General
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 date does 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 by completing the following action. 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 am–7 pm EST.
- Phone: 1-866-484-8049 (TTY 1-866-523-4759)
- Email: EUSSupport@cgi.com
- PECOS FAQs: PECOS.com.HHS.gov
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 the Centers for Medicare & Medicaid Services (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:
- 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.
- 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.
- 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 knowledgable about accurate billing and compliance?
Answer: Review the following resources:
Last Reviewed: 10/29/2025
1. Question: Is a copy of the Additional Documentation Request (ADR) letter required with the provider’s ADR response?
Answer: Submitting a copy of the ADR is listed on the ADR document issued to the providers as information to submit. If the provider does not have a copy of the ADR, they can place a cover sheet with the claim number, as well as the date of service (DOS) with Part A Medical Review (MR).
2. Question: Can a provider submit a response for a past-due ADR?
Answer: The Centers for Medicare & Medicaid Services (CMS) contractors may accept late documentation if the provider can demonstrate good cause (natural disaster, business interruptions, extenuating circumstances, etc.). Providers typically have a maximum 120 days to submit their ADR response to MR from the denial date for records not received timely. Submit the late response to the department that initially requested the documentation, not to the Appeals Department. However, this is not the recommended approach, as providers should typically respond to ADR requests within 45 days.
3. Question: Should the providers complete the provider contact box for each ADR response?
Answer: Yes, the provider should provide their point of contact information with each ADR response. This is stated on the ADR letter sent to the provider. The MR team uses the updated contact information to reach out to the contact person listed on the form. This will occur during the review process if documentation is incomplete or clarification is needed. However, if the contact information needs to be changed/updated, please call the PCC to have the information reviewed and send it to MR for updates. It is a best practice to provide first and second choices, should the initial contact be out of the office when MR attempts to reach you.
4. Question: Can the provider be given the assigned medical reviewers’ information?
Answer: Claims are randomly assigned to our medical reviewers. While we have dedicated reviewers for each line of business, we cannot inform providers in advance who will review their claim. If documentation is incomplete or clarification is needed, the assigned reviewer will contact the point of contact person on file to resolve the issue.
5. Question: Who do I contact after receiving the Targeted Probe and Educate (TPE) Final Results?
Answer: The Senior Provider Education Consultant for Medicare Part A will contact you within two weeks of receiving your TPE Final Results Letter. If you are moving on to a subsequent round, you’ll have 45–56 days before it begins, starting from the date of your education session. The Senior Provider Education Consultant will make a maximum of three attempts to contact the designated individual(s) for your office. If these attempts are unsuccessful, it will be your responsibility to initiate contact with the Senior Provider Education Consultant regarding your Medicare Part A education session. If this occurs, you will move on to a subsequent round and the 45–56-day period will begin on the date of the third missed attempt.
6. Question: When will the provider need to submit their appeal once their claims have been denied due to the TPE audit?
Answer: Providers may submit an appeal once they receive the official Claim Determination. Appeals must be submitted in writing within 120 days from the date on the Claim Determination. Providers should not wait until they receive the results letter, as it may be past the 120-day timeframe.
7. Question: Do incarceration periods include halfway houses?
Answer: Starting January 1, 2025, patients in custody no longer include patients who are:
- Released to the community pending trial (including those released on bail)
- On parole
- On probation
- On home detention
- Required to live in a halfway house or other community-based transitional facility
8. Question: My claims have been denied due to no records received; however, medical records were sent 30 days prior to the due date.
Answer: The provider will need to contact the PCC to have the medical records escalated to MR for review and possible reopening.
9. Question: Why are we getting non-response communications for ADRs with due dates 90 days from the letter date? I understand that the standard is 45 days, but the letter gives a due date 90 days from the ADR letter date.
Answer: Due to recent hurricanes and natural disasters, ADR letters had a due date of 90 days.
10. Question: Do we need to send the medical records with each level of appeal, or does the previous level send those records to the next level for us?
Answer: Yes, make sure you include the records with each level.
11. Question: Are the Reconsideration results added to eServices as well for us to download?
Answer: Yes, if a Reconsideration has been submitted, the status will be provided in eServices.
12. Question: Does an appeal have to be signed by the ordering physician, or can any physician sign the appeal?
Answer: It does not need to be signed by the ordering physician.
13. Question: Can you tell us again where to find the appeal details on the claim?
Answer: The remarks section of the claim.
14. Question: If the provider cannot provide the required documentation when CERT audits a Medicare Part A claim, when does recoupment for any overpayment begin?
Answer: Appealing an Overpayment Subject to Limitation on Recoupment. If you do not request redetermination or make payment in full by the 39th day:
- A withholding is initiated on the Remittance Advice (RA) dated the 40th day from the initial demand letter interest accrues on the money owed from the date of the initial demand letter.
- The withholding amount will appear in the 935-withholding section of the RA
Last Reviewed: 09/10/2025