General

Published 07/23/2026

Unlike private insurance carriers, Medicare Part B does not accept "corrected claims" submitted with the intent of overwriting previously processed and paid claims. In the event that we receive a claim with nearly identical information (Billing Group, Rendering Provider, Beneficiary, Date of Service, Procedure Codes, Diagnosis Codes, Modifiers, etc.), the incoming claim will likely receive a duplicate denial against the original claim. If a coding change is attempted via a “corrected claim,” you will potentially receive payment for both services requiring a voluntary refund to be initiated for the original incorrect service.

If a procedure code needs to be changed, the final payout of the new code compared to the previously paid code will determine what action needs to be taken. To downcode to a lower paying procedure code, please initiate a reopening via eServices, Telephone Reopening, or the submission of the Reopening: Simple Claim Correction form. However, in order to justify upcoding a procedure code to a higher paying service, we require an appeal along with supporting documentation reflecting the need for the increased code.

Resource: Instead of a Written Redetermination Consider Having Your Claim Reopened.

Last Reviewed: 07/23/2026

No, Medicare does not pay primary, secondary, or otherwise for services authorized under Veterans Health Administration (VHA) benefits. However, we may cover and pay for services not authorized under VHA benefits. Both Medicare and the U.S. Department of Veterans Affairs (VA) may recover duplicate payments in situations where both agencies made payments on the same claim services. Return Medicare’s payment for services that VA paid, as we consider this a duplicate payment.

Resource: CMS Medicare Learning Network® (MLN) Booklet (MLN006903) Medicare Secondary Payer (PDF).

Last Reviewed: 07/23/2026

The provider will need to contact our EDI department to have their account reinstated.

  • Jurisdiction J Part B: 877–567–7271
  • Jurisdiction M Part B: 855–696–0705

Resource: eServices User Manual (PDF).

Last Reviewed: 07/23/2026

There are several reasons.

  • If you have a paper claim, the claim may not have been delivered to Palmetto GBA, or if the claim was received through the U. S. mail, the claim may not yet have been entered into the claim processing system.
  • Your billing company or clearinghouse may not have forwarded the claim to Palmetto GBA.
  • Your electronic claim may have been stopped by billing software and additional action may be required to move the claim to transmit to Medicare.

Resources

Last Reviewed: 07/23/2026

The simplest and most efficient way to submit a redetermination is through Palmetto GBA’s eServices portal. Palmetto GBA also offer an eDelivery option for receiving your redetermination decision letters electronically. You can get your Medicare redetermination notices (MRNs) the same day that they are issued, delivered directly to your computer. You can even choose to get an email to let you know that the letter is waiting for you. The eServices User Manual (PDF) provides instructions on the submission process.

Last Reviewed: 07/23/2026

This type of claim denial is considered a contractual obligation. You are not allowed to bill the patient for this type of claim until the necessary information to adjudicate the claim has been received and reviewed. Palmetto GBA has a list of CPT®/HCPCS codes that require additional documentation be submitted with the claim. Claim rejections (no appeal rights listed on the remittance advice) must be refiled as new claims with the necessary documentation. If you sent documentation with your claim, review that documentation, and make sure is for the correct patient, date of service, and is complete. If the claim is a denial (appeal rights are listed on the remittance advice for the claim), you may submit a first level of appeal with the necessary documentation.

Palmetto GBA may issue an additional documentation request (ADR) as part of the review process. These letters are sent to the written correspondence address on file for the provider. Providers may also request to receive ADR letters through the Palmetto GBA eServices portal. This can be especially helpful in large practices to ensure the letters reach your appropriate internal department to fulfill the record request within the noted time frame.

Resources:

Last Reviewed: 07/23/2026

The date of service for the technical component (Healthcare Common Procedure Coding System [HCPCS] modifier TC) is the date the patient received the service. The date of service for the professional component (Current Procedural Terminology [CPT®] modifier 26) is the date the review and interpretation were completed.

Resource: CMS Medicare Learning Network® (MLN) Matters article SE17023 (PDF).

Last Reviewed: 07/23/2026

CMS allows up to 30 days (pre-payment) or 60 days (postpayment) from the date documentation is received to review and make a payment decision. Please refer to the Understanding the Targeted Probe and Educate Process module for details.

Last Reviewed: 07/23/2026

Documentation must be received within 45 calendar days from the date of the ADR letter. We encourage providers to use the Palmetto GBA eServices Portal to view ADR letters and submit requested documentation. Please refer to the Additional Documentation Requests (ADRs) module for details.

Last Reviewed: 07/23/2026

Eligibility can be verified by using self-service tools. The available self-service tools are eServices, billing agencies, clearinghouses or software vendors.

We have created an educational module to provide more information on how to use the eServices portal to check beneficiary eligibility. Please refer to the eServices: Eligibility Options module for details.

Last Reviewed: 07/23/2026

It can take up to 60 days from the date of receipt for a Redetermination to process. To check the status of the appeals that are within the 60-day timeframe, please use the JJ and JM Part B Redetermination Status tool. If it has been longer than 60 days, please call the Provider Contact Center to obtain the status of the appeal.

Last Reviewed: 07/23/2026

Yes, it is a payable code with a base code with CPT® modifier 25 and an allowed Part B service(s). These services include:

  • Part B preventive services
  • Immunization administrations
  • Annual Wellness Visits

Resource: CMS Medicare Learning Network® (MLN) article MM13473 (PDF).

Last Reviewed: 07/23/2026

A list of these codes is available in the CMS Internet-Only Manual, Medicare Claims Processing Manual, Pub. 100-04, Chapter 26, Section 10.5 (PDF). In addition, Palmetto GBA has created a Place of Service Code Set module.

Last Reviewed: 07/23/2026

If you are a mass immunizer using roster billing to submit your claims, only the billing NPI should be submitted on a CMS-1500 claim.

Resources

Last Reviewed: 07/23/2026

When billing Medicare, providers must choose the code that best characterizes the services rendered to the patient. Please refer to New Patient Visit Criteria for further information.

Last Reviewed: 07/23/2026

If more than one Evaluation and Management (E/M) (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Please refer to E/M Weekly Tip: Combined Billing for further information.

Last Reviewed: 07/23/2026

If you enrolled using the Provider Enrollment Chain and Ownership System (PECOS), access the status of your application through PECOS and take a screenshot of your status. You may also use the Provider Enrollment Status Lookup self-service tool on the Palmetto GBA website and take a screenshot of your status inquiry results. The articles below alert providers to the CMS allowed timeframes for Medicare Contractors to process enrollment applications.

Resources

Last Reviewed: 07/23/2026

Palmetto GBA is charged with protecting the confidentiality of personally-identifiable information (PII) and protected health information (PHI) as well as provider PII in accordance with the Privacy Act of 1974 and HIPAA. To do this, any person requesting information about a specific provider and/or patient must provide details that indicate a relationship with the patient and/or provider and have a reasonable need for the desired information.

Inquirers requesting information about a provider must be able to provide the billing provider’s National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), and the last five digits of the provider’s tax ID number. Inquiries regarding a specific patient and/or claim must include the billing provider information listed above and the patient’s first and last name, Medicare Beneficiary Identifier (MBI) number, and date of birth. Other details related to the specific inquiry type should also be available upon request. Having all the necessary information available before calling Palmetto GBA will help to expedite your call time.

Last Reviewed: 07/23/2026

A patient that is in custody of a state or local government under the authority of a penal statute at the time the provider renders the service is considered an incarcerated beneficiary. Medicare Administrative Contractors are notified through a patient’s Common Working File (CWF) of incarceration. The Centers for Medicare & Medicaid Services (CMS) relies on data from the Social Security Administration (SSA) for Medicare enrollment and eligibility. Upon release, the Medicare eligible individual should contact SSA at 800–772–1213 (TTY users can call 800–325–0778) to inquire about enrolling, reenrolling, or other enrollment related issues following their release from incarceration. Once a patient’s CWF is updated through Social Security to reflect release and all other Medicare eligibility regulations have been met for the date of service, the claim may be billed to Medicare.

Resource: Incarcerated Medicare Beneficiaries.

Last Reviewed: 07/23/2026

Medicare law and regulations require all entities that bill Medicare for services or items given to Medicare beneficiaries to decide whether Medicare is the primary payer for those services or items before submitting a claim to Medicare. (See Section 1862(b)(2) of the Social Security Act and regulations at 42 CFR 489.20g.) When you find another insurer as the primary payer, you must bill that insurer first. After receiving the primary payer remittance advice, bill Medicare as the secondary payer, if appropriate.

The resources below outline the Medicare Secondary Payer (MSP) guidelines and offer resources to help providers when it is determined that the patient has other insurance that should be billed before Medicare. You may also use the Palmetto GBA eServices secure portal to verify if the patient has other insurance that must be billed before Medicare. Another key factor is insuring the secondary claim billed to Medicare includes all the necessary information regarding how the primary insurer handled each service on the claim to consider making secondary payment.

Resources

Last Reviewed: 07/23/2026

Speak with your credentialing team to ensure the billing provider is enrolled with Medicare for the date of service billed. Also, verify the claim was billed in the correct state where the service was performed. Visit the Palmetto GBA Provider Enrollment web page for more information on enrollment and revalidation requirements.

Last Reviewed: 07/23/2026

Review your paper or electronic claim to verify that the correct rendering provider NPI number was entered into block 24J of the CMS-1500 claim form or in the equivalent electronic claim loop and segment. Verify that the rendering provider’s NPI was typed correctly.

Resource: NPI: Troubleshooting Rejections.

Last Reviewed: 07/23/2026

This type of claim denial is considered a contractual obligation and one you are not able to bill the patient for until the necessary information to adjudicate the claim has been received and reviewed. Palmetto GBA has a list of CPT® or HCPCs codes that require additional documentation to be submitted with the claim.

Claim rejections (no appeal rights listed on the remittance advice) must be refiled as new claims with the necessary documentation. If you sent documentation with your claim, review that documentation and make sure it's for the correct patient and date of service, and is complete. If the claim is a denial (appeal rights are listed on the remittance advice for the claim), you may submit a first level of appeal with the necessary documentation.

Palmetto GBA may issue an additional documentation request (ADR) as part of the review process. These letters are sent to the written correspondence address on file for the provider. Providers may also request ADR letters through the Palmetto GBA eService portal. This can be especially helpful in large practices/facilities to ensure the letters reach your appropriate internal department to fulfill the record request within the noted time frame.

Resources

Last Reviewed: 07/23/2026

Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter. For example, an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

Providers must provide enough detail to alert Palmetto GBA during the claim processing that each service represented two separate encounters meeting the above criteria. Two separate diagnosis codes listed on the claims is not sufficient to meet the criteria above. If your claim has been denied for two E/M visits on the same day, you may request an appeal and provide documentation to support the Medicare coverage for two E/M visits on the same day (listed above) has been met.

Resource: CMS Internet-only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7B (PDF).

Last Reviewed: 07/23/2026

Determining if a claim is workers' compensation, liability or no-fault related is driven by the diagnosis codes submitted on a claim. If the submitted diagnosis is the same or similar to what is on file for the workers' compensation, the claim will deny.

Providers that believe their denial is incorrect are encouraged to review the diagnosis codes submitted on their denied claim for accuracy and make any corrections and resubmit the claim. Providers may also resubmit or appeal the claim with an explanation of benefits from the primary (workers' compensation, no-fault, or liability) insurer that indicates the services are not covered under their plan.

Last Reviewed: 07/23/2026


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