Provider Outreach and Education Advisory Group (POE-AG) Minutes: November 12, 2025

Published 12/01/2025

The Jurisdiction J (JJ) and Jurisdiction M (JM) Part B POE Advisory Group (POE-AG) meeting was held on Wednesday, November 12, 2025.

Welcome and Introductions

Today’s meeting will be a look back on 2025 and a look forward to 2026 as we wrap this year up.

Special Agenda Topics

2025–2026 Comprehensive Error Rate Testing (CERT) Update and Forecast for JJ/JM

General CERT Announcements

  • Please make sure your address is up to date within the Provider Enrollment, Chain and Ownership System (PECOS)
  • Address changes must be reported within PECOS and failure to do so can result in revocation
  • Address updates must be initiated by the provider; Palmetto GBA is unable to update
  • It has come to our attention that providers may have mistakenly tagged the CERT Review Contractor (RC) phone number as spam or have otherwise blocked it. This has led to communication challenges that may impact dissemination of important information from the CERT RC concerning your documentation request or submission
    • Please note: (888) 779–7477 is a legitimate phone number used by the CERT for official communication
    • Blocking or marking this number as spam may prevent timely resolution of documentation requests and other important matters related to CERT reviews
    • Providers should ensure this number is whitelisted or otherwise marked as safe in their phone systems

CERT C3HUB Overview

  • The CERT C3HUB web site is designed to provide Medicare providers, suppliers and contractors with information about the CERT program and to facilitate coordination, collaboration and communications between all stakeholders.
  • Within the C3HUB, as a provider, you are able to:
    • Submit Records to CERT: The webpage provides instructions to providers and suppliers on how to submit medical documentation to the CERT Review Contractor. There are five submission methods.
    • View Letter and Contact Information: This notifies providers and suppliers of the schedule the CERT Review Contractor uses to mail out the initial and subsequent Additional Documentation Request (ADR) letters. The timeline includes when providers and suppliers can expect to receive a telephone call.
    • The page also identifies the source of the address the CERT Review Contractor will use to mail the initial and subsequent letters.
      • Telephone calls will be grouped in order to reduce multiple calls to the same provider.
      • Includes instructions on how providers that have 10 or more Provider Transaction Access Number (PTAN)/Online Survey Certification and Reporting (OSCAR) numbers can join the chain address program
  • Locate Completion Status Charts: These charts provide the completion status of the active report periods that the CERT Review Contractor is working on
  • Access the claim status search feature which provides the current status of a claim under CERT review.
    • This page is updated daily.
  • In the event of a natural disaster, there is a CERT Disaster Administrative Relief page that provides guidance for how CERT claims processing is affected.
    • There are also sample Attestation Letters that provide a sample of the Disaster Attestation Letter. Providers and suppliers are required to submit this letter when the medical documentation requested to support a claim has been wholly or partially destroyed in a disaster.
    • It also includes a sample of a Signature Attestation Letter that providers and suppliers can use when the signature is illegible/missing.
  • If you are the person responsible for sending letters and your aren’t sure what you should include, the C3HUB has a Document Request Listings page that includes a sample of the types of documents that the provider and supplier should include when they receive a CERT letter requesting medical records
    • There is a section that includes special instructions for providing documentation for psychotherapy claims
  • Access to important CMS links to include hyperlinks to various CMS topics/resources related to CERT:
    • CMS's CERT presentation
    • Medicare Quarterly Provider Compliance Newsletters
    • Information on encryption
    • How to contact CERT

Top CERT Part B Errors and Focus

  • Insufficient Documentation
  • Transitional Care Management
    • Charges for Current Procedural Terminology (CPT®) codes under these services should follow-up within two days of the visit
    • Must have the face-to-face visit within either 7 or 14 days based on which code is used
    • If you are unable to contact the beneficiary and are able to show where you made the effort, the claim won’t deny.
  • Chronic Care Management (CCM)
    • The Medicare Administrative Contractor (MAC) needs proof of where the care plan was provided to the beneficiary as well as consent.
    • Please review CMS MLN® Booklet, MLN909188, Chronic Care Management Services (PDF) as a resource.
  • Labs
    • Review any applicable National Coverage Determinations (NCDs) on frequency for vitamin D complete blood count (CBC) tests.
    • Urine drug screens are denying because we are missing the Risk Assessment and Tool.
    • Monitor frequently, as we are seeing an excess
  • Labs/Radiology
  • Chiropractic documentation
    • Missing documentation to support new or acute episode of care
    • Not sending records for maintenance or treatment for chronic condition
  • Signatures (attestations/signature logs)
    • Attestation forms can be found on C3HUB and can be used across all contractors.
  • Incorrect Coding
  • Not Medically Necessary
    • We are not seeing many denials at this time.
  • No Documentation
    • There was a letter change; instead of getting four letters, there are now only three letters.
    • With the change response is required within 60 days. This is a change from the 76 days required previously.
    • As a best practice, respond within 45 days to be timely.
  • In the event you have any questions about your results, education, concerns, please contact us at: JJ.JM.CERT@PalmettoGBA.com.

Preventive Services

  • Preventive services have been a major educational focus for CMS and the MACs this year. Palmetto GBA often publishes awareness articles to help remind you and promote these awareness screenings.
  • These services help your patients stay healthy and detect health problems early, when treatment works best, and can help keep your patients from getting certain diseases.
  • Preventive care services include:
    • Annual wellness visits and physical exams, for instance with a primary care doctor
    • Health screenings for blood pressure, cholesterol, blood sugar for diabetes and various cancer screenings such as colonoscopies and mammograms
    • Vaccinations and immunizations for flu and pneumococcal disease
    • Mental health screenings for conditions like depression and anxiety
    • Risk factor assessments to identify lifestyle or genetic factors that may contribute to chronic diseases
    • Counseling or lifestyle guidance on diet, exercise, managing stress and other ways to improve overall health and well-being
    • Checking when your patient is eligible for his or her next preventive service can be done through the Eligibility tab in Palmetto GBA’s internet portal, eServices.
      • The Preventive sub-tab provides information regarding the beneficiary’s smoking cessation and preventive services. The information on the screen is organized into the Healthcare Common Procedure Coding System (HCPCS) categories (e.g., cardiovascular, colorectal and diabetes).
      • Only HCPCS codes for which a particular beneficiary is eligible will be displayed and grouped together under their appropriate categories. If a service has been rendered, it is removed from the list until closer to the time the beneficiary is eligible to receive the service again.

MAC Health Access-Dementia Guide Model

  • The Guiding an Improved Dementia Experience (GUIDE) Model is a voluntary nationwide model test that aims to support people with dementia and their unpaid caregivers.
    • The model began on July 1, 2024, and will continue for eight years. To underscore the importance of this topic, dementia affected more than 6.7 million Americans in 2023; 14 million cases are projected by 2060.
  • The GUIDE Model focuses on comprehensive, coordinated dementia care and aims to improve quality of life for people with dementia, reduce strain on their unpaid caregivers, and enable people with dementia to remain in their homes and communities. It will achieve these goals through Medicare payments for a comprehensive package of care coordination and care management, respite services, caregiver education and support.
  • It advances key goals of the National Plan to Address Alzheimer’s Disease, which was established through the bipartisan National Alzheimer’s Project Act (NAPA) and has, for over a decade, accelerated federal actions to optimize the quality of care for people with dementia and their caregivers while advancing research towards a cure. The GUIDE Model builds off this extensive coordination within Department of Health and Human Services (HHS) and major input from various external stakeholders.
  • Future Actions

Ambulatory Surgical Center (ASC) Prior Authorization Demonstration

  • In an expansion of the Prior Authorization program currently in use for certain services in the Hospital Outpatient Department Services, CMS is introducing a Prior Authorization Demonstration for certain ASC Services.
  • The Demonstration is set to start in 10 states on December 15, 2025 and run for five years. Of the 10 states included in this demo, Palmetto GBA will be overseeing the two included in JJ, Georgia and Tennessee.
  • While the demonstration begins for services with dates of service on December 15, 2025, ASCs can submit their prior authorization requests beginning on December 1, 2025.
  • We are currently in the process of creating a prior authorization form specific to ASC settings along with the ability to submit via eServices. Like the Outpatient Department Prior Authorizations, physicians can submit the prior authorizations on behalf of the ASC facility, but the ASC is ultimately responsible for obtaining an affirmed decision prior to the procedure being rendered.
  • Services requiring the prior authorization for the purposes of this demo are:

National AB MAC Ambulance Provider/Supplier Coalition

  • A group of seven MACs put together a National A/B MAC Ambulance Provider/Supplier Coalition. There have been two coalitions to date:
    • Thursday, May 22, 2025
    • Wednesday, September 17, 2025
  • The goals of this coalition are to:
    • Improve communication
    • Support innovation
    • Preserve integrity
    • Provide quality customer service
    • Create a responsible, collaborative provider community
    • Protect beneficiaries and providers
  • The collaboration has been a success, and we look forward to the first coalition in 2026. When it’s open for registration, you’ll see it in our email updates. Please share this opportunity with any providers and suppliers who provide, bill and order ambulance services.
  • Once the next coalition is announced, it will be listed on the Events Calendar for your jurisdiction.
  • Handouts from previous coalitions are available:

Palmetto GBA/CMS 2025 Wrap Up & Announcements

Update on Processing of Telehealth and Acute Hospital Care at Home Claims

  • CMS has been publishing Special MLNs to keep providers abreast of how claims are being processed during the shutdown.
  • Palmetto GBA released claims that were on hold as instructed by CMS.
  • CMS released information on how they intend to handle behavioral and mental health services, as well as which claims they have instructed MACs to process based on place of service and diagnosis and which ones they have instructed MACs not to process based on specialty.
  • Additionally, MACs were instructed to process Medicare telehealth claims with a place of service code 10 (patient’s home) that contains a diagnosis code in the F01.A0-F99 range if the services were not performed by physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs) or audiologists.
  • The article also outlines challenges identifying some of the services due to system limitations and how they plan to handle them.
  • MLN Connects Special Edition: November 14, 2025

Proposed Medicare Physician Fee Schedule Final Rule CY2026

  • CMS has published the proposed CY 2026 physician fee schedule Final Rule. These are still in the proposal stage and not finalized yet, meaning they are subject to change
  • On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that announced final policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2026.
  • The current document is posted on the CMS.gov web page.

Final Rule Topics

CY 2026 PFS Rate Setting and Conversion Factor

As required by statute, beginning in CY 2026, there will be two separate conversion factors: one for qualifying alternative payment model (APM) participants (QPs) and one for physicians and practitioners who are not QPs.

Efficiency Adjustment

  • CMS historically has relied on survey data primarily provided by the American Medical Association Relative Value Scale Update Committee (AMA RUC) to estimate practitioner time, work intensity and aspects of practice expense, which are often reflected in the valuation of codes paid under the Physician Fee Schedule (PFS).
  • Only a small portion of the total codes are considered for revaluation annually, and this process relies primarily on subjective information from surveys that have low response rates, with respondents who may have inherented conflicts of interest (since their responses are used in setting their payment rates).
  • This would periodically apply to all codes except time-based codes, such as evaluation and management (E/M) services, care management services, behavioral health services, services on the Medicare telehealth list, and maternity codes with a global period of MMM.
  • To determine this efficiency adjustment, CMS is finalizing a proposal to use the Medicare Economic Index (MEI) productivity adjustment percentage. The MEI productivity adjustment is calculated by the CMS Office of the Actuary (OACT) each year, and we are finalizing a look-back period of five years.

Practice Expense

CMS is looking at AMA’s Physician Practice Information (PPI) Survey data from 2008 that measures specialty-specific practice costs. Due to a low data sample, they are looking for more efficient ways to set rates.

Telehealth Services under the PFS

For CY 2026, we are finalizing the streamline for the process for adding services to the Medicare Telehealth Services List:

  • Updating some frequency limitation
  • Simplifying the review process
  • Finalizing rules for services that require direct supervision

Comment Solicitation on Strategies for Improving Global Surgery Payment Accuracy

For CY 2026, as part of an iterative process towards improving the accuracy of global surgical service valuation and payment, we solicited public comment to ascertain what next steps we could take to improve the accuracy of payment for global surgical package

Policies to Improve Care for Chronic Illness and Behavioral Health Needs

Skin Substitutes

  • Finalizing payment scales
  • Currently, most skin substitutes are paid as if they are biologicals under the average sales price (ASP)-based payment methodology described in section 1847A of the Social Security Act. Using this methodology, each skin substitute product receives a unique billing code and payment limit. This has led to significant growth in spending under Medicare Part B for skin substitutes in the non-facility setting. According to Medicare claims data, Part B spending for these products rose from $252 million in 2019 to over $10 billion in 2024, a nearly 40-fold increase. Most of that increase is directly attributable to increases in payment rates and launch prices for skin substitute products.
  • For CY 2026, CMS is finalizing pay for skin substitute products

Drugs and Biological Products Paid Under Medicare Part B

  • Requiring manufacturers of certain single-dose container or single-use package drugs to provide refunds with respect to discarded amounts
  • Average sales price: Price concessions and bona fide service fees
  • Average sales price: Units sold at maximum fair price
  • Autologous cell-based immunotherapy and gene therapy payment

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

  • Finalizing the adoption of the optional add-on codes
  • Finalizing a policy to pay for services that are established and paid under the PFS and designated as care management services as care coordination services
  • Finalizing a policy for RHC and FQHC services requiring direct supervision
  • Finalizing policies for non-behavioral health visits furnished via telecommunication technology

Medicare Prescription Drug Inflation Rebate Program

CMS is finalizing new policies for the Medicare Part B Drug Inflation Rebate Program and Medicare Part D Drug Inflation Rebate Program

Calendar of Events – Educational Needs

eServices Enhancements

  • Recent update: Add filters to the Part B Claim results page
    • Value being added:
      • To assist Part B providers view a more specific group of results from their claim search, two new filters were added to the claim list screen
        • The Search filter will display results that contain the text entered in the field
        • The Status filter will display the results on the status option selected
        • Implementation was October 30, 2025
  • Projects on deck
    • Remove trailing spaces from user ids and passwords
    • Minor updates to profile verification pages
    • Ambulatory Surgical Center Prior Authorization form being added to portal
  • OnDemand Library
    • Members were asked to register and share registration information with their groups
    • You only have to register once and it is free to use
    • The library contains playbacks of webinars you may have missed as well as some that are specifically created as OnDemand sessions

Educational Opportunities

Documenting Inpatient and Outpatient Therapy Services Webinar

  • This live webinar event has been developed to cover information specific to current auditing and active medical review of inpatient and outpatient therapy services. This session provided a clear understanding of the differences between PT, OT and SLP services, as well as assist in comprehension of documentation guidelines for the federal Medicare program for all therapy services.
  • Subject matter experts explained the differences between maintenance and rehabilitative therapies, clarified general guidelines for physical and occupational therapy, as well as delivered information regarding documentation requirements for manual therapy, therapeutic exercise and activities and neuromuscular reeducation.
  • November 19, 2025

Part B Opioid Use Disorder Screening and Treatment Webinar

  • Opioid Use Disorder Screening and Treatment services were part of the CMS Behavioral Health Initiative in 2024. CMS is currently working on revising the CMS Behavioral Health Strategy as part of improving the way behavioral health is addressed under Medicare
  • This session reminds providers that there is now coverage for important services, defines them, and covers updates as related to billing. Topics include screening, treatment options, Opioid Treatment Programs and resources
  • November 20, 2025

Jurisdictions J and M, and Railroad Medicare CERT Lunch and Learn: Chronic Care Management with Advanced Primary Care Services Webcast

  • Register today and enjoy your lunch with Palmetto GBA JJ, JM and Railroad Medicare for the third event of our three-part series where we will discuss Comprehensive Error Rate Testing (CERT) and Chronic Care Management (CCM) services with a spotlight on Advanced Primary Care Management Services.
  • November 25, 2025

Medication Administration and Documentation Webinar

  • This webinar will explain utilization requirements for selected drugs and biologicals that are currently under active medical review.
  • December 1, 2025

Jurisdictions J and M Part B Quarterly Updates

December 9, 2025

New Provider Orientation Webinar

  • If you have any new associates or are new to billing services to Medicare, we invite you to join us for a three-day New Provider Orientation designed to strengthen your understanding of Medicare programs, processes and resources.
  • Each three-hour session will cover key topics, including provider enrollment, claims, coverage determinations, appeals and self-service tools.
  • Attend one day or the full series to enhance your Medicare knowledge and confidence
  • Tuesday, Wednesday and Thursday, December 2–4, 2025

To Be or Not to Be Hospice Related: A Deep Dive with CGS & Palmetto GBA

  • This webinar will review, and answer questions related to the Medicare Hospice Benefit, physician billing for Hospice patients, the use of the GW HCPCS modifier and condition code 07.
  • This event will also discuss how to verify if a beneficiary is in hospice, and how to determine if a medical condition is related or not related to the terminal condition.
  • Tuesday, December 9, 2025

Ornaments of Education Virtual Conference

  • Virtual celebration filled with expert-led sessions, compliance tips and the latest updates to keep providers informed and empowered
  • Wednesday and Thursday December 10–11, 2025

Website Navigation Quarterly Webinar

  • This is the last of a series of webinars held throughout the year.
  • We will provide you with a recap of all three resources
  • December 29, 2025

Collaborative Parenteral Nutrition Webinar

  • We will discuss Medicare’s criteria necessary for the coverage of parenteral nutrition
  • Representatives from all four Durable Medical Equipment MAC jurisdictions will join the Part A/B education staff to explain what is required in the orders, medical records and related documentation to support the coverage
  • December 9, 2025

Agenda Items Submitted by Members

None

Announcement of Next Meeting Date

To be determined – We will have new schedule out soon

Adjournment


Was this article helpful?

mln