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Erroneous Payments for BLS Non-Emergencies (A0428) with “GW” Modifier

December 11, 2013
AAA Member Advisory
TO: AAA Membership
FROM:      David M. Werfel, Esq.,  AAA Medicare Consultant
RE: ProposalErroneous Payments for BLS Non-Emergencies (A0428) with “GW” Modifier

In prior Member Advisories, we have notified you of the problem involving Part B claims being incorrectly reduced 10% when the “GW” modifier was used, with origin/destination modifiers other than for dialysis. This Member Advisory is intended to give you the latest and, hopefully, final update on this issue. All Medicare Administrative Contractors have now indicated they have fixed the problem for on-going claims. All MACs (except CGS) will issue mass adjustments by the end of December. CMS has provided the following schedule for each MAC:

MAC

Date Resolved

ETA for Adjustments

 First Coast

11/07/13

11/7/13

 Palmetto

11/14/13

12/13/13

 NGS

11/19/13

12/19/13

 Noridian

11/19/13

12/31/13

 CGS

11/14/13

SEE BELOW

 Cahaba

11/20/13

12/13/13

 Novitas

11/18/13

12/31/13

 WPS

11/14/13

11/20/13

CGS is not doing a mass adjustment due to the low volume of claims affected. A formal appeal is not needed. However, those with CGS as their MAC will have to contact CGS, list the claim numbers in issue and ask that they re-open and reprocess the affected claims.

Also, the fact that your MAC is listed above as having already reprocessed the adjustments, does not mean that you received the payment on that date, as the law requires MACs hold payments for approximately two weeks.

Finally, claims submitted to a MAC by a Part A provider were not affected by this issue, as Part A providers use a specific "Condition Code" in place of the "GW" modifier.

Guaranteed cash flow during transition.