General

Published 06/12/2026

Providers must verify the beneficiary’s information, including their MBI, before submitting Medicare claims. When an MBI changes, the provider should use the MBI that is valid for each specific date of service. Claims must be billed using the MBI that corresponds to the service dates listed on the claim.

Reference: What do Medicare Beneficiary Identifiers (MBIs) mean for health care providers & managers?

Last Reviewed: 06/12/2026

Reason code 33981 indicates that the MSP claim was submitted with an incorrect value code 44 amount. Value code 44 represents the “Obligated to Accept as Full” (OTAF) amount. This amount should equal the total claim charges minus any contractual obligation (CO) adjustments. To correct the claim, the provider should:
  1. Review the claim’s total charges.
  2. Confirm that all applicable CO adjustments have been applied correctly.
  3. Recalculate the OTAF amount (total charges minus CO adjustments).
  4. Update value code 44 with the accurate amount.

Additional helpful information:

  • Claim adjustment reason codes (CARCs) explain why the primary insurer denied or adjusted the claim.
  • CARC resources are available at https://x12.org/.

Reference: Change Request 6426 (PDF).

Last Reviewed: 06/12/2026

Hospital Outpatient Departments (OPDs) that demonstrate compliance with Medicare coverage, coding and payment rules related to prior authorization (PA) may be eligible for exemption. To be eligible, OPDs need to submit at least ten prior authorization requests (PARs) during the standard review period and achieve a provisional affirmation compliance rate of at least 90 percent during an annual assessment.

Exempt providers will be given the option to opt-out of the exemption process. By opting out of exemption, providers will return to the standard review process and be required to submit PARs.

References

Last Reviewed: 06/12/2026

Inpatient hospital or inpatient skilled nursing facility (SNF) claims that return to provider with reason code 12206 states the claim “from” and “through” dates do not equal the number of sums of covered days and non-covered days.

Occurrence span code 74 is used to report the dates the leave began and ended.

Important Points to Remember

  • Ensure the number of days submitted for covered and non-covered
  • Ensure that any lifetime reserve days are being calculated with sum of the covered days while billing inpatient hospital claims
  • Ensure that a leave of absence is calculated with sum of the non-covered days
  • Ensure that the “through” date is not included in the count if the patient status code is a discharge status
  • Ensure that one additional day must be added, if the patient status code is equal to “30”

References

Last Reviewed: 06/12/2026

Inpatient hospital or inpatient skilled nursing facility (SNF) claims that return to provider with reason code 15202 indicate that the covered days on the claim are greater than zero; however, the total number of units billed under accommodation revenue codes (any revenue codes between 10X and 21X) doesn't match the number of cost report days on the claim.

Claims will also assign this reason code if the provider bills an occurrence code A3 with an incorrect date. Occurrence code A3 represents the last date Part A benefits were available for the beneficiary.

Important Points to Remember

  • Ensure covered units are in the "covered" field, not only the "total units" field
  • Ensure that the covered units equal the same amount of cost report days (covered days) reported on the claim
  • Ensure that the occurrence code A3 has the correct date if benefits have exhausted

Reference: Reason Code 15202.

Last Reviewed: 06/12/2026

Providers should make checks payable to Palmetto GBA or Medicare; otherwise, the check can't be accepted for deposit.

Ensure that the Voluntary Refund Overpayment form is completed either via eServices or by mail. Attach detailed information regarding the overpayment. For overpayments that involve multiple patients, please submit detailed information for each patient/claim.

If the claim has truly been overpaid, the money will be applied accordingly. If it is determined that the facility has not been overpaid and no monies are due to Medicare, the provider will be refunded.

Reference: Overpayments and Recoupment.

Last Reviewed: 06/12/2026

Does the cost for an inpatient stay exceed the cost outlier threshold amount?

  • If no, submit the claim as a regular inpatient claim
  • If yes, are there enough benefit days (regular or lifetime reserve) to cover the medically necessary days?
    • If yes, submit the claim as a regular inpatient claim. Don't indicate occurrence code 47
    • If no, indicates occurrence code 47 and date of the first full day of cost outlier status (the day after, the day that covered charges reaches the cost outlier threshold)
      • For Medicare purposes, cost outlier payments are paid for each day during the outlier period that the beneficiary has an available benefit day (regular, coinsurance and/or lifetime reserve)
      • Diagnosis related group (DRG) claims without cost outlier payments can never have regular benefit days combined with lifetime reserve benefit days. When regular benefit and lifetime reserve days are billed on the same claim, lifetime reserve usage begins on the cost outlier date (should be equal to occurrence code 47 date).

Reference: IPPS Billing for Cost Outlier Module.

Last Reviewed: 06/12/2026

Initial CMS 855A applications can be submitted up to 180 days prior to the effective date listed on an application. All other applications can be submitted up to 60 days prior to the effective date provided on the enrollment form. 

References

Last Reviewed: 06/12/2026

Last Reviewed: 06/12/2026

1. Question: Where should an independent RHC send a bill for the total component (technical and professional components) of an electrocardiogram (EKG)?

Answer: The professional component is included in the all-inclusive rate and is not separately payable.

  • Independent (freestanding) RHCs: The technical component of an EKG performed is billed under the practitioner's ID to Part B, on the CMS-1500 claim form, with appropriate place of service
  • Provider based RHCs: The technical component of the EKG performed is billed by the base-provider on the UB-04 claim form

References

2. Question: When we file a redetermination for an overpayment is recoupment stopped?

Answer: You may stop recoupment at two points:

  • When a valid and timely request for a redetermination (i.e., within 30 days from the date of the overpayment letter) is received. Recoupment stops or is delayed pending results of the appeal.
  • When receipt of an unfavorable or partially favorable redetermination decision and there is notification that the qualified independent contractor received a valid and timely request for reconsideration within 60 days of the redetermination

Note: Interest continues to accrue even when recoupment stops.

Reference: I Received a Demand Letter for an Overpayment.
 

3. Question: If a surgery date is changed or cancelled, can we request a prior authorization extension of the 120 days?

Answer: No, a new Prior Authorization Request (PAR) would be required. PAR decisions and Unique Tracking Number (UTN) for these services are valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on January 1, 2021, the PAR will be valid for dates of service through April 30, 2021. Otherwise, the provider will need to submit a new PAR to obtain a new UTN timeframe that includes the dates of service.

Reference: Prior Authorization (PA) Program for Certain Hospital Outpatient (PDF).
 

4. Question: If there is an approved UTN for a certain date of service (but never billed), but the procedure got rescheduled, do I need to do a new PAR? The rescheduled date is within the 120-day period.

Answer: If the procedures Date of Service (DOS) has been rescheduled and the same procedure that was affirmed still falls within the 120-day timeframe of the UTN, nothing additional is required.

Note: If the UTN has not been used and is still valid then it can be used.

Reference: Prior Authorization (PA) Program for Certain Hospital Outpatient (cms.gov).
 

5. Question: If I provide a service under arrangement to a SNF that is subject to SNF consolidated billing, what rate do we charge the SNF for that service?

Answer: The SNF and the provider/supplier agree to contractual terms prior to providing services. As part of this agreement, the SNF and the supplier (could be an ambulance) negotiate the terms and amount of payment. According to the CMS Publication 100-04, Claims Processing Manual, Chapter 6, Section 10.4.1 (PDF), “Medicare does not prescribe the actual terms of the SNF’s relationship with its suppliers (such as the specific amount or timing of payment by the SNF), which are to be arrived at through direct negotiation between the parties to the agreement.”
 

6. Question: Can I submit a no-pay claim (210) and a Part B ancillary claim (22X) at the same time?

Answer: No. The 210 Medicare claim must be finalized before the 22X claim can be submitted.

References

7. Question: Do the botulinum toxin J-codes require prior authorization when they are used for injection procedures other than 64612 and 64615?

Answer: No. Prior authorization is only required when one of the required Botulinum Toxin codes (J0585, J0586, J0587 or J0588) is used in conjunction with one of the required CPT injection codes (64612, injection of chemical for destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face).

Use of these Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.

References

8. Question: How do I adjust a claim that has medically denied lines?

Answer: All lines that were medically denied must be left in non-covered. These lines cannot be removed from the claim or moved to covered. An appeal must be submitted to adjust these lines. It is not sufficient to just enter comments, "Not adjusting medically denied lines." The lines must be submitting in non-covered exactly as they were on the original claim. If there is a GZ Modifier on any line on the original claim, it must be present with charges in non-covered on new claim also.

Reference: Appeals and Clerical Error Reopenings Module.
 

9. Question: What happens if someone ignores a demand letter request regarding Part A overpayment?

Answer: When Medicare is notified of a settlement, judgment, award, or other payment, including ORM, the recovery contractor will perform a search of Medicare paid claims history. When the most recent search is completed and related claims are identified, the recovery contractor will issue a demand letter advising the debtor of the amount of money owed to the Medicare program and how to resolve the debt by repayment. The demand letter also includes information on administrative appeal rights. Reimbursing Medicare. 

Assessment of Interest and Failure to Respond
Interest accrues from the date of the demand letter but is only assessed if the debt is not repaid or otherwise resolved within the time period specified in the recovery demand letter. Interest is due and payable for each full 30-day period, the debt remains unresolved; payments are applied to interest first and then to the principal. Interest is assessed on unpaid debts even if a debtor is pursuing an appeal or a beneficiary is requesting a waiver of recovery; the only way to avoid the interest assessment is to repay the demanded amount within the specified time frame. If the waiver of recovery or appeal is granted, the debtor will receive a refund.

Failure to respond within the specified time frame may result in the initiation of additional recovery procedures, including the referral of the debt to the Department of Justice for legal action and/or the Department of the Treasury for further collection actions. Reimbursing Medicare.

For a more detailed breakdown of this process, please review the information below:

  • If there is no response after 30 days, one 30-day period of interest is accrued, and a second demand letter is sent out
  • If there is no response to the second demand letter, a third demand letter will be sent with current interest calculations. The third demand letter will also include the intent to refer debt to the Department of Treasury's Debt Collection Center for cross-servicing and offset of Federal payments and certain eligible State payments information.
  • If there is no response on day 61, the matter will be referred to the Department of the Treasury Debt Collection Center. The provider will also remain on payment withholding at the contractor level.
    • The Debt Collection Center will use various tools to collect the debt, including offset, demand letters, phone calls, referral to a private collection agency and referral to the Department of the Justice for litigation. Other collection tools available, which may be used, include Federal salary offset, administrative wage garnishment and the offset of income tax returns through the Internal Revenue Service. If the debt is discharged, it may be reported to the IRS as potential taxable income. During the collection process, interest will continue to accrue on the debt, and the provider will remain legally responsible for any amount not satisfied through the collection efforts.

Reference: I Received a Demand Letter for an Overpayment.
 

10. Question: Can I get a letter indicating a patient’s Medicare Part A benefits are exhausted?

Answer: Medicare benefits exhaust letters are not issued. This information will appear on your remittance advice. Please review the example below for clarity:

  • Claim status code 432 — Date benefits exhausted
  • CARC 78 — Non-covered days/Room charge adjustment
  • RARC N374 — Primary Medicare Part A insurance has been exhausted, and a Medicare Part B Remittance Advice is required
  • RARC N587 — Policy benefits have been exhausted
  • CARC 119 — Benefit maximum for this time period or occurrence has been reached

References

11. Question: When is it proper to use pre-entitlement billing instructions and what are some billing tips?

Answer: Use pre-entitlement billing instructions for inpatient admissions when you:

  • Admit the patient before their Medicare Part A entitlement date
  • Discharge them after their Part A entitlement effective date

Billing and Claims Tips

  • Room and Board Revenue Codes = 010X – 016X • Admission Date = Patient’s formal inpatient admission date
  • Statement Covered Period "From" Date = Effective date of Part A entitlement
  • Statement Covered Period Through Date = End date of the inpatient stay
  • Covered Days with Value Code (VC) 80 = The number of days in the "Covered From" to "Covered Through" date range
  • Accommodation Days/Units = The number of days reported in VC 80
  • Only include room and board charges for the days the patient had Part A entitlement
  • Don’t bill the patient or anyone else for days of care before the patient’s Part A entitlement, except for days above the outlier threshold
  • Report all revenue codes from the admission date through the discharge, transfer or death date as covered charges
  • Include surgical procedure codes from the admission date to the discharge, transfer or death date
  • Include diagnosis codes from the admission date to the discharge, transfer or death date
  • Include Part A entitlement date, in the remarks

References

Note: If a beneficiary’s group health plan coverage terminates prior to their Medicare entitlement date, MSP rules do not apply. MSP status is determined by reason for Medicare entitlement (age, disability or ESRD) and requires overlapping coverage, without coverage on or after the entitlement date, the MSP provisions cannot be applied.

Last Reviewed: 06/12/2026

1. Question: Can we use hospice inpatient days as the three-day qualifying stay for SNF?

Answer: Section 1861(i) of the Act provides that to be covered under Part A, inpatient care in a SNF must be preceded by a qualifying hospital stay of at least three consecutive days (not including a day of discharge). Section 409.30(a) of 42 Code of Federal Regulations (CFR) further specifies that the stay must have been in a participating, or qualified hospital for medically necessary inpatient hospital care. There is no policy preventing a hospital stay covered under the hospice benefit from serving as the required Skilled Nursing Facility (SNF) three-day hospital stay.

Additional Resource: Skilled Nursing Facility Billing Reference.
 

2. Question: Can I submit a no-pay claim (210) and a Part B ancillary claim (22X) at the same time?

Answer: No. The 210 claims must be finalized before the 22X claim can be submitted.
 

3. Question: Can I appeal against a claim that was denied because it was submitted to Medicare untimely?

Answer: Denials for untimely filing are not appealable unless one of the exception situations described in the Centers for Medicare & Medicaid Services (CMS) Publication 100-04, Claims Processing Manual, Chapter 1, Section 70.7 — Exceptions Allowing Extension of Time Limit (PDF) applies to the claim in question.
 

4. Question: What actions do I need to take if I receive a favorable appeal decision from a higher level of appeal (e.g., administrative law judge)?

Answer: If you receive a favorable appeal decision beyond the first level of appeal (redetermination), the contractor that determined the appeal was favorable, will notify Palmetto GBA to reprocess your claim for payment.

Additional Resources

5. Question: How can I bill an MSP claim if there is an open worker's compensation, auto or liability file on the common working file, but the services provided are not related to the open file?

Answer: The original claim will reject if diagnosis code(s) on page 5 appears to be related. The provider will need to submit an adjustment with remarks specifying the services are unrelated. The processing unit will review comments and diagnosis codes reported on the claim when making their determination. Please call customer service if you need assistance in preparing the claim.

Additional Resources

6. Question: Can you tell me why my partial hospital discharge claim returned with reason code 38205?

Answer: Reason code 38205 occurs when a partial hospitalization discharge claim is received and there is no claim in history that contains a line-item date of service within seven days prior to the "from" date of the incoming claim. Partial hospitalization claims must be submitted in sequence with the most appropriate patient status code. For partial hospitalization discharge claims (XX4), the patient status code should be "01," discharge home. Reporting any other patient status code will cause the claim to be out of sequence and returned to you.

Additional Resources

7. Question: How do I view or print an ADR in FISS?

Answer: Access the claim summary inquiry screen in FISS (selection 12 on the inquiry menu) type a provider number or Medicare Beneficiary ID number and press enter. If the status / location is "S B6001" there is an ADR available on this claim.

  • Type "S" in the "SEL" field; press "Enter"
  • Go to page 6, hit F8 to view/print the ADR
  • Submit the printed ADR letter along with the documentation

Additional Resources

8. Question: Where do my ADR letters and medical review (MR) correspondence go?

Answer: In FISS, the address in the “other address” field is used for mailing MR correspondence and ADR letters. Unfortunately, Palmetto GBA cannot update or change the designation for mailing correspondence and ADRs to a different address. However, it is important to note that you can update the address listed in the “other address” field by completing a Medicare Enrollment Application (CMS-855A) (PDF).
 

9. Question: Can I get a letter indicating a patient’s benefits are exhausted?

Answer: We do not issue benefit exhaust letters. This information will appear on your remittance advice. We’ve included the link to the X12 Website which contains links to various code lists, including claim adjustment reason Codes (CARCs); remittance advice remark codes (RARCs); provider adjustment reason codes; claim status codes; and much more.

Examples of what you may see on the remittance advice:

  • Claim status code 432: Date benefits exhausted
  • CARC 78: Non-covered days, room charge adjustment
  • RARC N374: Primary Medicare Part A insurance has been exhausted, and Part B Remittance Advice is required
  • RARC N587: Policy benefits have been exhausted
  • CARC 119: Benefit maximum for this time period or occurrence has been reached

Additional Resource: Publication 100-04, Section 150.17 — Benefits Exhausted (PDF).
 

10. Question: The patient’s surgery is scheduled for seven days. Can I submit my Prior Authorization Request (PAR) now? 

Answer: A PAR should be submitted prior to scheduling the patient for the surgery. Providers should not schedule surgery until the affirmed decision letter and Unique Tracking Number (UTN) are received for a PAR. Once a PAR is received, a decision will be made within seven calendar days. Do not submit an expedited PAR unless the Beneficiary’s life or functional status is in jeopardy.
 

11. Question: Where can I locate information on Medicare’s Next Generation ACO Model waiver of the SNF three-day rule?

Answer: Three-Day Inpatient Hospital Stay Requirement for Care in a Skilled Nursing (PDF).
 

12. Question: I would have liked more information on when an audit is done in our own practice. And we need to correct coding to a higher-level E/M after six months have gone by. I seem to struggle with the correct process for this type of situation. It seems like no options work to fix the issue.

Answer: You can generally correct a Medicare claim to a higher-level E/M service more than six months after the original service date, provided the date of service is within the 12-month (one calendar year) timely filing limit for original claims. Corrected Claim Submission: If the date of service is within the 12-month window, you can submit a corrected claim to the MAC using the appropriate frequency code (often "7" for replacement of a prior claim = XX7). The corrected claim does not reset the original timely filing clock; it's still tied to the original date of service.

The CMS Medicare Claims Processing Manual outlines the specific reopening and adjustment rules.

Last Reviewed: 06/12/2026

1. Question: My claim is editing for reason code 38022. How do I resolve this issue?

Answer: Reason Code 38022 assigns when the discharge and admit dates do not match on both the inpatient hospital's claim and the skilled nursing facility's claim. Per guidance received from CMS, the only way to correct this issue is either the hospital can change their admission date to match the SNF's discharge date, or the SNF must change their discharge date to match the hospital's admit date. Once the dates on both claims match, the claim will no longer be assigned this reason code.
 

2. Question: I can't log into the Provider Enrollment, Chain, and Ownership System (PECOS). Who can assist me?

Answer: For technical issues within PECOS, please call the PECOS help desk. The External User Services (EUS) contact information hours of operation are Monday – Friday, 7 a.m. – 7 p.m. ET.

3. Question: Will my payment be recouped because of negative reimbursement?

Answer: When a claim has a negative reimbursement amount, it means the beneficiary’s coinsurance and/or deductible are more than the provider’s reimbursement amount. When this happens, the negative amount will be withheld from the provider on future remittance advice. Please review Palmetto GBA's Clarification of Negative Reimbursement article for more information.
 

4. Question: My claim is editing for reason code U5200. How do I resolve this issue?

Answer: Outpatient claims are reimbursed through the Part B Payment Perspective System. Therefore, the beneficiary must have Part B entitlement. Inpatient claims are reimbursed through the Part A Payment Perspective System. Therefore, the beneficiary must have Part A entitlement. If claims are submitted and the beneficiary does not have either Part A or Part B entitlement it can cause the claim to be rejected. It is the provider's responsibility to ensure that eligibility/entitlement is verified before providing services.
 

5. Question: Can I get a letter indicating a patient's Medicare Part A benefits are exhausted?

Answer: We do not issue benefit exhaust letters. This information will appear on your remittance advice. Examples of what you may see on the remittance advice for benefits exhaust are listed below:

  • Claim status code 432: Date benefits exhausted
  • CARC 78: Non-covered days/Room charge adjustment
  • RARC N374: Primary Medicare Part A insurance has been exhausted, and Part B Remittance Advice is required
  • RARC N587: Policy benefits have been exhausted
  • CARC 119: Benefit maximum for this time period or occurrence has been reached
     

6. Question: When there is a takeback on a remit, there are no patient names, only Medicare numbers. This makes it very difficult to determine which patient the takeback is for. Can this be modified in the future so that patient names are associated with takeback?

Answer: On Palmetto GBA’ s remittance advice (RA), patient names are not listed for a takeback or recoupment. Instead, you must use the invoice number provided in a separate overpayment demand letter to identify the specific patient. The RA primarily contains financial information, such as payment adjustments and recoupments, to adhere to privacy regulations. All MACs operate under strict privacy rules from CMS. They are required to protect beneficiary privacy and limit the disclosure of information. Please follow the steps below to identify the patient for recoupment:

  1. Review the overpayment demand letter: Before a takeback appears on your RA, Palmetto GBA will mail you a demand letter. This letter contains the specific invoice number(s) and lists the patient(s) and dates of service associated with the overpayment.
  2. Match the invoice number to the financial control number (FCN): When you see a recoupment on your RA, match the FCN on the remittance notice with the corresponding invoice number on your overpayment letter to correctly identify the patient account.
  3. Contact your software vendor if necessary: If your billing software does not correctly map the invoice number data from the electronic remittance file, you may need to contact your vendor for assistance.
     

7. Question: How long does it take to process an application?

Answer: Please refer to the article Provider Enrollment Application Processing Time, located on the Palmetto GBA website.
 

8. Question: I file the cost report for dialysis facilities. How do I obtain additional information that I need regarding dialysis?

Answer: When submitting a cost report to Palmetto GBA, there are only two acceptable ways of submission, either:

  • Through Medicare Cost Report Electronic Filing system (MCREF)
  • By mailing into Palmetto GBA's physical location in Camden

Ensure the Worksheet S (WS S) is signed and, if submitted through MCREF, that the checkbox in item 2 is selected. Additionally, if bad debts are being claimed when submitting an End Stage Renal Dialysis (ESRD) cost report, a bad debt log will always need to be submitted with the cost report. The electronic cost report (ECR) files should always be submitted with a full cost report, which consist of the renal Dialysis (RD) and Print Image (PI) file.

  • If submitting a No Utilization cost report, ensure the WS S is signed, and you send the letter on company letterhead. It must be stated that no covered services were furnished during the reporting period, and no claims for Medicare will be filed for this reporting period.
  • If submitting a Low Utilization cost report, the Medicare net reimbursement must be less than $200,000, a signed WS S must be submitted, along with a balance sheet with statement of revenues and expenses
     

9. Question: How can I become more knowledgeable about accurate billing and compliance?

Answer: Review these resources:

Last Reviewed: 06/12/2026


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