Railroad Medicare – Top 10 Medical Review Denials


Practicefirst would like to share with you the latest news from Railroad Medicare. The goal of Palmetto GBA’s (Railroad Medicare) medical review program is to ensure that payment is only made for services that meet all Medicare coverage guidelines, coding and medical necessity requirements. The following are the 10 most common provider errors identified in the 4th fiscal quarter of 2018:

  • Alternative services were available and should have been utilized.

  • Documentation received lacks the necessary radiology report.

  • Claim billed in error per provider.

  • Documentation lacks the necessary provider order.

  • Documentation received lacks the necessary beneficiary or authorized representative signature.

  • Payer deems information submitted does not support medical necessity of services billed.

  • Information submitted is deemed illegible.

  • Information submitted contains an invalid/illegible provider signature.

  • Documentation requested for this date of service was not received or was incomplete.

  • No response received from provider related to Additional Documentation Request (ADR) letter.

For Billing questions, please contact Tammy Bartlett at 716-389-3223 or tammyb@pracfirst.com.

275 Northpointe Pkwy, Suite 50

Amherst, NY 14228

866.234.5017 (Toll-free)

info@pracfirst.com

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