How to Submit an Appeal: The Redetermination Level

Transcription

1 How to Submit an Appeal: The Redetermination Level FEBRUARY 17, 2016 Presented by: Part B Provider Outreach and Education John Florence Jurisdiction J A/B Medicare Administrative Contractor 1

2 Disclaimer This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. 2

3 Acronyms Acronym AOR ADR ALJ DAB ICN MRN NCCI NPI PHI PTAN Term Appointment of Representative Additional Documentation Request Administrative Law Judge Departmental Appeals Board Internal Control Number Medicare Redetermination Notice National Correct Coding Initiative National Provider Identifier Protected Health Information Provider Transaction Access Number 3

4 Agenda Levels of Appeals & Where to File Redeterminations Requirements for Submission via Letter How to send Appeal Request Completion of CMS Form Completion of Cahaba Redetermination SMART Form Brief discussion of what constitutes an invalid first level appeal Required information when submitting a first level appeal Identified first level appeal request errors Appeal resources 4

5 Who May File an Appeal Request Beneficiary Participating physician or supplier Nonparticipating physician or supplier Nonparticipating physician not accepting assignment A Medicaid state agency, or party authorized to act on behalf of the state Any individual whose rights with respect to the particular claim being reviewed may be affected by such review Requests for an appeal submitted by someone other than those listed will be dismissed unless Appointment of Representative (CMS-1696) is filed 5

6 Five Levels of Appeals: Where to File Level of Appeal Where to File Redetermination Reconsideration Administrative Law Judge (ALJ) Hearing Departmental Appeals Board Federal Court Medicare Administrative Contractor (Cahaba) Qualified Independent Contractor (C2C Innovative Solutions, Inc.) Office of Medicare Hearing and Appeals (OMHA) Medicare Appeals Council (MAC) Review Board as instructed on ALJ decision United States District Court 6

7 Level 1- Redetermination Independent re-examination of claim(s) Must be received within 120 Days from the Initial Claim Denial A written redetermination request on company letterhead with the required information CMS Form The Cahaba GBA Medicare Part B Redetermination SMART Form Submit supporting documentation Provide any additional information needed with the redetermination request that will support medical necessity for service(s) Allow 60 Days for review and completion The date request is received by Cahaba 7

8 Redetermination Request- Letterhead If neither form is used for a written redetermination request, the request must be submitted with all the following: Beneficiary s name Beneficiary s Health Insurance Claim Number (HICN) Date(s) of service at issue The specific services or items for which the redetermination is being requested Name and signature of the party or representative of the party Provider information such as Provider Transaction Access Number (PTAN), National Provider Identifier (NPI) and Tax Identification Number (TIN) 8

9 Appeals on Full or Partial Denials A full or partial denial may occur on the claim: Your remittance advice (RA) will let you know which procedure(s) are paid and which were denied, if applicable When submitting your appeal for denied service(s), you should let us know if you are appealing the entire claim or only specific lines on the claim by indicating the procedure code(s) you are appealing Only one appeal should be requested per Internal Control Number (ICN), regardless of multiple codes on the claim being appealed 9

10 Redetermination Outcomes Redetermination can have 5 possible outcomes: Full Reversal (favorable) Remittance Advice (RA) is notification Partial Reversal (partially favorable) Medicare Redetermination Notice (MRN) is notification Remittance Advice (RA) is other notification Full Affirmation (unfavorable) MRN is notification Dismissal Letter to appellant Affirmation-Claim Paid Claim has been paid already 10

11 Medicare Redetermination Notice The redetermination letter issued is the Medicare Redetermination Notice (MRN) The MRN will contain all the information necessary to request the next level of appeal The Appeals Department will send the QIC reconsideration request form with the redetermination letter *Received for an Affirmation or Partial Reversal* 11

12 Medicare Redetermination Notice (MRN) cont d The MRN contains the following: Summary of facts containing specific claim(s) information (e.g. Claim Number, DOS, TOS, Initial Determination Date) Explanation of decision Provides logic/rationale for the decision (for affirmations and partial reversals) No MRN is furnished for a decision of full reversal Requestor will need to refer to remittance advice (RA) for payment notification Who is responsible for bill (provider or beneficiary) Person responsible for non-covered service What to include in your request for independent appeal at the next level Proceeding to Reconsideration level 12

13 Where to Locate Appeals Forms 13

14 How to Submit CMS Form Section 1 & 2 Section 3 & 4 Beneficiary Information Claim Information Section 5 Section 5A Section 5B Date of Initial Determination Name of Contractor (optional) Is this an overpayment appeal Section 6 Reason for Request Section 7 Additional Information Section 8 Additional Documentation Section 9 Person Appealing Section 10 Provider Information Section 11 & 12 Signature and Date 14

15 CMS Form- (Top Portion) Place the Internal Control Number (ICN) Here 15

16 CMS Form- (Bottom Portion) Bradley General 16

17 How to Submit Redetermination SMART Form Section 1 Jurisdiction J State Information Section 2 Section 3 Beneficiary/ Claim Information Reason for Request Section 4 Section 5 Requestor Information Requestor s Signature Section 6 Provider Information 17

18 Cahaba Medicare B Redetermination SMART Form- (Top Portion) 18

19 Cahaba Medicare B Redetermination SMART Form- (Bottom Portion) 19

20 Appeals Mailing Address All paper redetermination request must be submitted to: Alabama Georgia Tennessee Part B Redeterminations PO Box 6169 Indianapolis, IN Part B Redeterminations PO Box 6169 Indianapolis, IN Part B Redeterminations PO Box 6169 Indianapolis, IN

21 Appeals Fax Number All Medicare B Redetermination (SMART form only) request must be faxed to: State Fax Number Alabama Georgia Tennessee 21

22 Redetermination Request Issues Handwritten Part B Redetermination SMART Forms Faxing Redetermination Request made on CMS Redetermination Request with invalid ICN Multiple SMART Forms faxed as one batch Coversheet on top of Redetermination SMART Form Placing 2 digits in each box of the SMART Form Too many digits for Item 6 of SMART Form Wrong Date Format (e.g. MM/DD/YY) Wrong Forms (e.g. Part A Redetermination SMART Form, CMS Reconsideration) 22

23 Resolving Appeal Request Form Errors Error Use of auto or organization fax coversheet Resolution Allow the Cahaba Part B Redetermination SMART Form Not completing the date of the initial determination Refer and Verify information from your remittance advice (RA) Incorrect number in the claim number field Refer and Verify the ICN number found on your remittance consists of a total of 13 numbers Wrong number in the provider number field Verify the provider number on your remittance Using the wrong form Visit the Cahaba website and locate the correct form under the Forms tab- Appeals Placing information in the overpayment field Do not place any marks or information in the overpayment field unless Yes is selected 23

24 Top Denial Reasons received in Appeals Medical Necessity Duplicate Bundling National Correct Coding Initiative (NCCI) Pre- and post-op visits are included in the global surgery package Evaluation and Management (E/M) Non-covered services Addition of Modifiers Time Limit Denials Services deny as routine Medically Unlikely Edits (MUEs) 24

25 Important E/M Appeal Tips On Part B appeal request Submit signed medical records (e.g., progress notes, history and physical notes, office notes, etc.) as evidence to show why more than one visit was submitted on the same date either by similar providers from different groups or different providers with different subspecialties from the same group Identify the subspecialty for the provider, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed 25

26 Medical Necessity Denial Appeals Local Coverage Determinations (LCDs) are created by Cahaba s Contractor Medical Director (CMD) and Medical Review staff in collaboration with clinicians/mds appointed to assist by medical associations and societies. They are intended to help providers by identifying indications that have been shown to be medically appropriate for the procedure for which they are created. LCDs also include frequency parameters and, in some cases, accompanying billing instructions. Claims submitted to Cahaba that fall outside of either the allowed diagnoses, CPT codes or frequency limitations identified in LCDs are denied for medical necessity Claims submitted with allowed diagnoses, CPT codes and/or are within published frequency limitations that are denied in error can be submitted for a Redetermination to be performed if it is deemed a valid request(s). 26

27 Duplicate Claims sent for Appeals Requests Data analysis has shown an increase in the number of Appeal request which are also being resubmitted as new claims Duplicate requests affects the Part B Appeals process at various levels Redetermination Reconsideration Administrative Law Judge This causes problems and delays in processing 27

28 Part B Redetermination Cycle Diagram Appeal Request is received and accessed by analyst Analyst will research the request and review any documentation attached Analyst will determine whether request meets the requirements to move forward as a valid request Analyst receives the Medical Review decision rendered and process final determination Analyst will request for a decision from a Medical Review Clinical Nurse Analyst will make decision whether or not to send to Medical Review Analyst sends decision letter (MRN) and/or complete adjustment if needed 28

29 Part B Medical Review Flowchart The Part B Claim hits Medical Review Edit An Additional Documentation Request (ADR) letter is sent to provider for additional records (if needed) Provider sends requested additional documentation to Cahaba and it is received in allotted timeframe The Part B Clinical Medical Review Nurse reviews claim for Medical Necessity Requirements The Part B Claim is reviewed and either denied, and/or paid

30 Difference between Denial and ADR Denial Reasons can be based on the claim(s) not meeting coverage criteria NCD Denials LCD Denials ICD-10 diagnosis Codes to CPT procedure code edits A coverage determination cannot be made based on the given information from claim Complex Medical Review ADR is when a decision of medical necessity cannot be rendered without supporting documentation requested Specific documentation is located on letter 30

31 Helpful Redetermination Reminders Providing all of the information needed to support payment of your claims. The following information will assist you with the appeals process, and more specifically, provide clarification regarding the appropriate information to submit with appeal requests for analyst/nurse. Operative report Radiology report Progress/office notes History and physical Visual field study Admission summary Surgical pathology report MRI and CAT scan reports Radiology report with provider, date and time notated *Not All-inclusive listing* 31

32 Redetermination Timeliness September 23 rd, 2015 Initial Claim Determination rendered. Claim denied for medical necessity JAN SEPTEMBER DEADLINE January 21 st, 2016 Last day to have appeal request submitted and postmarked to Cahaba For more info visit our Appeals Calculator at: 32

33 Appeals Calculator 1 33

34 Appeals Calculator 2 MM / DD / YYYY 34

35 Appeals Calculator 3 35

36 Fore See Survey This survey will ask you to rate the following (not all-inclusive): Quality of Information Freshness of content Clarity of Organization Convenience of the services Your ability to find the information you want Consistency of speed Overall satisfaction 36

37 Correct Cahaba Address Reminder Overpayment/Refund Checks Sending overpayment/refunds have been identified to cause processing delays and the offsetting of overpayment This does not change or extend the collection process timeline Make checks payable to Cahaba GBA Send your demanded overpayment or voluntary refund checks to the Cahaba Lockbox mailing address below: Cahaba Medicare Part B Lockbox 6029 Post Office Box 7247 Philadelphia, PA

38 2016 Medicare Expo Coming Soon!! Cahaba s 2016 Medicare Expo to be held back in the Peach State of Georgia For more updated information, Please make sure you are signed up for our listserv and frequently visit our website.

39 Appeals Forms-Redetermination Level Level 1: Redetermination Cahaba GBA Redetermination SMART Form CMS Form Forms/downloads/cms20027.pdf Level 2: Reconsideration CMS Form Forms/downloads/cms20033.pdf 39

40 Appeal References Appeals Quick Reference Chart The CMS Medicare Appeals website Grievances/OrgMedFFSAppeals/index.html?redirect=/OrgMedFFSAppeals/ The CMS Medicare Appeals Process Brochure MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf The Claims Processing Manual Chapter

41 Question & Answer Session THE END 41

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