According to a recent article published on www.palmettogba.com, Palmetto GBA will perform service-specific prepay complex review on claims billed for selected Home Health HIPPS codes.  Palmetto GBA will be setting service-specific complex targeted medical review edits for the two HIPPS codes with the highest claim count denial rate.

Palmetto GBA is the Medicare Intermediary for Jurisdiction 11, which includes the following states: Illinois, Indiana, Ohio, Kentucky, North Carolina, South Carolina, Tennessee, Arkansas, Louisiana, New Mexico, Oklahoma, Texas, Alabama, Georgia, Florida, and Mississippi.  These states will be affected by this billing probe.

The Medical Review department identified the top 20 Home Health HIPPS codes, ranked by provider disbursement. Information was contained within the reports regarding the number of claims medically reviewed, and the number of claims that contained a medical review denial. Further analysis determined a claim count denial rate for each of these HIPPS codes.

Palmetto GBA will be setting service-specific complex targeted medical review edits for the two HIPPS codes with the highest claim count denial rate. These edits will be set for four regions within the J11 Home Health and Hospice jurisdiction.

Because this probe is a “service-specific prepay complex review on claims billed for selected Home Health HIPPS codes”[1], agencies will see delayed payment for these selected bills. The problem, however, is that Palmetto has not disclosed which two HIPPS codes have been selected for audit.

Agencies affected by this audit probe will be notified that they have an Additional Documentation Request (ADR). The agency will have 30 days to submit this requested documentation to Palmetto. Once Palmetto receives the ADR, they have 30 days to review submitted documentation. Once this review is completed by the intermediary Palmetto will pay in part, pay in full, or deny payment of the episode claim. If the agency does not agree with the decision made, they may appeal or request a ”redetermination” within 120 days from the date of the remittance advice. Individuals with excessive denials may be contacted for further education by Palmetto.

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

Palmetto GBA
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238

Or fax to (803) 699-2436.

Agencies may check DDE for pending ADRs as well. To do so, log into your DDE account, then go to the inquiry screen (01), then (12) for claims summary, then put in claim location SB6000 to review claims awaiting the creation of an ADR. Claims with status SB6001 are those claims which have been selected and awaiting a provider response to an ADR letter.  By checking DDE, you may have additional days to collect, copy, review and ready your claim for submittal because you can see ADR status in DDE before you receive the actual mailed ADR letter from Palmetto.

For additional information, you may contact Palmetto GBA at 866-830-3925.