Top 10 Phone Inquiries FAQs

Top 10 Phone Inquiries (Excluding Claim Status and Eligibility Issues):
Second Quarter FY 2012

Description Occurrences
Claim Denials - Coding Errors/ Modifiers 4,250
Payment Explanation/Calculation 2,178
Claim Denials - Claim Overlap 1,974
Claim Denials - CWF Rejects 1,846
Claim Denials - Duplicate 1,747
Claim Denials - MSP 1,647
Claim Denials - Contractual Obligations Not Met 1,581
Claim Denials - Frequency/Dollar Amount Limitation 1,513
Claim Denials 1,476
Offsets 1,378

WPS Medicare publishes the following FAQ based upon topics we identify as generating a high volume of telephone inquiries to Customer Service. We hope the answers to the questions below assist you in reducing your need to call our telephone centers and help you eliminate claim errors associated with these topics.

  1. How do I notify Medicare of an overpayment?

    Providers who identify a Medicare overpayment should complete the appropriate Overpayment Notification Form (depending on whether the overpayment is due to MSP or not). Once we receive the form, we will set up the overpayment and send a request for the refund. Providers who prefer to send their refund along with their notification of the overpayment should complete the appropriate Voluntary Refund Form (MSP or Non-MSP) and mail it to us with their refund check.

    These forms and the corresponding instructions are located in the Financial section of our Forms web page.

    Please note that our Customer Service Representative can no longer set up an overpayment over the telephone. Providers must use the forms on our website to notify WPS Medicare of an overpayment.

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  2. If a patient's primary insurance pays a claim in full, are we still required to file a secondary claim with Medicare?

    Yes. If a provider has the necessary information to submit an MSP claim, Medicare's Mandatory Claim Submission guidelines require the provider to submit a claim even if the charge is paid in full by the primary insurer. This allows Medicare to properly credit the beneficiary's Medicare deductible. In certain situations, it may also protect the provider in case a retroactive change causes the primary insurer to recoup their payment.

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  3. Do I need to receive a timely filing denial on a claim before I can request a waiver of timely filing from Medicare?

    No. Providers may submit their requests for a timely filing waiver to our Claims Manager without first receiving a timely filing denial. Providers who have good cause for filing an untimely claim should follow the process for requesting a timely filing waiver without submitting a claim that will be automatically denied.

    Medicare contactors will deny any claim submitted one year after the date of service or after. (This means for a service provided on January 1, 2011, Medicare will deny any claim submitted on January 1, 2012, or after.) Claims denied for timely filing do not have appeal rights. Redeterminations requested on untimely claims will not be processed.

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  4. Is there a list of valid CPT/HCPCS code and modifier combinations?

    We have not published a list of valid procedure code and modifier combinations. However, we do have a portion of our website dedicated to modifier information that you may find helpful.

    A few of the more common errors we see include:

    • Modifier 76 is invalid for use with surgical codes
    • Modifiers 24 and 25 are ONLY valid for evaluation and management (E/M) services
         (not valid on surgical codes)
    • Modifiers 78 and 79 are ONLY valid for surgical procedures (not valid on E/M codes)
    • Modifier 91 is only valid for clinical laboratory services

    Invalid modifier usage will result in an unprocessable claim rejection, which does not have appeal rights.

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  5. We have a Medicare patient who insists Medicare is her primary insurance, but Medicare denies her claims indicating that Medicare is not the primary payer. How I can resolve this matter?

    The MSP information we have on file for a patient generates from the Coordination of Benefits Contractor (COBC). As a contractor, we do not have the ability to add and/or delete primary payer information. If our files are incorrect and/or require updating, the patient needs to contact the COBC at 1-800-999-1118 for assistance.

    Additional information on the COBC is available on the CMS websiteExternal Link.

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  6. My remit shows an offset. How can I find more information about the withholding?

    If you are a C-SNAP user, you may use the Duplicate Remittance Advice option to find information about most offsets. On your remit, locate the FCN number at the bottom of the page next to the PLB Reason Code "WO." If it is a 15 digit number, you many use C-SNAP to find the original claim by dropping the first two digits of the number and any letters at the end. The remaining 13 digit number is the ICN of the offset claim. Use the ICN to locate the original remit, and then search for the ICN using the search function. This will provide you the claim information for the offset.

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Page Last Updated: Friday, 27-Apr-2012 08:01:36 CDT