Self-Service Pulse: What You Need To Know This Week

As your MAC, National Government Services wants to provide you with a comprehensive source containing the most current information available for our self-service tools.

Medicare BLAST is a quick, ten-question game that will challenge the Medicare knowledge of you and your peers. Who were our victorious winners on 5/29/2024?

Congratulations to our winners! If you weren't able to play Medicare BLAST, don't worry. We will offer more opportunities to play in the near future.

Curious on the questions that were asked during this Medicare BLAST? Scroll to the bottom of this edition to obtain the questions and correct answers.

Watch your Email Updates for your next opportunity to emerge victorious with Medicare BLAST.

All Providers are Encouraged to Subscribe to NGS Email Updates

It’s easy to keep current with the latest Medicare information and to maximize your billing. Subscribe to our email lists to receive important Medicare updates in your email box. This service is free and will keep you apprised of important Medicare information. When you subscribe, we’ll send you periodic emails with the latest news and updates from NGS and CMS including:

• Updates to LCDs and NCDs
• Educational opportunities conducted by webinar, teleconference, YouTube video or through our on-line learning system, Medicare University
• Our weekly Self-Service Pulse newsletter, a comprehensive source containing the most current information available for our self-service tools
• The Medicare Monthly Review, our monthly newsletter that combines news articles from the past month from NGS and CMS
• Provider compliance
• Information on claims, fee schedules and codes
• Medicare Learning Network Publications and multimedia

To sign up for our email updates, click Subscribe to Email Updates or visit our website, select Subscribe to Email Updates on the top of every page.

Verifying Eligibility Search Requirements Reminder

To initiate an eligibility search in NGSConnex you will need to enter the CMS required beneficiary demographic information, then select the Submit button.

You will then need to Select Years of Data that you would like to view, by selecting 1–4 years. The historical eligibility information displayed will be limited based on the filter’s selection. If you think the Eligibility information displayed after selecting the Search button, verify you have made the correct Years of Data selection.

Avoiding Duplicate Denials with Computer-Based Training

We have a valuable CBT course available that will assist you in avoiding duplicate claim denials. Correctly submitting your claims the first time will avoid processing delays and denials.

• PTB-C-0046: Top Medicare Part B Denials and How to Avoid Them

This CBT will provide you with information, resources and tools to help you avoid or reduce unnecessary referrals, appeals and other submission errors.

To learn how to access CBTs visit the Self-Paced Computer-Based Training section of the Medicare University User Guide.

Inquiry Reference ID in the IVR

Did you know that you can obtain an Inquiry Reference ID when you dial the IVR? On the IVR main menu you will be asked for the state you are calling from and once you have indicated the state you will be asked if you would like an Inquiry Reference ID number before any information is provided. This Inquiry Reference ID number might be helpful if you need or want to document your call to the IVR.

Refer to the Interactive Voice Response User Guide for all available features:

• Part A
• Part B

Completing the CMS 855I Paper Application

Watch this video to learn how to complete the CMS 855I Paper Application.

Medicare BLAST – Prior Authorization Exemption

1. If you have been identified as an Exempt Provider, you are exempt from submitting PARs for all services that require prior authorization.
   True
   
   Rationale: OPD Operational Guide
   January 1: The exemption cycle begins for providers who met the compliance rate threshold. PARs received during an exemption period for exempt providers will be rejected. 
   
   October 1-October 31: MACs calculate the affirmation rate of initial PARs for non-exempt providers for all eight service categories combined and notify those providers with an affirmation rate of 90% or greater.
    
2. Which services are eligible for the additional documentation request (ADR) process for exempt providers?
   1. The original five services (Blepharoplasty, Vein Ablation, Botulinum Toxin Injections, Rhinoplasty, Panniculectomy)
   2. All services that require prior authorization
   3. Cervical Fusion with Disc removal and Implanted Spinal Neurostimulators
   4. None of these

Rationale: OPD Operational Guide
Exempt providers will receive a post payment additional document request (ADR) for a 10-claim sample from the period such providers were exempt to determine continued compliance. The sample may include claims across all services that are currently part of the HOPD PA program.

3. If you are being withdrawn from the exemption cycle, a Notification of Withdrawal will be sent by November 2 and the withdrawal will take effect January 1 of the following year.
   True
   
   Rationale: OPD Operational Guide
   On or after November 2, providers will receive a Notice of Withdrawal of Exemption if they receive less than a 90% claim approval rate during their exemption cycle.
   
   January 1: Providers who are not exempt must have an associated PAR for any claim submitted on or after this date.
    
4. How does a provider obtain an initial exemption status?
   1. 100% provisional affirmation rate
   2. At least 90% PAR provisional affirmation rate with initial PARs
   3. At least 90% claim approval rate
   4. Post payment review

Rationale: OPD Operational Guide
October 1-October 31: MACs calculate the affirmation rate of initial PARs for non-exempt providers for all eight service categories combined and notify those providers with an affirmation rate of 90% or greater.

5. How does a provider maintain exemption status?
   1. At least 90% claim approval rate with selected post-payment claims
   2. At least 90% PAR provisional affirmation rate
   3. 100% review of all claims billed during the exemption period
   4. Through pre-pay review

Rationale: OPD Operational Guide
August 1: Exempt providers will receive a postpayment Additional Document Request (ADR) for a 10-claim sample from the period such providers were exempt to determine continued compliance. Providers must have at least 10 claims submitted and paid by June 30 in order to be considered for the exemption. If the exempt providers have less than 10 claims submitted, their exemption status will be withdrawn.

6. I am an exempt provider. While I am on exemption, I do not need an associated PAR/Unique Tracking Number (UTN) for the claim.
   True
   
   Rationale: OPD Operational Guide
   January 1: The exemption cycle begins for providers who met the 90% or greater compliance rate threshold. Exempt providers should not submit PARs.
    
7. How many days’ notice does NGS provide prior to any process change (continue, withdraw, newly exempt) as it relates to exemption?
   1. 30 days
   2. 45 days
   3. 60 days
   4. 90 days

Rationale: OPD Operational Guide
Notice of an exemption or withdrawal of an exemption will be provided at least 60 days prior to the effective date.

8. How many prior authorization requests does a provider need to submit in order to qualify for exemption?
   1. 20
   2. 10
   3. 15
   4. 25

Rationale: OPD Operational Guide - CMS or its contractors would exempt providers that submitted at least 10 requests and achieve a PA provisional affirmation threshold of at least 90 percent during annual assessment.

9. Once an ADR is sent, how many days does the provider have to respond back with the requested documentation?
   1. 30 days
   2. 60 days
   3. 45 days
   4. 90 days

Rationale: OPD Operational Guide - Providers have 45 days to submit documentation, and MACs will complete their review within 45 days of receipt of the requested documentation.

10. If my facility has not billed at least 10 claims by June 30 of each year, we will be withdrawn from exemption the following January and PARs will be required for all services requiring PA.
    True
    
    Rationale: Providers must have at least 10 claims submitted and paid by June 30 in order to be considered for the ADR review process. If exempt providers have less than 10 claims submitted, their exemption status will be withdrawn and PARs will be required the following January.

Related Content

• Prior Authorization
• OPD Operational Guide

Posted 6/3/2024