Denials Chapter 6 Appeals Flashcards
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Appeals:
An appeal is a formal request from a physician or employee of a healthcare provider or facility for a third-party payer or insurance carrier to reconsider a decision about a denied claim. An appeal is filed when the provider disagrees with the determination made by the insurance carrier to deny a claim.
Before submitting an appeal make sure all of the documentation needed to perform the appeal is gathered. The following documents are needed to successfully appeal a denied claim:
Copy of the remittance advice for the denied claim
Copy of the medical record (supporting documentation)
Copy of the original claim
Letter (or form specified by the insurance carrier) detailing why the claim should be paid
Every insurance carrier has an appeals process and some carriers will identify when a claim should be sent as a corrected claim or appealed. Some insurance carriers may have a specific form to complete when appealing claims. Most insurers have multiple levels of appeals
Use These Tips When Appealing a Denial
1.Review Remark Codes
It’s easy to miscommunicate if you’re speaking a different language. Make sure you understand exactly what a payer requires — and then format your appeal letter and claim accordingly.
The EOB or explanation of Medicare benefits (EOMB) will be your compass rose in navigating the error codes or denial codes that you need to understand and utilize in order to get your claim and appeal processed successfully. The error or denial codes are often at the bottom of the EOB or EOMB, she advises.
2.Check Bundling Issues
Many claims are denied because of incorrect coding — due to bundling. This could be another example of accidentally not speaking the same “language” as the payer, and it’s easy enough to correct.
Review your bundling edits to determine if it is bundled and if a modifier is allowed. If a modifier is allowed, check the documentation to see if the modifier is reported correctly.
3.Utilize Regulations, Correct Citations for Context and Support
While making sure that your appeal is legitimate, your responsibility includes due diligence on research. Citing proof that you’re playing within the rules protects you and boosts your appeal, but it also means holding up your contractual obligations.
If you can’t find regulations to support your case with the carrier that denied the claim, check with other payers to see if there is a trend you can cite. Don’t forget that your code books can be used as sources too.
4.Bring in the Patient
One may forget that the patient is central to the whole claim/denial/appeal process. If you stay on top of your denials and appeals, you have more time to involve the patient, if necessary, which could mean a better outcome for both the patient and your practice.
5.Know Your Contractual Rights
Figure out who is reviewing the claim and issuing the denial. If the reviewer’s credentials don’t necessarily suggest a knowledge base or background that are qualifying to understand the procedure or encounter in question, you have an avenue forward.
Many denial letters are signed by nurse case managers, but nurses may not always have the expertise to really understand the minutiae and nuance of the encounter described in your claim. In cases like these, you may need to get a physician involved.
In every payer contract it generally states: A physician in the same specialty with the same credentials reviews the appeal. If your physician can make a case for medical necessity, demand a peer review and use the extra time to make sure your physician documented everything comprehensively and properly.
6.Be Timely in Your Appeals
While the timeline ceiling for getting appeals in may seem expansive, you’re doing your patients and practice a disservice - and creating more headaches for yourself - if you let the denials languish on your desk.
Starting early gives you the time you need to pursue all avenues of research and preparation. This may involve researching regulations - including provisions of the Affordable Care Act, for example - as well as speaking to the patient, pulling reports, scrutinizing documentation, and fully understanding what you’re looking at.
7.Send to the Correct Department
If you’re sending your appeal requests to the same place you’re sending initial claims, yet not hearing back, your requests may be getting lost in the system. Luckily, there’s an incredibly simple fix: double-check the address for the particular department you’re trying to reach.
Make sure you send your appeal to the right department. If you send it to the post office box that you submit claims to it can get lost or misdirected and your claim will not be resolved. There is a different department that handles claim appeals. If you are not aware of the correct address check with the insurance company and when you comment on the patient account that the appeal was sent note the address it was sent to as well as date, method sent (i.e., mail, FedEx®, UPS®, etc.).
Medicare Appeals Process
Healthcare professionals who are participating providers can appeal Medicare (Parts A and B) denials. Under original Medicare there are five levels of the claims appeal process. All requests for appeals must be in writing.
Level 1 - Redetermination
The first level of appeal after initial determination on a claim is the redetermination. A redetermination is an examination of the claim by the MAC personnel. The personnel who review the redetermination is different from the personnel who made the initial claim determination.
A redetermination request must be filed within 120 days from the date of receipt of the remittance advice, which lists the initial determination. There is not a minimum monetary threshold required to request a redetermination.
The request for redetermination must be a written request or be filed on Form CMS-20027. The instructions are provided on the remittance advice and the form can be found on the CMS website at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS020385. In the search box type Form CMS 20027. Your MAC may have specific redetermination requirements as well, so it is important to check with them on how they request you submit your redetermination in.
The following elements listed below are required for the redetermination:
Beneficiary’s name
Medicare Health Insurance Claim (HIC) number or Medicare Beneficiary’s Identifier (MBI)
Specific service(s) and/or item(s) for which a redetermination is being requested
Specific date(s) of service
Name and signature of the party or the authorized or appointed representative of the party
In addition to the above information on the written request, the supporting documentation should also be attached to the request. Generally, the decision on the issue will be sent within 60 days of receipt of the redetermination request. You will receive notice of the decision via a Medicare Redetermination Notice (MRN) from your MAC, or if the initial decision is reversed and the claim is paid in full, you will receive a revised RA.
Level 2 - Reconsideration
If dissatisfied with the redetermination decision, a reconsideration by a Qualified Independent Contractor (QIC) can be requested.
The request for reconsideration must be filed with a QIC within 180 days of receipt of the redetermination. This request must be submitted on the standard CMS-20033, which is sent with the Medicare Redetermination Notice (MRN) or with a written request including the following information:
Beneficiary’s name
Beneficiary’s Medicare health insurance claim (HIC) number or Medicare Beneficiary’s Identifier (MBI)
Specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service
Name and signature of the party or representative of the party
Name of the contractor that made the redetermination
The request should clearly explain why the disagreement with the redetermination and include any and all documentation that supports the service. A copy of the MRN also needs to be included. Check with your local MAC to see if this can be submitted online. Generally, the decision will be sent within 60 days of receipt of the reconsideration.
Level 3 - Administrative Law Judge
If the reconsideration is not fully favorable, the next step is to request a hearing with the Administrative Law Judge (ALJ) within 60 days of receipt of the reconsideration decision. To request a hearing the amount remaining in controversy must meet the threshold requirement.
The reconsideration letter includes the details regarding the procedure for requesting an ALJ hearing. The Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal – OMHA-100 (Office of Medicare Hearings and Appeals) form may be used to file a request.
If the form is not used, the request must contain all of this information:
The name, address, and Medicare number of the beneficiary whose claim is being appealed, and the beneficiary’s telephone number if the beneficiary is the appealing party and not represented
The name, address, and telephone number, of the appellant, when the appellant is not the beneficiary
The name, address, and telephone number, of the authorized or appointed representative, if any
The Medicare appeal number or document control number, if any, assigned to the QIC reconsideration or dismissal notice being appealed
The dates of service of the claim(s) being appealed
The reasons the appellant disagrees with the QIC’s reconsideration or other determination being appealed
The ALJ hearings are generally held by video-teleconference or by telephone; however, you may ask for an in-person hearing. The ALJ decision will generally be issued within 90 days of receipt of the hearing request.
Level 4 - Appeals Council
When dissatisfied with the ALJ’s decision, a request for review by the Medicare Appeals Council is the next level. There are no requirements regarding the amount of money in controversy. The request must be submitted in writing within 60 days of receipt of the ALJs decision and must specify the issues and findings that are being contested. The Appeal Form DAB-101 should be submitted. Generally, the decision will be issued within 90 days of receipt of a request for review.
A written request may be sent in place of the form that must include the:
Beneficiary’s name
Beneficiary’s Medicare number
Specific service(s) or item(s) for which the review is requested
Specific date(s) of service
Date of the ALJ’s decision or dismissal order
Name of the party or the representative of the party
A party may also file electronically on the Council’s website at https://dab.efile.hhs.gov/mod/. Generally, the decision will be issued within 90 days of receipt of a request for review.
Level 5 - Judicial Review
The final level of appeal for Medicare is to request a judicial review in federal district court. The threshold for review in federal district court is calculated each year. A request must be made within 60 days of receipt of the Medicare Appeals Council’s decision.
Question: What regulations should I turn to for appeals?
Answer: The Affordable Care Act (ACA) has some advantages for appeals. The ACA spells out specific appeals rights for providers, and payers are seeing more appeals that cite compliance with the statute. At 45 CFR § 147.136, the ACA statute describes provider rights to external review during an appeal. This section outlines the process for bringing in a neutral independent review organization (IRO) to resolve the issue. (Note that because an IRO’s decision is binding, you can’t appeal the claim after that.)
In addition to the ACA, your state may have external review regulations that further support your provider’s right to appeal.
Throughout the letter, use phrasing that signals to knowledgeable reviewers that you’re aware of the ACA’s requirements. Such phrases can work to grab a reviewer’s attention, escalate the appeal to a higher level, or invite the payer to join you in a logical dialogue about nuts-and-bolts policies.
(Resource: To read the part of the ACA that spells out providers’ appeals rights, go to: https://www.healthcare.gov/glossary/affordable-care-act/).
