Claim Submission

Published 9/20/2023

If you provided the services as a part of group practice or organization, please submit the group’s National Provider Identifier (NPI) in item 33a as the billing provider NPI and your individual NPI in the unshaded portion of item 24j as the rendering provider NPI. Your individual NPI must be entered in the unshaded portion of item 24J on each line that contains claim details.

If you provided the services as a solo practitioner and you do not have a group or practice NPI, submit your individual NPI in item 33a of the claim form. It is not necessary for you to enter your individual NPI in item 24J in this case. If you do enter your NPI in item 24J, you must enter it in the unshaded portion of item 24j on each line that contains claim details.

Last Reviewed: 9/20/2023

No, CPT® modifier 90 can only be submitted by an independent clinical laboratory (provider specialty 69) when billing for tests referred to another (referral) laboratory.

Resource: IOM 100-04, Chapter 16, Sections 40.1.1.1 and 40.1.1.2 (PDF).

Last Reviewed: 9/20/2023

No. Non-referred and referred laboratory tests cannot be billed on the same paper claim. When a billing laboratory performs some laboratory tests (non-referred) and refers some testing to another laboratory, it must submit two separate claims: one claim for non-referred tests performed by the billing lab, and the other for referred tests performed by the reference lab. The tests performed by the reference lab must be billed with CPT® modifier 90. A paper claim that contains both non-referred and referred tests will be rejected as unprocessable.

If billing for services that have been referred to more than one laboratory, the referring laboratory must submit a separate claim for each laboratory to which services were referred (unless one or more of the reference laboratories are separately billing Medicare).

Resource: IOM 100-04, Chapter 16, Sections 40.1.1.1 (PDF).

Last Reviewed: 9/20/2023

Yes. When a billing laboratory performs some laboratory tests and some testing is referred to another laboratory, the electronic claim does not have to be split.

  • The CLIA numbers from both the billing and reference labs must be submitted on the claim
    • Report the billing laboratory's CLIA number in loop 2300, REF02. REF01 = X4
    • Report the referral laboratory's CLIA number at the appropriate claim line level in loop 2400, REF02. REF01 = F4
  • CPT® modifier 90 must be used on the line item tests performed by the reference laboratory
  • The performing (reference) laboratory's name, address and NPI must be entered in the appropriate facility provider loop for line items billed with CPT® modifier 90

Note: When the reference laboratory is not located in the same billing jurisdiction as the referring laboratory, the referring (billing) laboratory must report their own NPI with the name, address and ZIP Code of the performing provider in the appropriate data field for reporting purposes. The billing provider should keep a record of the performing provider’s NPI in the clinical records for auditing purposes.

Resource: IOM 100-04, Chapter 16, Sections 40.1.1.2 (PDF).

Last Reviewed: 9/20/2023

  • Providers may not bill for drug wastage for multi-does/multiuse vials or packages from which an amount is administered to one patient
  • Even if a provider is unable to store unused doses for later use because the pharmacy incorrectly reconstituted the drug using sterile water instead of bacteriostatic water, a provider may not bill for drug wastage in a multi-dose/multiuse vial or package

Tips for Submitting Accurate Claims

  • Each HCPCS code is associated with a specific number of units and type of units may be described by various units of measure
  • Verify the number and type of units associated with the HCPCS code before calculating the quantity on your claim
  • Verify calculations with the physician if needed
  • Submit the number of units (based on the HCPCS code) for the amount actually administered and not the number of units in the entire multi dose/multiuse vial or package

Last Reviewed: 9/20/2023

Yes. According to the CMS IOM, Publication 100-4, Medicare Claims Processing Manual, Chapter 1, Section 30.3.13, CMS’ policy is to allow physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments. The amount charged for missed appointments must be the same for Medicare beneficiaries and non-Medicare patients. 

The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.

Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers. Charges to beneficiaries for missed appointments should not be billed to Medicare.

Resource: IOM Pub. 100-04. Medicare Claims Processing Manual, Chapter 1, Section 30.3.13 (PDF).

Last Reviewed: 9/20/2023

As a National Contractor with coverage for all fifty States and U.S. Territories, Railroad Medicare does not establish Local Coverage Decisions (LCDs) outside those LCDs which may be in use by the contractor or local A/B Medicare Administrative Contractor (MAC).

Last Reviewed: 9/20/2023

With the two exceptions listed below, prior authorization or precertification is not required for any Part B services billed to Palmetto GBA Railroad Medicare at this time. As the Centers for Medicare & Medicaid Services (CMS) continues to expand its preauthorization and prior authorization programs, it’s important that you visit our website regularly for updates to this policy.

Prior authorization may be required for Part B services provided to Railroad Medicare patients when the claim for the service will be billed to and processed by another Medicare Administrative Contractor. Part B claims for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) that are under DME MAC jurisdiction are billed to your local DME MAC for Medicare and Railroad Medicare patients. Part B outpatient facility claims that you bill on UB-04 CMS-1450 forms or equivalent electronic claim forms are billed to your jurisdictional A/B MAC for Medicare and Railroad Medicare patients. Part B claims for Railroad Medicare patients that are submitted to a DME MAC or jurisdictional A/B MAC are subject to any prior authorization or precertification requirements that apply to the services you are billing to that MAC.

1. Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services — The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services. 

Effective for dates of service on or after July 1, 2020, prior authorization must be requested for the hospital OPD claim for the following services:

  1. Blepharoplasty
  2. Botulinum toxin injections
  3. Panniculectomy
  4. Rhinoplasty
  5. Vein ablation

Effective for dates of service on or after July 1, 2021, prior authorization must be requested for the hospital OPD claim for the following services:

  1. Cervical Fusion with Disc Removal
  2. Implanted Spinal Neurostimulators

Effective for dates of service on or after July 1, 2023, prior authorization must be requested for the hospital OPD claim for the following services:

  • Facet Joint Interventions

The prior authorization is requested for the OPD service, not the Part B professional service, so the PA requests must be submitted to the jurisdictional Medicare Administrative Contractor (MAC) that will process the hospital outpatient department facility claim. No PA requests should be submitted to Palmetto GBA Railroad Medicare. Part B claims for associated/related services, such as physician services performed in hospital OPDs, will not be paid for services that require prior authorization as a condition of payment for hospital OPD claims, if the service requiring prior authorization is not eligible for payment. For more information, see our Outpatient Department (OPD) Prior Authorization (PA) page.

2. Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transports (RSNAT) — CMS implemented the RSNAT Prior Authorization (PA) model in 2014 for limited states and expanded the model to additional states in 2015. The model was successful in reducing RSNAT services and total Medicare spending while maintaining overall quality of, and access to, care. The model met all expansion criteria and CMS has expanded the RSNAT PA model nationwide.

On July 18, 2022, the RRB SMAC implemented the model for Railroad Medicare beneficiaries nationwide for transports on and after August 1, 2022.

Prior Authorization for RSNAT includes the Healthcare Common Procedure Coding System (HCPCS) codes: 

  • A0426 — Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
  • A0428 — Ambulance service, basic life support (BLS), non-emergency transport

Associated service HCPCS code A0425 (Ground mileage, per statute mile) should be billed with the appropriate transport code but is not subject to prior authorization. 

Ambulance suppliers can receive prior authorization for up to 40 non-emergency scheduled round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period.

For more information, see our Ambulance Prior Authorization page.

Last Reviewed: 9/20/2023

The annual per-beneficiary incurred expense amounts once referred to as "therapy caps" are now called the "KX Modifier Thresholds". These amounts are the thresholds above which claims for outpatient therapy must include the KX HCPCS modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Medicare will deny claims for therapy services above these amounts when the services are billed without the KX HCPCS modifier.

There are two KX HCPCS modifier thresholds: one for Physical Therapy (PT) and Speech Language Pathology (SLP) services combined and one for Occupational Therapy (OT) services.

Annual KX Modifier Threshold Amounts 

  • For 2023, the KX HCPCS modifier threshold amounts on outpatient therapy services are $2,230 for PT and SLP services combined, and $2,230 for OT services
  • For 2022, the KX HCPCS modifier threshold amounts on outpatient therapy services are $2,150 for PT and SLP services combined, and $2,150 for OT services s 

You may access the accrued amount or remaining amount of therapy services from the Medicare beneficiary eligibility inquiry and response transactions.

Resources

  • Change Request 12923 (PDF): 2023 Annual Update of Per-Beneficiary Threshold Amounts
  • Change Request 12470 (PDF): 2022 Annual Update of Per-Beneficiary Threshold Amounts

Last Reviewed: 9/20/2023

HCPCS code J9999 should only be used for chemotherapy drugs that do not already have an assigned code. When HCPCS code J9999 is used, the name, strength, total dosage and route of administration must be on the claim. If the drug is compounded, the invoice/acquisition cost must be included with the description. Listing the NDC alone does not give enough information to enable adjudication of the claim. Without the above information, the claim will be denied because there is no supporting documentation.

Last Reviewed: 9/20/2023

You can either file electronic claims to Railroad Medicare through a clearinghouse or other third-party claims submitter, or you can submit paperless claims directly through Palmetto GBA’s online provider portal eServices eClaims option. With eClaims you will receive confirmation that your claim has been submitted, you can correct and resubmit a rejected claim, and your claim will be processed in 14 days. See the User Manual (PDF) for more information on eClaims. 

Note: Before registering for eServices you will need to have an Electronic Data Interchange (EDI) enrollment agreement on file. 

Last Reviewed: 9/20/2023

ASCA, or the Administrative Simplification Compliance Act, requires electronic claim submissions (except for certain rare exceptions) in order for providers to receive Medicare payment. Providers must submit their claims electronically using the X12 Version 5010 and NCPDP Version D.0 standards. As an alternative, providers can submit paperless claims directly online through the Palmetto GBA eServices portal eClaims option. Note: Before registering for eServices you will need to have an Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA. For more information about ASCA requirements, including the exceptions to filing electronically, please see our article Mandatory Electronic Submission of Medicare Claims.

Last Reviewed: 9/20/2023

Patients can receive payment on covered services when a claim is submitted with an amount in item 29 of the CMS-1500 (02/12) claim form. Item 29 should only be completed to report the amount a patient has paid for covered services. Submitting an amount in item 29 may result in payment being made to the patient.

Providers should not use item 29 to report the amount a primary insurance paid on the service or the amount Medicare paid on a previous submission of the claim.

Resource: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4 (PDF).

Last Reviewed: 9/20/2023

Yes, the complete address of the location where the services were rendered is required in block 32 for all place of service codes.

Last Reviewed: 9/20/2023

Medicare law dictates that all fee-for-service (FFS) claims be submitted within one calendar year from the date of service. There are four exceptions to this rule:

  1. Administrative Error: This is where the failure to meet the filing deadline was caused by an error or misrepresentation of an employee, the Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority. There must be a clear and direct relationship between the administrative or system error and the late filing of the claim(s).
  2. Retroactive Medicare Entitlement: This is where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished, but it is after the timely filing period has expired
  3. Retroactive Medicare Entitlement Involving State Medicaid Agencies: This is where a State Medicaid Agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary
  4. Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization: This is where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier six months or more after the date the service was furnished

For more information, see our Checklist for Timely Filing Extension.

If your claim denied for timely filing, and you have documentation that clearly supports a waiver based on one of the exceptions above, you may request a waiver in writing. Please submit your waiver request using our Railroad Medicare Provider Contact Center Written Inquiry Request form (PDF). Include documentation to support your request. eServices users can submit a Provider Contact Center General Written Inquiry Request Form online and upload supporting documentation in a PDF file.

You should not submit a request for a redetermination to the Appeals department. When a claim is denied for having been filed after the timely filing period, the denial does not constitute an "initial determination." As such, a redetermination request for a timely filing denial will be dismissed per the CMS appeals guidelines in IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 310.6. 

Last Reviewed: 9/20/2023

Failure to submit one or more of the following requirements can result in the rejection of services billed with CPT® modifier 55. 

CMS-1500 (02/12) Paper Claims

  • Enter the total number of post-op days in either item 24G or in item 19
  • Enter the date(s) the post-op care was assumed and/or relinquished in item 19
  • Enter the date the surgical procedure was performed as the date of service

Electronic claims — ASC 837 v5010 Loop, Segment, Element

  • Enter the total number of post-operative days in either the:
    • Days or units field, Loop 2400, SV1, 04 (03=UN)
    • Narrative Loop 2300 or 2400, NTE, 02
  • Enter the date(s) the post-op care was assumed and/or relinquished in either:
    • Loop 2300, DTP/90, or 91, 03
    • Narrative Loop 2300 or 2400, NTE, 02
  • Enter the date the surgical procedure was performed as the date of service

As a reminder, claims that are rejected with remittance message MA130 should be corrected and resubmitted as new claims. Rejected claims do not have appeal rights. Reopening and redeterminatation requests received for rejected claims will be dismissed.

Last Reviewed: 9/20/2023

Information entered on the claim directs Railroad Medicare to process as the primary or secondary payer. If this information is missing or incorrect, the claim will reject with an MA83 message code. 

For paper claims, this means information is missing in Block 11 of the CMS 1500 (02/12) claim form. For claims which Railroad Medicare should process as the primary payer, enter NONE in item 11. If Railroad Medicare should process as the secondary payer, enter the name of the primary insurance in items 11, complete 11a, 11b and 11c, and submit the claim with a copy of the primary insurance Explanation of Benefits (EOBs). 

Last Reviewed: 9/20/2023

  • On a CMS-1500 (02/12) claim form, enter the statement "Homebound" in block 19
  • On an ANSI ASC 837 v5010 electronic claim, complete the homebound indicator Loop 2300, Segment CRC/73, Element 03
  • Claims submitted with the statement "Homebound" in the narrative Loop 2300 or 2400 NTE segment will be rejected

Last Reviewed: 9/20/2023

Railroad Medicare uses remittance message N198 for rejected claims when the rendering provider does not have a Railroad Medicare Provider Transaction Access Number (PTAN) that is affiliated with the pay-to provider. This can mean the rendering provider either is not enrolled with Railroad Medicare under the TIN on the claim or the rendering provider does not have a PTAN linked to the billing provider’s group/organization NPI on the claim. 

Unlike paper claims, electronic claims should not be submitted to credential a provider with Railroad Medicare. A rendering provider must have a Railroad Medicare Provider Transaction Access Number (PTAN) affiliated with the tax identification number (TIN) and the group/billing NPI before an electronic claim is submitted.

To avoid these rejections: 

  • Verify the rendering provider has been assigned a Railroad Medicare PTAN for the TIN before submitting an electronic claim 
    • If the provider has not been assigned one for the TIN, submit a request for a Railroad PTAN and wait until the PTAN is assigned before submitting an electronic claim. NOTE: Before requesting a Railroad Medicare PTAN, the provider must first be enrolled under the TIN with your local Medicare Administrative Contractor (MAC). 
    • See our Provider Enrollment resources for more information on enrolling a provider with Railroad Medicare 
  • Verify the rendering provider has an individual Railroad Medicare PTAN that is linked to the Group PTAN for the billing provider NPI submitted on your claim
  • In the case of multi-state or multi-jurisdiction practices, verify the rendering provider has an individual Railroad Medicare PTAN for the state or jurisdiction in which the services were rendered. The rendering provider must have an enrollment record with each jurisdiction’s Part B MAC and a corresponding RR PTAN for each jurisdiction.
  • Verify the correct billing provider NPI was submitted for the group the rendering provider is affiliated with and/or for the location where the services were rendered

There may be other scenarios that also result in this rejection including the billing or pay-to address, or the provider taxonomy code billed on the claim.

If you are unable to determine which scenario may have caused your rejection, and would like to speak with a Customer Service Representative, please call our Provider Contact Center at 888–355–9165, Monday through Friday from 8:30 a.m. to 4:30 p.m. for all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m.

Last Reviewed: 9/20/2023

Please check the information you are billing in items 24J and 33a of the claim form.

In item 24J, you should enter the rendering provider's NPI number in the unshaded portion of the field. The rendering provider’s NPI must be entered in the unshaded portion of each line that contains claim details.

In item 33a, you must enter the NPI of the billing provider or group. This is a required field.

  • If you are billing for a member of a group practice, the NPIs billed in 24J and 33a should not be the same
  • If you are billing for a solo practitioner and the provider does not have a group or practice NPI, the NPIs in 24J and 33a should be the same. You are not required to bill an NPI in item 24J in this case.
  • If you are billing for a provider/supplier, such as an ambulatory surgical center, laboratory, or ambulance company, and you are not billing for the services of a physician or nonphysician practitioner, the NPIs in 24J and 33a should be the same. You are not required to bill an NPI in item 24J in this case

Last Reviewed: 9/20/2023

No. Since both physicians reassign benefits to the group, there is no need to identify the portion of the global package each one provided. Submit the service so the physician who performed the surgery is shown as the performing provider. Do not include CPT® modifiers 54 or 55 on the claim.

Resource: CMS IOM Pub. 100-04, Chapter 12, Section 40.2 (PDF). 

Last Reviewed: 9/20/2023

PTANs and other legacy provider numbers are not to be submitted on a Medicare claim. Claims should be submitted with NPIs only to identify the ordering, referring, rendering, and billing providers.

NPIs should be entered in the following fields of the CMS 1500 (02/12) claim form:

  • The ordering or referring provider’s NPI should be submitted in Item 17b
    Item 17a — Leave blank
  • The rendering provider’s NPI should be submitted in the lower unshaded portion of Item 24J
    Item 24J (top shaded portion) — Leave blank
  • The Facility NPI should be submitted in Item 32a when billing for a purchased service
    Item 32b — Leave blank
  • The billing provider’s NPI should be submitted in Item 33a on all claims
    Item 33b — Leave blank

As a reminder, effective April 1, 2014, Medicare can only accept paper claims submitted on the revised CMS 1500 (02/12) version claim form. Please see our Interactive CMS-1500 (02/12) Claim Form for instructions on completing the claim form including reporting provider identification information. 

Last Reviewed: 9/20/2023

The ACN or attachment control number is an optional number unique to your claim that will help you track your claim internally. The ACN number can be 1–50 bytes. The ACN number on the PWK cover sheet should exactly match the ACN number in the PWK loop on your claim.

Last Reviewed: 9/20/2023

For all services paid under the Medicare Physician Fee Schedule (MPFS), with two exceptions, the place of service (POS) code to be used by the physician and other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. In cases where the face-to-face requirement is obviated, such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test from a distant site, the POS code assigned by the physician/practitioner will be the setting in which the beneficiary received the technical component of the service.

The two exceptions to this general rule are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code, regardless of where the face-to-face service occurs, is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus).

Resources

  • IOM 100-04, Claims Processing Manual, Chapter 13 (PDF), Section 150 
  • IOM 100-04, Claims Processing Manual, Chapter 26 (PDF), Section 10.6

Last Reviewed: 9/20/2023

When the referring laboratory is the billing laboratory:

  • CPT® modifier 90 should be reported with the test procedure code to indicate test was performed by a reference laboratory;
  • The reference laboratory’s name, address, and ZIP Code should be reported in item 32 to show where the service (test) was actually performed;
  • The reference laboratory’s NPI should be reported in item 32a; and
  • The CLIA number of the reference laboratory should be reported in item 23

Note: If the reference laboratory is not located in the same billing jurisdiction as the referring laboratory, the referring (billing) laboratory must report their own NPI in item 32a for reporting purposes. The billing provider should keep a record of the performing provider’s NPI in the clinical records for auditing purposes. 

A paper claim that does not have the name, address, and ZIP Code of the reference laboratory in item 32, the NPI in item 32a or the CLIA number of the reference laboratory in item 23 will be rejected as unprocessable.

Resource: IOM 100-04, Chapter 16, Sections 40.1.1.1 (PDF).

Last Reviewed: 9/20/2023

You should only enter an amount in item 29 when the patient made a payment for covered services. Enter the total amount the patient paid on the covered services. Do not enter the amount a primary insurance paid on the service claim or the amount Medicare paid on a previous submission of the claim.

Resource: CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4 (PDF).

Last Reviewed: 9/20/2023

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, required that Social Security Numbers be removed from all Medicare cards by April 2019. This CMS resource provides additional information.

Last Reviewed: 9/20/2023

As a national Medicare contractor, Railroad Medicare adjudicates claims based on the Medicare fee schedules set forth by the Centers for Medicare & Medicaid Services (CMS). Therefore, payments made by Railroad Medicare are based on the fee schedule for your state and locality. You can verify the Medicare allowed amount on the fee schedules posted on your local Medicare Administrative Contractor’s website or with the fee schedules found on the CMS website.
Links to the fee schedules on the CMS website are found below:

Last Reviewed: 9/20/2023

Unlisted, or not otherwise classified (NOC), codes require a description of the service or supply so that Medicare can properly adjudicate and price the service. Without the description of the service, Medicare cannot determine whether the service is covered or, if covered, what the allowance should be.

When an unlisted code is billed, a concise description of the service, along with any other supporting documentation that the provider deems relevant must be included on the claim. On paper claims, enter the description in item 19 of the CMS 1500 (02/12) claim form. On electronic claims, the description can be entered in the narrative field (ASC 837 v5010 Loop 2300 or 2400, Segment NTE, Element 02).

Claims for unlisted codes that do not contain a description of the service or supply will be rejected as unprocessable. These claims can be identified by the MA-130 code on the remittance notice.

Last Reviewed: 9/20/2023

All claims must be filed with your Medicare contractor no later than one calendar year (12 months) from the date of service or Medicare will deny them. If a claim requires correction, a corrected claim must be filed 12 months from the date of service. The fact that the original submission was filed timely does not change the timely filing period for a corrected claim. Each claim filed to Medicare is considered individually.

Filing a claim to Medicare as soon as possible after the service is rendered can help to ensure there is time to resubmit a corrected claim, if necessary.

Last Reviewed: 9/20/2023


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