Notification Letters

Notification Letters Prior to the start of the TPE, providers are being placed on medical review will receive a notification letter. The notification will have the edit name, the reason for review, instructions for sending in the ADR and [...]

LVAM Request Form

Counting 90-Day Election Periods - Leap Year

Who May File an Appeal?

Who May File an Appeal?Any of the following persons or entities is considered a party to an appeal of a claim for items or services payable under Medicare and, therefore, may appeal the initial claim determination and any subsequent appeal [...]

What Documents are Needed

What Documents are NeededYou are required to submit all necessary medical documentation to support the services billed on your claim as part of your participation agreement; you must submit a complete medical record when requesting an appeal. [...]

Comprehensive Error Rate Testing Program

Medicare Diabetes Prevention Program (MDPP)

This section gives you access/education about first time Enrollment.

Supplemental Right Side Content Part A

Helpful ResourcesTPE Manual

How to Respond to Additional Development Requests for Herceptin Billing

How to Respond to Additional Development Requests for Herceptin BillingSeveral providers are responding to Herceptin-related ADRs without providing the required information. Herceptin billing must contain the number of milligrams that were used [...]

How to View and Print ADRs from FISS/DDE

How to View and Print ADRs from FISS/DDESteps to View and Print ADRs from FISS/DDE Provider Online SystemAccess the claims through the Claims Inquiry screen/option. Type 01 at the FISS/DDE Online System Main Menu and then type 12 on the [...]

Medical Policy Contact Information

Medical Policy Contact Information

Medical Policy Contact Information

Medical Policy Contact Information

Dental Codes Billed As Principal Diagnosis Code Cause Claim Rejections

Claims Submitted With Dental Codes As Principal Diagnosis Will RejectOn 1/3/2021, EDI added a new edit to the EDI Front-End. If an 837I claim contains principal diagnosis code 2300 HI with qualifier ABK (principal diagnosis) that is a dental [...]

Use NGSConnex to Submit Quarterly Credit Balance Reports

Use NGSConnex to Submit Quarterly Credit Balance ReportsWe recently posted a news article that explained the process and benefits of using NGSConnex to submit quarterly credit balance reports. Today’s article contains the resolutions for common [...]

Reminder: General Anesthesia and Conscious Sedation is Not Medically Necessary for Facet Joint Interventions

Reminder: General Anesthesia and Conscious Sedation is Not Medically Necessary for Facet Joint InterventionsOn 4/25/2021 National Government Services revised the Local Coverage Determination L35936 “Facet Joint Interventions for Pain [...]

Prior Authorization Exemption: Part B Provider Role

Prior Authorization Exemption: Part B Provider RoleCMS has identified certain Part A HOPDs as having a prior authorization affirmation rate of 90% or greater. As a result, these HOPDs are currently exempt from submitting prior authorization [...]

National Government Services Proposed LCDs for Comment

National Government Services Proposed LCDs for CommentThe proposed LCDs listed below are being presented for comment for the Jurisdiction 6 and Jurisdiction K MACs. The formal comment period extends from 6/3/2021 through 7/17/2021.These draft [...]