Provider Appeals Submission Best Practices

Transcription

1 Provider Appeals Submission Best Practices

2 Objective As a result of this session, you should: Be familiar with Harvard Pilgrim s Provider Appeals Policies Understand the most common reasons for submitting provider appeals to Harvard Pilgrim and what documentation is required Be prepared to avoid common mistakes providers make when submitting appeals Refer to the Provider Manual for specific requirements for your appeals 2

3 Provider Manual Appeals Section 3

4 Request for Claim Review Form A separate Request for Claim Review Form required for each claim appeal being submitted Consult attached Reference Guide for helpful information for completing the Request for Claim Review Form 4

5 Agenda Appeals Overview Types of Appeals Filing Limit Referral Denial Duplicate Claim Corrected Claim Pre-certification or Prior Authorization Denials Contract Rate/Payment Policy/Clinical Policy Request for Additional Information Response to Appeals Re-Appeal/Second Level Appeals Questions 5

6 Appeals Overview

7 Appeals Policy If a provider disagrees with Harvard Pilgrim s decision regarding the denial or reimbursement of a claim, the provider has the option to file an appeal for reconsideration Appeals must be supported by relevant documentation Harvard Pilgrim recognizes the following types of provider appeals: Filing limit appeal Referral appeal Duplicate claim appeal Corrected claim appeal Clinical and all other Administrative Appeals 7

8 Time Limit for Receipt of Appeal Request Time limit days are calculated from the date on Harvard Pilgrim s original denial or Explanation of Payment (EOP) Appeal Type Filing limit appeal All other provider appeals Time Limit 90 days 180 days 8

9 Filing Limit Appeals

10 Filing Limit Appeals Policy Filing limit appeals must be received within 90 days of the original EOP date Any claim with a date of service more than a year old will not be considered for filing limit appeal Any appeal received after the applicable appeal filing limit will not be considered and cannot be appealed Members cannot be held liable for claims denied for exceeding the appeal filing limit 10

11 Filing Limit Appeal Examples A first time claim submission that denied for, or is expected to deny for untimely filing A re-appeal of a claim denied for insufficient filing limit documentation Claim originally submitted with misidentified member or billed to wrong carrier, resulting in untimely filing to Harvard Pilgrim 11

12 Filing Limit Appeals Required Documentation Information required on backup documentation to validate and cross reference the information on the claim being appealed includes: Completed Request for Claim Review Form Patient name Date(s) of service Charges being appealed Date the first claim was submitted to Harvard Pilgrim or proof that the claim was sent to another insurance company or the member 12

13 Supporting Documentation EDI Claims When appealing an EDI claim rejected for exceeding the filing limit, only the following will be accepted: Copy of an EDI vendor report indicating that the claim was accepted for processing by Harvard Pilgrim within the filing limit period, Harvard Pilgrim Response Report or information from your 277 Acknowledgement (277 ACK) Providers who submit claims through intermediaries are responsible for obtaining these reports. A copy of the Patient Account Ledger is not acceptable for EDI claims except in the case of a misidentified member, i.e., the patient was not initially identified as a Harvard Pilgrim member 13

14 Supporting Documentation Paper Claims When appealing a paper claim that was denied for exceeding the filing limit, submit: Copy of the computerized printout of the Patient Account Ledger, with the submission date circled in black or blue ink If your practice management system uses an internal code to identify the payer to whom the claim was billed Provide a copy of all code definitions applicable to your appeal submission Failure to do so may result in the denial of your filing limit appeal 14

15 Supporting Documentation Misidentified Members Complete a Request for Claim Review Form(even if initial claim submission) Submit proof that the member or another insurer had been billed Other insurer s denial EOP Other plan correspondence that makes a plan determination Copy of the bill to member with your appeal in this situation Copy of a patient ledger that clearly indicates dates of patient billing and discovery of Harvard Pilgrim insurance A misidentified member claim with a date of service more than one year old will not be considered for filing limit appeal 15

16 Supporting Documentation Coordination of Benefits All COB filing limit appeals must be submitted on paper with a completed Harvard Pilgrim Request for Claim Review Form and a copy of the Explanation of Benefits from another insurer attached showing timely submission of the COB claim to Harvard Pilgrim Timely submission requirements for COB claims State Filing Limit From the date the other insurer MA 90 days Processed the claim ME 120 days Processed the claim or retroactively denied a previous claim NH 180 days Retroactively denied a previously paid claim 16

17 Referral Denial Appeals

18 Overview Referral denial appeal an appeal request for a claim whose original reason for denial was invalid or missing PCP referral Required documentation: Completed Request for Claim Review Form Corrected CMS-1500 indicating valid PCP NPI and name 18

19 Referral Denial Examples A claim submission denied for a missing/invalid PCP referral that is greater than 90 days from the date of service and within 180 days from the original denial A claim for a POS member paid at the out of network rate due to invalid/missing PCP referral information on the claim form A re-appeal of a claim denied for a missing/invalid PCP referral that is within 180 days from the original denial date 19

20 Referral Denials Helpful Tips If you are submitting A corrected or referral appeal request for a date of service within the initial filing limit Then Resend the claim electronically Correct the missing or incorrect information on the original transmission An appeal for a date of service that is over the initial filing limit Follow the paper appeal submission process Resending an appeal electronically will result in a filing limit denial (EX code 46) 20

21 Duplicate Claim Appeals

22 Overview Duplicate claim appeal examples A first time claim submission that denied for, or is expected to deny for duplicate filing Original claim or service lines within a claim that denied duplicate Required documentation Completed Request for Claim Review Form CMS-1500/ADA/UB form with additional information that was not included in the original claim submission Applicable surgical/operative/office notes, pathology reports, medical invoices [e.g., DME or pharmaceuticals], medical record entries, etc. that support why the service is not a duplicate 22

23 Corrected Claim Appeals

24 Overview Corrected claim appeal examples Original claim billed under a terminated member ID and there is an active member ID on file Original claim denied for any of the following: incorrect member, incorrect date of service, incorrect/missing procedure/diagnosis code, incorrect count, and modifier added/removed Original claim denied for invalid or missing location code 24

25 Corrected Claim Required Documentation Completed Request for Claim Review Form Corrected CMS-1500/ADA/UB claim form One of the following relating to the correction being made: EOP HPHConnect claim detail screen print from the Web browser NEHEN Claim Status Response claim detail screen print from the Web browser 25

26 Corrected Claim Denials Helpful Tip Adding a modifier to a claim previously paid or denied without a modifier, to obtain additional reimbursement requires supporting clinical documentation, such as office or surgical notes Examples: Modifiers -25,

27 Pre-certification or Prior-authorization Denial Appeals

28 Overview Pre-certification/notification/prior-authorization denial appeal examples A claim denied because no notification or authorization is on file for the date of service A claim denied for exceeding authorized limits 28

29 Required & Supporting Documentation All documentation specific to the denied claim, including medical record documentation for clinical appeals Examples include copies of one or more of the following: Surgical/operative notes Office visit notes Pathology notes Medical invoices (e.g., DME or pharmaceuticals) Medical record entries Letter or explanation describing the issue Letters of explanation will not be considered without medical record documentation 29

30 Telephone Appeals For notification non-compliance only, Harvard Pilgrim accepts three types of telephone appeals: Maternity Admission/No Delivery Patient was admitted for a normal delivery/labor, but was discharged without delivering Incorrect Insurance Information Incorrect insurance information was given at the time of admission No Insurance Information No insurance information was given at the time of admission due to extenuating circumstances or patient status 30

31 Telephone Appeals Process After a claim has been denied for failure to notify (Deny EX code NY), or Prior to claim submission, to notify within 14 days of discharge For the three telephone appeals situations, call or fax Phone: , option 7 Fax: (and marked Attn: Supervisor ) 31

32 Contract Rate, Payment Policy or Clinical Policy Appeals

33 Overview & Required Documentation Contract rate, payment policy or clinical policy examples Provider believes that incorrect contract terms/rates were applied to payment made resulting in either an under- or overpayment Provider believes that final claim payment was incorrect because of global reimbursement or (un)bundling of billed services (e.g., claim editing software) Required & supporting documentation Completed Request for Claim Review Form Copy of supporting EOP, HPHConnect claim detail screen or NEHEN Claim Status Response claim detail screen Supporting documentation 33

34 Request for additional information

35 Overview & Required Documentation Request for additional information examples A first time claim submission that denied for additional information An unlisted procedure code not submitted with supporting documentation A procedure code that was denied or not submitted with: operative notes, anesthesia notes, pathology report, and/or office notes. Required Documentation Completed Request for Claim Review Form Copy of supporting EOP, HPHConnect claim detail screen or NEHEN Claim Status Response claim detail screen Supporting clinical documentation When applicable, provide the Case # on the appeal form for routing purposes. 35

36 Response to Appeals

37 Overview If the appeal request Is beyond the 180-day filing limit Is within the 180-day filing limit Then It will not be considered It will be considered A determination will be made with 30 days following receipt 37

38 Resolution Letter After the appeal has been reviewed, Harvard Pilgrim will send a resolution letter that outlines Outlines the reason(s) for denying the appeal and upholding the original decision, or Explains that the claim will be adjusted in accordance with payment policy, member agreement and hospital contract EOP EX Code TF TE Description After review of appeal, additional reimbursement is not warranted After review of appeal, additional reimbursement is appropriate 38

39 Re-Appeal/Second Level Appeal

40 Re-Appeal Filing Limit Appeal Denials Providers may submit additional supporting documentation for any filing limit appeal denied for insufficient documentation as long as it is received within 90 days from the original denial date. When a denial is upheld on appeal, Harvard Pilgrim will not consider a re-appeal. 40

41 Clinical and All Other Administrative Appeals A second appeal may be submitted in instances where Harvard Pilgrim Health Care upholds the original claim denial or reimbursement decision and the provider has additional information to substantiate a second review Second level clinical provider appeals must be received within 30 days of the date on the original appeal resolution letter you received from Harvard Pilgrim that explained the reason for upholding the original denial or reimbursement decision 41

42 Supporting Documentation - Second Appeals Completed Harvard Pilgrim Request for Claim Review Form Copy of the original EOP Supporting documentation for the denied claim that specifically substantiates your reason for a second level appeal Recipients of the HIPAA-compliant 835 Electronic Remittance Advice must submit one of the following documents in place of the paper EOP report: HPHConnect claim detail screen print from the Web browser NEHEN Claim Status Response claim detail screen print from the Web browser 42

43 Harvard Pilgrim Response If the request for a second appeal Is beyond the 30-day filing limit* Is within the 30-day filing limit* Then It will not be reconsidered Harvard Pilgrim will review the appeal A determination will be made within 30 days following receipt of a second level appeal that is accompanied by the appropriate documentation After the second level appeal has been reviewed, Harvard Pilgrim will send a resolution letter *From the date of Harvard Pilgrim s letter upholding the original denial 43

44 Resolution Letter After the appeal has been reviewed, Harvard Pilgrim will send a resolution letter that Outlines the reason(s) for upholding the original decision, or Explains that the claim will be adjusted in accordance with payment policy, member agreement and hospital contract EOP EX Code TF TE Description After review of appeal, additional reimbursement is not warranted After review of appeal, additional reimbursement is appropriate 44

45 Appeals Resources 45

46 Additional Appeals Information Visit Web sites listed for details on submitting appeals for claims administered on behalf of Harvard Pilgrim: Passport Connect ( HPI ( StudentResources ( 46

47 Thank You