Master Core Curriculum

1. Master Core Curriculum Part B Basic Module 7 Appeals

2. Learning Outcomes At the end of this module, participants will be able to: • Identify under which circumstances an appeal is warranted and whether appeal rights exists • describe the processes for appealing a denied claim • identify and resolve unprocessable claim denials • identify the appropriate level of appeal for their situation • submit an appeal request correctly  

3. Who can appeal a claim? • Providers and Beneficiaries may have appeal rights depending upon: • Assigned Claims • Nonassigned Claims

4. Clerical Error Reopenings • Effective 1/1/06 • Omission or error made by the provider • All other corrections must be made in writing

5. Requesting a Clerical Reopening The following must be provided when requesting a telephone reopening: • Patient’s Name • Health Insurance Claim Number (HIC) • Birth Date (new requirement) • Date of Service • Total amount billed for each correction

6. Requesting a Clerical Reopening The following issues can be handled over the telephone reopening line: • Number of units billed incorrectly; • Adding a diagnosis code; • Changing a CPT code; • Changing a date of service; • Adding modifiers; • Changing billed amounts • Scanner errors (that are not RUC)

7. Requesting a Clerical Reopening The following issues cannot be handled over the telephone reopening line: • Ambulance claims • Medical necessity denials • Frequency denials • Concurrent care • Surgery claims

8. Five Levels of Appeal for Medicare Part B • Redetermination • Reconsideration • Administrative Law Judge (ALJ) Hearing • Departmental Appeals Board (DAB) Review • Federal Court Review

9. Redeterminations- First Level of Appeal • Performed by the Medicare Contractor • Submit 120 days from initial claim determination date • No monetary threshold

10. Written Redeterminations • Request must be in writing and signed – for example a CMS- 20027 form • Attach supporting documentation • Carrier response must be completed within: • 45 days – 95% • 60 days – 100%

11. Reconsideration-Second level of Appeal • Dissatisfied with the redetermination • No monetary threshold • Must be filed within 180 days of redetermination decision • Prepared by the Medicare contractor and forwarded to the Qualified Independent Contractor (QIC) • Medicare contractor may have effectuation responsibilities for decisions made by the QIC

12. Administrative Law Judge-Third Level of Appeal • Requests on or after 1/1/06 $110 remains in controversy • Must be filed within 60 days of the reconsideration notice • Case file prepared by the QIC and forwarded to the HHS Office of Medicare Hearings and Appeals • Medicare contractor may have effectuation responsibilities for decisions made by the ALJ

13. Departmental Appeals Board Review – Fourth Level of Appeal • Dissatisfied with the ALJ’s decision • No Monetary threshold to be met • Request for DAB must be within 60 days of receipt of that ALJ decision • Medicare contractor may have effectuation responsibilities for decisions made by the DAB level

14. Federal Court Review –Fifth Level of Appeal • Requests on or after 1/1/06 at least $1,090 remains in controversy • Must be filed within sixty days of receipt of the DAB decision • Medicare contractor may have effectuation responsibilities for decisions made at the Federal Court level

15. Chapter Review Slide • Question 1: What are the five levels of the appeals process? • Question 2: What three items must be provided when conducting a telephone Clerical Error Reopening? • Question 3: A Departmental Appeals Board request must be filed within how many days of the Administrative Law Judge decision?

16. Chapter References/Citations: • CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 29, Appeals of Claims Decisions • Medicare Resident & New Provider Training (Facilitator’s Kit)