Understand Florida Medicare IVR operation

Additional IVR instructions are available via our IVR Florida Medicare Part B


Part B interactive voice response (IVR) operating guide 1-877-847-4992

First Coast Service Options Inc. (FCSO) strives to provide you with the most up-to-date automation features as possible. The IVR operating guide will help to increase your knowledge of the technology and services we offer our providers.

Hours of operation

IVR unit hours of availability

The IVR is available 24 hours a day, 7 days a week except for regularly scheduled maintenance. However, specific claim and/or eligibility information is available during the following times with the exception of holidays:

Monday-Friday 7:00 a.m. to 6:30 p.m., ET
Saturday 7:00 a.m. to 3:00 p.m., ET

Touchtone or speech

Providers in Florida have the option of selecting speech or touchtone when using the IVR. Touchtone is available to providers in the U.S. Virgin Islands and Puerto Rico. In order to receive the maximum results that you deserve when speaking, we offer the following tips:

• Use a telephone with a handset or headset

• Avoid using a speakerphone or cell phone

• Avoid calling from areas with loud background noise

• Speak the requested information clearly and in a quiet environment

*When using the speech recognition option on the IVR and keying the date is required (date of service, date of birth, etc.), the date must be given in an 8-digit format (mm/dd/yyyy).

In the event the system does not accept the spoken information, touch-tone is always available. In order to receive the maximum results that you deserve when using touch-tone, we offer the following tips:

• Dates should be entered in the following format (mm/dd/yy)

• To signal you are entering an alpha suffix or letter, press the * key

• Press the key that includes the letter, then the corresponding number that denotes where the letter is located on the number key.

• After all letters desired have been keyed, press the pound (#) sign to end your entry.

Use the numbers on the telephone keypad that corresponds to the patient or provider number:

A = *21#

Q =*72#

R = *73#

Z = *94#

Helpful tips

As a result of the Health Insurance Portability and Accountability Act (HIPAA), we are required to protect the privacy of all individuals. You must have the following information available for authentication to access patient eligibility, deductible and claims information via the IVR:

• National Provider Identifier (NPI)

• Tax Identification Number (TIN)

• Provider Transaction Access Number (PTAN)

• Beneficiary Medicare number

• Beneficiary name,

• Beneficiary date of birth

• Date of service (If applicable)

Main menu -- number/option

1. Closures. hot topics, outreach events, general questions and hours of operation

2. Status and reopenings

3. Eligibility

4. Pending claims

5. Check status

6. Remittance codes/pricing

7. Enrollment information

Closures and general information - press 1

• Training and holiday closures, press 1

• Hot topics, press 2

• Provider outreach and education information, press 3

• General appeals, website and information to have when calling Medicare, press 4

• Hours of operation, press 5

Claim and correspondence status and telephone reopenings - press 2

• For claim status, press 1

Assigned claim status

Pending, finalized, denied

Date of service

Amount submitted

Processed date

Deductible

Payment amount

Payment date

Check number

Internal Control Number (ICN)

Supplemental insurance (Forwarded or not)

Non - assigned claims

Processed date

Amount submitted

Payment date

• Additional claim detail

*This menu is offered after the information above has been voiced.

• Procedure code

• Date of service

• Billed amount and allowed amount for each procedure code

• Denial message

• For correspondence status, press 2

• IVR will voice date correspondence was completed and the Correspondence Control Number (CCN)

• To request a telephone reopening of a claim, press 3

This option provides callers with the ability to request a telephone reopening on a single detail line of a claim with the exception of hospice and entitlement related services.

Changes to date of service, press 1

To add, delete, or change a modifier, press 2

To change a diagnosis, press 3

Note: This option is only for the primary diagnosis for a procedure.

To have MSP, entitlement and Medicare Advantage claim denials reprocessed, press 4

Eligibility, Medicare Secondary Payer, Medicare Advantage, deductible and physical and occupational therapy information - press 3

• For current eligibility information, press 1

• Entitlement date

• Termination date (if applicable)

• Part B deductible

• Current Year deductible

• Previous Year deductible

• Medicare Advantage information

• Medicare is primary or secondary

If a Medicare Advantage plan is found, you can press 1 for more information.

• Medicare Advantage number

• Plan type

• Plan name

• Effective and termination date of policy

• Address of Medicare Advantage servicing provider

If Medicare is secondary, press 1 for MSP details

• Type of primary insurance

• Effective and termination date for all valid Insurers

• (Current or previous date of service)

• For eligibility for a previous date of service, press 2

• For physical and occupational therapy information, press 3

• For Medicare Advantage Plan information, press 4

• enters a specific Medicare Advantage plan number to receive specific information such as:

• Plan name

• Type of plan

• Address of plan provider

*Note - The Medicare Advantage plan number was formerly known as HMO Plan number.

Note: After primary eligibility information is obtained, the IVR will prompt the caller to press an option for additional eligibility.

Sub menu for additional eligibility menu

• Hospice

• Hospice effective date

• Termination date (if applicable)

• Servicing provider number

• Home health

• Home health effective date

• Termination date (if applicable)

• Servicing provider number

• Skilled nursing facility

• SNF effective date

• Termination date (if Applicable)

• Servicing provider number

Pending claims information and month-to-date or year-to-date dollar amount on file - press 4

• For pending claim information, press 1

• For month or year-to-date dollar amount, press 2

• For the previous year paid amount, press 3

Check information - press 5

• For the last three checks, press 1

• For check history by issue date, press 2

• For check history by check number, press 3

Definitions of remittance codes and pricing for procedure codes - press 6

• For remittance code information, press 1

• For pricing of a procedure code, press 2

Enrollment information - press 7

• For status of an enrollment application, press 1

• For a summary of applications and when to use them, press 2

• For a summary of documents required for certain specialties, press 3

• For mailing address and PECOS Internet enrollment information, press 4

• For open enrollment and participation in Medicare information, press 5

• For a summary of enrollment information available on our website, press 6

Repeat menu - press 8

This option returns callers to the main menu.

End call - press 9

This option ends the call in the IVR.

PAYMENT FOR CPT 96101, 96118

Payment and Billing Guidelines for Psychological and Neuropsychological Tests


The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Accordingly, CPT psychological test code 96101 should not be paid when billed for the same tests or services performed under psychological test codes 96102 or 96103. CPT neuropsychological test code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120.



Under the physician fee schedule, there is no payment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by CPT codes 96102 and 96119 when performed by a student or a trainee. However, the presence of a student or a trainee while the test is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119.

Who May Bill for Diagnostic Psychological and Neuropsychological Tests

• CPs – see qualifications under chapter 15, section 160 of the Benefits Policy Manual, Pub. 100-02.

• NPs –to the extent authorized under State scope of practice. See qualifications under chapter 15, section 200 of the Benefits Policy Manual, Pub. 100-02.

• CNSs –to the extent authorized under State scope of practice. See qualifications under chapter 15, section 210 of the Benefits Policy Manual, Pub. 100-02.

• PAs – to the extent authorized under State scope of practice. See qualifications under chapter 15, section 190 of the Benefits Policy Manual, Pub. 100-02.

• Independently Practicing Psychologists (IPPs)

• PTs, OTs and SLPs – see qualifications under chapter 15, sections 220-230.6 of the Benefits Policy Manual, Pub. 100-02.



Psychological and neuropsychological tests performed by a psychologist (who is not a CP) practicing independently of an institution, agency, or physician’s office are covered when a physician orders such tests. An IPP is any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist. (It is CMS’ understanding that all States, the District of Columbia, and Puerto Rico license
psychologists, but that some trust territories do not. Examples of psychologists, other than CPs, whose psychological and neuropsychological tests are covered under the diagnostic tests provision include, but are not limited to, educational psychologists and counseling psychologists.)

The carrier must secure from the appropriate State agency a current listing of psychologists holding the required credentials to determine whether the tests of a particular IPP are covered under Part B in States that have statutory licensure or certification. In States or territories that lack statutory licensing or certification, the
carrier checks individual qualifications before provider numbers are issued. Possible reference sources are the national directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board-certified, the records and directories of the State or territorial psychological association, and the National Register of Health
Service Providers. If qualification is dependent on a doctoral degree from a currently accredited program, the carrier verifies the date of accreditation of the school involved, since such accreditation is not retroactive. If the listed reference sources do not provide enough information (e.g., the psychologist is not a member of one of these sources), the carrier contacts the psychologist personally for the required information. Generally,
carriers maintain a continuing list of psychologists whose qualifications have been verified.

NOTE: When diagnostic psychological tests are performed by a psychologist who is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the psychological tests.

The carrier considers psychologists as practicing independently when:

• They render services on their own responsibility, free of the administrative and professional control of an employer such as a physician, institution or agency; • The persons they treat are their own patients; and

• They have the right to bill directly, collect and retain the fee for their services. A psychologist practicing in an office located in an institution may be considered an independently practicing psychologist when both of the following conditions exist:
• The office is confined to a separately-identified part of the facility which is used olely as the psychologist’s office and cannot be construed as extending throughout the entire institution; and

• The psychologist conducts a private practice, i.e., services are rendered to patients from outside the institution as well as to institutional patients.

Time limit for Medicare appeals

Carrier appeals process for redeterminations and Over payment appeal address


The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.

For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.

The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.

There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.



The five levels of appeal are as follows:

1st Level - Redetermination

Time limit to file request: 120 days from date of receipt of the initial determination notice

Monetary threshold: None

Request is sent directly to the carrier



2nd Level - Reconsideration

Time limit to file request: 180 days from date of receipt of the redetermination

Monetary threshold: None

Request is sent directly to the QIC

3rd Level - Administrative Law Judge (ALJ) Hearing

Time limit to file request: 60 days from the date of receipt of the reconsideration

Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).


4th Level - Departmental Appeals Board (DAB) Review

Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision

Monetary threshold: None

5th Level - Federal Court Review

Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB

Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.


Overpayment appeals address

The address for overpayment appeals is as follows:

First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248

Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.

TOBACCO-USE CESSATION COUNSELING SERVICES

■ Intermediate (greater than 3 minutes and less than 10 minutes); or
■ Intensive (greater than 10 minutes).

Cessation counseling sessions may be performed “incident to” the services of a qualified practitioner. During the 12-month period, the practitioner and the beneficiary have flexibility to choose between intermediate or intensive counseling for each session.

DOCUMENTATION Medical record documentation must show, for each Medicare beneficiary for whom a smoking and tobacco-use cessation counseling or counseling to prevent tobacco use claim is made, standard information along with sufficient beneficiary history to adequately demonstrate

COVERAGE INFORMATION Medicare provides coverage of smoking and tobacco-use cessation counseling services for outpatient and hospitalized beneficiaries who meet the following criteria:
 ■ Who use tobacco and have been diagnosed with a recognized tobacco-related disease or who exhibit symptoms consistent with tobacco-related disease; or
 ■ Who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease);


Additional coverage criteria:
■ Beneficiaries must be competent and alert at the time that counseling services are provided; and
■ Counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive counseling sessions. The total annual benefit covers up to eight smoking and tobacco-use cessation counseling sessions in a 12-month period.

The beneficiary may receive another eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare-covered cessation counseling session was performed. Example: The beneficiary received the first of eight covered sessions in January 2011. The count starts beginning February 2011. The beneficiary is eligible to receive a second series of eight sessions in January 2012.

Medicare’s prescription drug benefit also covers smoking and tobacco-use cessation agents prescribed by a physician. Eligible beneficiaries are covered under Medicare Part B. Both the coinsurance and deductible are waived. NOTE: Medicare covers minimal cessation counseling (defined as 3 minutes or less in duration) as part of each Evaluation and Management visit, and it is not separately billable.

CESSATION COUNSELING ATTEMPT A cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. A cessation counseling attempt includes the following:

■ Up to four cessation counseling sessions (one attempt = up to four sessions)

■ Two cessation counseling attempts (or up to 8 cessation counseling sessions) are allowed every 12 months.


CESSATION COUNSELING SESSION A cessation counseling session refers to face-to-face patient contact at one of two levels.

2012 Anesthesia conversion factors for Florida

The revised conversion factors for use in calculating payment for anesthesia services (procedure codes 00100 through 01999) for service dates January 1 through February 29, 2012, are as follows:

Locality    Participating Physician       Nonparticipating Physician

03             23.41                               22.24

04             24.97                               23.72

99 (01 & 02)  22.35                         21.23

The conversion factors for non-medically directed certified registered nurse anesthetists (CRNAs) are identical to the participating physician anesthesia conversion factors for each payment locality.

The conversion factors for medically directed CRNAs (for both physician medical direction and medically directed CRNAs) are based on 50 percent of the sum of the anesthesia base units and time units, multiplied by the appropriate participating physician locality conversion factor (i.e., 50 percent of the sum of (base units + time units) x locality conversion factor = anesthesia allowance). The medical direction 50 percent payment policy applies if both a CRNA (or anesthesia assistant) and an anesthesiologist are involved with the same case.

Limiting charge for anesthesia

The limiting charge for unassigned anesthesia services is determined as follows:

Step 1: Determine the allowance for the anesthesia service.

Use this formula for physician personally performed services:
(base units + time units) x nonparticipating physician locality conversion factor.
Use this formula for the physician’s claim for physician medical direction services --
[.5 x (base units + time units)] x nonparticipating physician locality conversion factor.

Step 2: Multiply the result of the above calculation by 1.15 to determine limiting charge.

Note: Limiting charge does not apply to CRNA or anesthetist claims; assignment is mandatory on these claims.