56-day period will begin on the date of the third missed attempt.
 

6. Question: When will the provider need to submit their appeal once their claims have been denied due to the TPE audit?

Answer: Providers may submit an appeal once they receive the official Claim Determination. Appeals must be submitted in writing within 120 days from the date on the Claim Determination. Providers should not wait until they receive the results letter, as it may be past the 120-day timeframe.
 

7. Question: Do incarceration periods include halfway houses?

Answer: Starting January 1, 2025, patients in custody no longer include patients who are:

  • Released to the community pending trial (including those released on bail)
  • On parole
  • On probation
  • On home detention
  • Required to live in a halfway house or other community-based transitional facility
     

8. Question: My claims have been denied due to no records received; however, medical records were sent 30 days prior to the due date.

Answer: The provider will need to contact the PCC to have the medical records escalated to MR for review and possible reopening.
 

9. Question: Why are we getting non-response communications for ADRs with due dates 90 days from the letter date? I understand that the standard is 45 days, but the letter gives a due date 90 days from the ADR letter date.

Answer: Due to recent hurricanes and natural disasters, ADR letters had a due date of 90 days.
 

10. Question: Do we need to send the medical records with each level of appeal, or does the previous level send those records to the next level for us?

Answer: Yes, make sure you include the records with each level.
 

11. Question: Are the Reconsideration results added to eServices as well for us to download?

Answer: Yes, if a Reconsideration has been submitted, the status will be provided in eServices.
 

12. Question: Does an appeal have to be signed by the ordering physician, or can any physician sign the appeal?

Answer: It does not need to be signed by the ordering physician.
 

13. Question: Can you tell us again where to find the appeal details on the claim?

Answer: The remarks section of the claim.
 

14. Question: If the provider cannot provide the required documentation when CERT audits a Medicare Part A claim, when does recoupment for any overpayment begin?

Answer: Appealing an Overpayment Subject to Limitation on Recoupment. If you do not request redetermination or make payment in full by the 39th day:

  • A withholding is initiated on the Remittance Advice (RA) dated the 40th day from the initial demand letter interest accrues on the money owed from the date of the initial demand letter
  • The withholding amount will appear in the 935-withholding section of the RA

Last Reviewed: 03/18/2026


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