No, the correct process is to file your MSP claim(s) 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. For more information on where to enter the primary EOB information contact your software vendor.
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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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. Please note that if you have suppressed a claim in the TB9997 status/location, you will be able to see it but not correct or adjust it.
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- MD order and progress notes showing medical necessity.
- Requisition forms or MD order forms needed with MD signature.
- MD signatures
- Signature key or attestation statement is needed if MD signature illegible - by MD or Compliance Officer with typed name and MD signature
- Progress note by ordering physician is needed also to show the medical necessity of the services ordered. MD signature also needed with progress note.
- 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
- 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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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.
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.
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- 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 logon ID
Please Note: The name associated with a logon ID cannot be changed to reassign to a different employee.
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- EDI Enrollment
- Forms Section (choose EDI Guided Enrollment Form)
The FISS/DDE Provider Online System functions allow providers to view ADRs online. 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.
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To avoid denials on claims for postoperative care:
- The date of service = the original surgical date of service
- Be sure to enter the correct surgical date, including the year of service
- Unit of service = one
- Include the date span of assumed care in the comments of the claim
- Ensure the date formats are MM/DD/YYYY
- Do not enter the span of assumed care in the From and To dates of service
Visit Global Surgery for more detailed information on submitting postoperative claims.
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.
You'll 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. For additional information, visit Drugs and Biologicals.
It is important to ensure the name is submitted exactly how it appears on their Medicare card.
- Do not submit special characters (i.e., period, comma, dash, etc.) in the name field. This may cause the claim to deny.
For additional information, visit CMS-1500 Claim Form Completion Instructions.
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.
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.
View CMS’ Medically Unlikely Edits web page for details on MUE. Access the MUE tables as appropriate to your provider’s line of business.
Medicare Part B providers may view a full list of published HCPCS/CPT codes subject to MUE and their maximum allowed units in the Practitioner Services MUE Table.
- Always use the current version.
- Some MUE values are confidential, therefore, certain CPT/HCPCS codes will not be published in the posted files. The confidential status of an MUE is subject to change.
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.
National Government Services accepts documentation by NGSConnex, mail, esMD, CD/DVD and fax.
Visit Methods for Submitting an ADR for additional information and guidance.
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.
When your facility has determined that a Medicare claim is not related to a liability, no fault (including medical payment), or Workers’ Compensation accident, injury or illness for which there is an MSP record in the CWF, enter comments on the first line of the Remarks field to indicate this.
For example, report in the Remarks field, "services are not related to the liability MSP record in the CWF." Use similar comments to indicate, as applicable, the services are not related to a no-fault, medical payment or Workers' Compensation MSP record in the CWF. Do not use comments in Remarks that include the term "unrelated" as our system does not recognize this term when you report it in the Remarks field for this purpose. Maintain your documentation that supports your use of these comments in Remarks such as your completed MSP questionnaire/form.
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Call the EDI Help Desk at the applicable number below and press 2 to request a password reset.
- J6: 877-273-4334
- JK : 888-379-9132
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- EDI Help Desk Contact Information