2021 Part B MACtoberfest Questions and Answers: Learn about the Railroad Medicare Program with a Spotlight on Medical Review Webinar

Published 11/15/2021

The following questions were received during our October 19, 2021, MACtoberfest® webinar.

Question 1: Do we have to be in-network with Railroad Medicare?

Answer: There is no "network" for Railroad Medicare. Part B Medicare providers are eligible to provide care to Railroad Medicare patients. But you will need to request and receive a Railroad Medicare Provider Transaction Access Number (PTAN) before we can process your claims.

As long as you are a Medicare Part B provider at the time you render service and we receive your claim within 12 months from the date of service, your claim can be covered because the effective date of your Railroad Medicare PTAN will be retroactive to the effective date of your Medicare PTAN.

Question 2: What is the number of claims filed that would meet an exception to mandatory electronic billing? 

Answer: An exception to mandatory electronic billing is providers that submit fewer than 10 claims per month to all MACs on average during a calendar year. This includes the combination of claims submitted to all MACs, not just claims submitted to Railroad Medicare.

We know that there are some providers who have very few Railroad Medicare claims to submit but this exception is not based only on the amount of claims that you submit to Palmetto GBA Railroad Medicare.

Question 3: If we already bill claims electronically to Palmetto GBA Jurisdiction J or M, do we have to enroll separately to bill electronic claims to Railroad Medicare?

Answer: Yes. You would need to complete a separate EDI enrollment for Palmetto GBA Railroad Medicare to bill Railroad Medicare claims.

Question 4: Can claims for Railroad Medicare patients be submitted directly to Medicare? 

Answer: Part B claims for Railroad Medicare patients should be submitted to Palmetto GBA Railroad Medicare, not to your local Part B Medicare Administrative Contractor (MAC).  

Other types of claims for Railroad Medicare patients should be submitted to the same jurisdictional MACs that you file your Medicare claims to. 

  • Part A Claims — The jurisdictional A/B Medicare Administrative Contractors (A/B MACs) process hospital facility claims and skilled nursing facility claims for both Medicare and Railroad Medicare beneficiaries
  • Home Health and Hospice Claims — The four A/B MACs that process jurisdictional home health and hospice (HHH) claims process those claims for both Medicare and Railroad Medicare beneficiaries
  • Durable medical equipment (DMEPOS) Claims — The jurisdictional DME Medicare Administrative Contractors (DME MACs) process claims for designated DMEPOS items for both Medicare and Railroad Medicare beneficiaries. The CMS annual DMEPOS Jurisdiction List on the CMS Durable Medical Equipment (DME) Center webpage designates the MAC jurisdiction for DMEPOS HCPCS codes.  

You can use the CMS MAC Website List to find your local A/B MAC, HHH MAC, or DME MAC.

Question 5: How can I verify if my provider information is current and current? 

Answer: You can call the Railroad Medicare Provider Contact Center at 888–355–9165. To speak with a Provider Enrollment representative, press 3.  

Railroad Medicare representatives are available to handle provider inquiries Monday through Friday, from 8:30 a.m. to 4:30 p.m. for all time zones with the exception of Pacific Time (PT) which receives service from 8 a.m. to 4 p.m. PT. The PCC will be unavailable during weekly training and holidays.

Question 6: How can we find out what codes we are under pre-payment review, post-payment review, and Targeted Probe and Educate (TPE) review for?

Answer: We are posting articles that will list the codes under Active Review on our website.

Correction: Providers will receive Notification letters that will inform them of their involvement in our complex TPE reviews, and additional documentation request (ADR) letters will be sent to inform them of their involvement in traditional prepayment and traditional postpayment reviews. 

You can refer to our notification article titled, “Active Medical Reviews: October 2021 Through September 2022,” for a list of codes that Railroad Medicare will be reviewing within this timeframe. In this resource, the codes are listed by review type. They are also identified by their service type and their code description. 

Resource: Palmetto GBA Active Medical Reviews: October 2021 Through September 2022 notification article.

Question 7: Our office collects specimens for COVID-19 tests prior to the specimen samples being sent to the lab. We do not purchase the COVID-19 tests. The tests are supplied by the lab. What procedure code should we use for the collection of COVID-19 specimens?

Answer: Physician offices can use CPT code 99211 when office clinical staff furnish assessment of symptoms and specimen collection incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher level visit code should be billed and the specimen collection would not be separately payable. 

Resource: COVID-19 Frequently Asked Questions (FAQ) (PDF, 1.35 MB) on Medicare Fee-for-Service (FFS) Billing.

Question 8: What is the course ID for this event? 

Answer: The course ID for today’s event is RRB3372139.