How to Submit an Appeal: “The Redetermination Level” P B

How to Submit an Appeal:
“The Redetermination Level”
PRESENTED BY
PART B
PROVIDER OUTREACH & EDUCATION
MAY 21, 2013
1
Disclaimer
This resource is not a legal document. This presentation
was p
prepared
p
as a tool to assist our p
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.
p
of this material for p
profit is p
prohibited.
Reproduction
2
Acronyms
Acronym
Term
ADR
Additional Documentation Request
ALJ
Administrative Law Judge
CCI
Correct Coding Initiative
CERT
Comprehensive Error Rate Testing
DAB
Departmental Appeals Board
ICN
Internal Control Number
MRN
Medicare Redetermination Notice
NPI
National Provider Identifier
PHI
Protected Health Information
PTAN
Provider Transaction Access Number
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Agenda
• Levels
L
l off A
Appeals
l & Wh
Where tto Fil
File
• Redeterminations
• Requirements for Submission via Letter
• How to send Appeal Request
• Completion of CMS 20027 Form
• Completion of Cahaba Redetermination SMART Form
• CERT and Self-Service Tools
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Five Levels of Appeals: Where to File
Level of Appeal
Where to File
Redetermination
MAC (Cahaba GBA)
Reconsideration
Qualified Independent Contractor (Q2A)
Administrative Law Judge (ALJ)
Hearing
Office of Medicare Hearing and
Appeals (OMHA)
Departmental Appeals Board
Medicare Appeals Council (MAC)
Review Board as instructed on ALJ
decision
Federal Court
United States District Court
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Level 11 Redetermination
•
Parties dissatisfied with their initial determination can file an appeal
120 days from the initial claim denial
•
Submit a redetermination request via the following:
– CMS-20027 Form
– the Cahaba GBA Medicare Part B Redetermination SMART Form or
– a written redetermination request on companyy letterhead with the
required information
•
Requests are completed within 60 days of receipt
– The date request is received into our mailroom
•
Submit all supporting documentation
– Provide anyy additional information needed with the redetermination
request
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Redetermination RequestRequest Letterhead
If neither form is used for a written redetermination request,
q
the request must be submitted with all the following:
•
•
•
•
•
•
Beneficiary name
name.
Beneficiary’s Health Insurance Claim Number (HICN).
Dates 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).
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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 p
paid and which were denied,, if applicable.
pp
 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.
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Redetermination Outcomes
Redetermination can have 5 possible outcomes:
•
Full Reversal (favorable)
•
Partial Reversal (partially favorable)
•
Full Affirmation (unfavorable)
•
Dismissal
•
Affirmation-Claim Paid
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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
q
form with the
redetermination letter
*Received for an Affirmation or Partial Reversal*
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Top 5 Reasons for Redeterminations
1) Medical Necessity
2) Duplicate Charge
3)) CCI and Frequency
q
y
4) Screening/Preventive
Services
5)
Modifiers
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Where to Locate Appeal Forms?
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CMS 20027 Form
Form- (Top Portion)
Place the Internal Control
Number (ICN) Here
13
CMS 20027 Form
Form- (Bottom Portion)
Bee Medicare
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Cahaba Medicare B Redetermination
SMART F
Form- (Top
(T Portion)
P ti )
15
Cahaba Medicare B Redetermination
SMART F
Form- (Bottom
(B tt
Portion)
P ti )
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Appeals Mailing Address
All paper redetermination request must be submitted to:
Alabama
Georgia
Tennessee
Cahaba GBA Part B
Redeterminations
P.O. Box 1921
Birmingham,
g
, AL 35201-1921
Cahaba GBA Part B
Redeterminations
PO Box 12967
Birmingham,
g
, AL 35202
Cahaba GBA Part B
Redeterminations
P O Box 12724
Birmingham,
g
, AL 35202-6724
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Appeals Fax Number
All Medicare B Redetermination (SMART form only) request must be
faxed to:
State
Fax
a Number
u be
Alabama
Georgia
855-215-9290
Tennessee
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Redetermination Request Issues
•
•
•
•
•
•
•
•
•
•
Handwritten SMART Forms
Faxing Redetermination request made on CMS 20027
Redetermination Request with invalid ICN
Multiple SMART Forms faxed as one batch
Coversheets on top of SMART Forms
Pl i 2 digits
Placing
di it in
i each
h box
b off the
th SMART F
Form
Writing Multiple ICNs in box and attaching spreadsheet
Not enough digits for Item 6 of SMART Form
Wrong Date Format (i.e. MM/DD/YY)
Wrong Forms (i.e. CMS 20033-Reconsideration)
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Comprehensive
Error Rate Testing
p
g (CERT)
(
)
CERT Program:
• Medicare Trust
Fund
Measures improper payments in the
Medicare fee-for-service program and is
designed to comply with the Improper
Payments Elimination and Recovery Act
of 2010 (IPERA)
CERT Documentation Contractor:
Measure
• Correct Claim
Process/Payment
Assess
A
Evaluate
•Contractor and
Provider
Protect
Responsible for requesting and
receiving the medical record
documentation from providers
C
CERT
Review C
Contractor:
Review selected claims and associated
medical record documentation
http://www.cms.gov/cert/
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Online Eligibility and Claim Status Portal
Eligibility Verification:
Claims Status:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Part A & B Entitlement
ESRD
Preventive Service
Medicare Secondary
Advantage Plan
Home Health
Hospice
Claim Number
Date of Service
Total Submitted Charges
Allowed Charge Amounts
Status of Claim
Amount Paid
Deductible Amounts
Adjustment Date
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Connectivity Vendor
• Effective July 1
1, 2013
2013, Cahaba GBA
will no longer support dial-up
connections
• All electronic transactions should be
routed through a Cahaba GBA
approved Network Service Vendor
(NSV)
• Current user ID and password can
be used
• Direct questions to the Cahaba GBA
EDI Helpdesk
http://www.cahabagba.com/part-b/claims-2/electronic-data-interchange-edi/connectivity/
EDI Helpdesk 1-866-582-3253
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Appeals Decision Tree
SHOULD YOU
YOU SUBMIT
SUBMIT AN
AN APPEAL
or NOT
NOT to
Cahaba GBA?
SHOULD
APPEAL or
to Cahaba
GBA?
 Designed to help you determine if you should file a
redetermination request
q
 Series of Questions
 Yes or No
 Eliminates submission of request in error
 Accuracy
 Interactive Decision Tree
 Saves Time and Postage
 Click your way to the correct answer
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Appeals Calculator
1
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Appeals Calculator
2
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Go Green Campaign
•
Sign-up for Electronic Funds Transfer (EFT)
•
Enroll to receive Electronic Remittance Advice (ERA)
•
Complete and/or update enrollment application via
Provider Enrollment Chain and Ownership System
(PECOS)
•
Submit Additional Documentation after it is requested
through Electronic Submission of Medical
Documentation (esMD)
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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
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References
• Appeals
pp
Brochure
http://www.cahabagba.com/documents/2013/02/2013-appeals-brochure.pdf
• Appeals
A
l Q
Quick
i kR
Reference
f
G
Guide
id
http://www.cahabagba.com/documents/2013/02/2013-appeals-quick-reference-chart.pdf
• The CMS
C S Medicare Appeals Process Brochure
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MedicareAppealsprocess.pdf
• The Claims Processing Manual 100-4 Chapter 29
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf
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Question & Answer Session
THE END
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