Introduction to the Medicare Appeals Process
|
|
|
- Stephanie Dean
- 7 years ago
- Views:
Transcription
1 for Acknowledgments This resource was developed by the Deciphering the Regulations Task Force Task Force of the Practice Committee of the Task Force Members Nikki Gilroy, PT, DPT Task Force Leader Sheri Yarbray, PT, MS Judy Schank, PT, MS I would like to thank the Executive Committee of the for its approval and support in the development of this resource. Additionally, I would like to extend my sincerest thank you to Nikki Gilroy for leading this Task Force and to Sheri Yarbray and Judy Schank for working to create this useful resource for both the novice and seasoned clinician working in this specialty practice setting. Kenneth L Miller, PT, DPT. CEEAA Chair, Practice Committee Liaison to Task Force Published January P age
2 for Providers Tips for avoiding the Appeal Process Know your regulations federal and state levels MACs have to publish their activity and will have the top reasons for denials Be prepared for an Additional Documentation Request (ADR) know how to look to see if you have an ADR and check; possible signature log for every record; ask for the electronic policy from the Medical Doctor (MD)hospital etc. if you accept their electronic signature; and education to the staff on medical necessity, regulations, and proper documentation. Were the orders received before the services were rendered? Document MD approval to the POC and visit frequency for EACH discipline. Are you including proper content in your order? Medicare Appeal Process There are five levels in the claims appeal process under the Original Medicare entitlement and not the Medicare Advantage plans. At any time, a party may appoint any individual, including an attorney, to represent him or her during the processing of a claim or appeal. The representative helps the party by providing assistance and expertise. You must complete Form CMS 1696 called, Appointment of Representative. ( Forms/CMS Forms/CMS Forms Items/CMS html ) If a claim contains a minor error or omission, the claim may be corrected through the reopening process rather than the appeals process. Consult this link to correct minor errors and omissions, and Education/Medicare Learning Network MLN/MLNMattersArticles/Downloads/SE0420.pdf First Level of Appeal: Redetermination 1. First level of appeal after the initial determination on a claim. It is a second look at the claim. 2. You must file a request for redetermination within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination. 3. File request in writing by following instructions provided in the RA. Remember you, or your representative, must include your name and signature. 4. MAC staff unassociated with the initial claim determination performs the redetermination. 2 P age
3 for 5. MACs generally issue a decision within 60 days of receipt of the request for redetermination. You will receive notice of the decision via a Medicare Redetermination Notice (MRN) from your MAC. Second Level of Appeal: Reconsideration 1. Disagree with the MAC redetermination decision you can request reconsideration by a QIC. Reconsideration is a review of the redetermination decision. 2. You must file a request for reconsideration within 180 days of receipt of the MRN. 3. File your request in writing by following instructions provided on the MRN. Clearly explain why you disagree with the redetermination decision. The representative must include your name and signature. Submit 1) Copy of the RA or MRN; 2) Any evidence noted in the redetermination as missing; 3) Any other evidence relevant to the appeal; and 4) Any other useful documentation. 4. Documentation submitted after you file the reconsideration request may extend the Quality Improvement Organization s (QIO) decision timeframe. 5. NOTE: Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you demonstrate good cause for submitting the evidence late. 6. Qualified Independent Contractor (QIC) conducts the reconsideration, which is an independent review of the redetermination. The reconsideration may include review of medical necessity issues by a panel of physicians or other health care professionals. 7. Generally, QICs send a decision to all parties within 60 days of receipt of the request for reconsideration. If the QIC cannot complete its decision in the applicable timeframe, it will inform you of your rights and the procedures to escalate the case to an Administrative Law Judge (ALJ). May want to wait an additional 5 10 days for mail delays prior to escalating your appeal to an ALJ. Third Level of Appeal: ALJ Hearing 1. If you disagree with the reconsideration decision, or you wish to escalate your appeal because the reconsideration period passed, you may request an ALJ hearing. The ALJ hearing gives you the opportunity, via video teleconference (VTC), telephone, or occasionally in person, to explain your position to an ALJ. The U.S. Department of Health and Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA), which is independent of CMS, is responsible for the Level 3 Medicare claims appeals. 3 P age
4 for 2. To file a request for an ALJ hearing within 60 days of receipt of the reconsideration decision letter or after the expiration of the reconsideration period. There is a minimum Amount in Controversy (AIC) requirement and you may only request an ALJ hearing if a certain dollar amount remains in controversy following the QIC s decision. This threshold is updated annually. For current amount visit and Grievances/OrgMedFFSAppeals/HearingsALJ.html on the CMS website. 3. File your request in writing by following instructions provided in the reconsideration letter. Alternatively, you may request an ALJ hearing by completing Form CMS A/B REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE. For the requirements for a written request, tips on filing an ALJ hearing request, or to access Form CMS A/B, (called Request for Medicare Hearing by an Administrative Law Judge), visit on the HHS website. 4. If you do not want a VTC or telephone hearing, you may ask for an in person hearing, but you must demonstrate good cause. The ALJ determines whether the case warrants an in person hearing on a case by case basis. You may also ask the ALJ to make a decision without a hearing (on the record). 5. You must send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. If you are requesting the case be escalated to the Appeals Council, a copy of the request must be sent to all other parties and to the ALJ. The ALJ sets hearing preparation procedures. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and the parties to the hearing. 6. The ALJ makes the decision and if it cannot be completed in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to the Appeals Council. The ALJ forward the decision and case file to the Administrative QIC (AdQIC), which serves as the central manager for all ALJ Original Medicare claim case files. In certain situations, the AdQIC may refer the case to the Appeals Council on CMS behalf. If no referral is made to the Appeals Council, and the ALJ decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim, according to the ALJ decision, within days. 7. The OMHA oversees all Level 3 Medicare appeal hearings. Due to an overwhelming number of new requests and the existing workload, OMHA has delayed new requests received after April 1, 2013, for ALJ hearing assignments. OMHA will be processing ALJ hearing requests in the order received and as quickly as possible. 8. Due to a record number of appeal requests, if 22 weeks have not lapsed since your initial ALJ hearing submission request, do not resubmit your request. For more info on the timeframes, 4 P age
5 for visit on the HHS website. 9. Two pilot programs were implemented due to the number or requests and delays which are Settlement Conference Facilitation (SCF) and Statistical Sampling Initiative. SCF is an alternative dispute resolution process that uses medication principles. Statistical Sampling Initiative applies to appellants with a large volume of claim disputes. For more information, visit on the OMHA website. Fourth Level of Appeal: Medicare Appeals Council Review 1. If you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review. You must file your request for Medicare Appeals Council review within 60 days of receipt of the ALJ s decision or after the ALJ ruling timeframe expires. There is no Minimum AIC requirement for this level. 2. File your request in writing by following the instructions provided by the ALJ. Alternatively, you may request an Appeals Council review by completing Form DAB 101. Remember to explain which part of the ALJ decision you disagree with and your reasons for disagreement. You must send a copy of the Appeals Council review request to all the parties included in the ALJ s decision. If you are requesting escalation to U.S. District Court, a copy of the request must be sent to all other parties and to the Appeals Council The Appeals Council makes the decision. If the Appeals Council cannot complete its decision in the applicable timeframe, it will inform you of your right and procedures to escalate the case to U.S. District Court. The Appeals Council forward the decision and case file to the AdQIC, which serves as the central manager for all ALJ Original Medicare claim case files. If the Appeals Council overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim, according to the Appeal Council s decision, within days. 3. Generally, the Appeals Council issues a decision within 90 days from receipt of a review of an ALJ decision. If the Appeals Council review stems from an escalated appeal, then the Appeals Council has 180 days from the date of receipt of the request for escalation to issue a decision. A decision may take longer due to a variety of reasons. If the Appeals Council does not issue a decision within the applicable timeframe, you may ask the Appeals Council to escalate the case to the judicial review level. 5 P age
6 for Fifth level of Appeal: Judicial Review in U.S. District Court 1. If you disagree with the Appeals council decision, or you wish to escalate your appeal because the Appeals council ruling timeframe passed, you may request judicial review. You must file a request for judicial review within 60 days of receipt of the Appeals Council s decision or after the Appeals Council ruling timeframe expires. 2. The Appeals Council decision (or notice of right to escalation) contains information on how to submit a claim in the U.S. District Court. The U.S. District Court will make the decision and has no statutory time limit to make the decision. 3. You may only request judicial review if a certain dollar amount remains in controversy following the Medicare Appeals Council decision. The AIC threshold is updated annually. For current amount, visit and Grievances/OrgMedFFSAppeals/Review Federal District Court.html on the CMS website. Tips for Filing an Appeal Starting at Level 1, consolidate into one appeal as many similar claims as possible; File timely request with the appropriate contractor; Include a copy of the decision letter(s) issued at the previous level; Include a copy of the demand letter(s) if appealing an overpayment determination; Include a copy of the Appointment of Representative (AOR) form if representing a provider/supplier/beneficiary; Respond promptly to the contractor requests for documentation; Sign your request appeal Poor Documentation noted in the chart possibly look at adding attestations stating facts and signed with current date. Remember to check copies you are sending. Make sure signatures or part of the chart are not missing. Medicare Appeal Processing Manual: and Guidance/Guidance/Manuals/Downloads/clm104c29.pdf Medicare Learning Network (MLN) Guided Pathways: and Education/Medicare Learning Network MLN/MLNEdWebGuide/Downloads/Guided_Pathways_Basic_Booklet.pdf Document Oversight: Practice Committee 6 P age
Medicare Appeals: Part D Drug Denials. December 16, 2014
Medicare Appeals: Part D Drug Denials December 16, 2014 2013 Appeals Statistics by Type 23,716 Part D Reconsideration Appeals* Appeals Type Percentage of Total Appeals Appeals Per Million Medicare Beneficiaries
Guide to EHR s Governmental Appeals Management. Updated: November 2011-1 -
Guide to EHR s Governmental Appeals Management Updated: November 2011-1 - Introduction to EHR s Appeals Management Services EHR is committed to helping your hospital respond to the increase in appeals
RACs AND THE MEDICARE AND MEDICAID APPEALS PROCESS
RACs AND THE MEDICARE AND MEDICAID APPEALS PROCESS Lorman Educational Services Independence, Ohio Presenter Thomas W. Hess Dinsmore & Shohl LLP 191 W. Nationwide Blvd., Suite 300 Columbus, Ohio 43215 Phone:
SETTLEMENT CONFERENCE FACILITATION. Cherise Neville Senior Attorney Office of the Chief Judge
SETTLEMENT CONFERENCE FACILITATION Cherise Neville Senior Attorney Office of the Chief Judge Open Door Teleconference Objectives Understand the concept of Settlement Conference Facilitation (SCF) or mediation
Medicare Claims Processing Manual Chapter 34 - Reopening and Revision of Claim Determinations and Decisions
Medicare Claims Processing Manual Chapter 34 - Reopening and Revision of Claim Determinations and Decisions Transmittals for Chapter 34 (Rev. 2241, 06-17-11) Table of Contents 10 - Reopenings and Revisions
CENTERS FOR MEDICARE & MEDICAID SERVICES. Medicare Appeals
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Appeals This official government booklet has important information about: How to file an appeal if you have Original Medicare How to file an appeal if
Medicare Claims Processing Manual
Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions Table of Contents (Rev. 2926, 04-11-14) Transmittals for Chapter 29 110 - Glossary 200 - CMS Decisions Subject to the Administrative
Guide to EHR s Governmental Appeals Management. Updated: October 2012-1 -
Guide to EHR s Governmental Appeals Management Updated: October 2012-1 - Introduction to EHR s Appeals Management Services EHR is committed to helping your hospital respond to the increase in appeals volume
Guide to EHR s Governmental Appeals Management
Guide to EHR s Governmental Appeals Management Updated: April 2012-1- Introduction to EHR s Appeals Management Services EHR is committed to helping your hospital respond to the increase in appeals volume
Indiana State Medical Association Coalition Meeting May 23, 2014
Indiana State Medical Association Coalition Meeting May 23, 2014 Coalition Topics 1. Due to the increased number of billing errors with new patients, please provide a reminder of when a patient is a new
Medicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Prescription Drug Coverage: How to File a Complaint, Coverage Determination, or Appeal Medicare offers insurance coverage for prescription drugs through
Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)
CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal) Medicare Advantage Plans (like an HMO or PPO) and Medicare Cost
Inquiries, Reopenings, & Appeals Chapter 13
Chapter 13 Contents 1. Telephone Inquiries 2. Written Inquiries 3. mycgs The Jurisdiction C Web Portal 4. Provider Outreach and Education (POE) Department 5. Reopenings for Minor Errors and Omissions 6.
RAC Auditing Reform is Essential to Fix Urgent, Critical Problems
RAC Auditing Reform is Essential to Fix Urgent, Critical Problems Recovery Audit Contractors (RACs) audit Medicare claims submitted by hospitals and other health care providers. They are one of many different
Guide to EHR s Governmental Appeals Management. Updated: EŽǀĞŵďĞƌ 2013-1-
Guide to EHR s Governmental Appeals Management Updated: EŽǀĞŵďĞƌ 2013-1- Introduction to EHR s Appeals Management Services Executive Health Resources is committed to helping your hospital respond to the
Jimmo v. Sebelius. Glenda Mack, Division Vice President Clinical Operations
Jimmo v. Sebelius Glenda Mack, Division Vice President Clinical Operations Jimmo v. Sebelius Specifics 1. Settlement approved by Federal Judge on January 24 th 2013 2. Class action suit on behalf of beneficiaries
How to Successfully Appeal a RAC Audit. Kelly McCloskey Cherf Hogan Marren, Ltd.
How to Successfully Appeal a RAC Audit Kelly McCloskey Cherf Hogan Marren, Ltd. General Background RAC - Recovery Audit Contractor The Medicare Prescription Drug, Improvement, and Modernization Act (2003)
How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan
How to Request an Exception or Appeal a Decision From Your Prescription Drug Plan Exceptions What is an Exception? Sometimes you may not be able to obtain a prescription medication that your healthcare
You recently called the Medicare Rights helpline for assistance with a denial from your Medicare private health plan.
Date: Dear Helpline Caller: The Medicare Rights Center is a national, nonprofit organization. We help older adults and people with disabilities with their Medicare problems. We support caregivers and train
Representing Yourself In Employment Arbitration: An Employee s Guide
Representing Yourself In Employment Arbitration: An Employee s Guide What is the American Arbitration Association? The American Arbitration Association (AAA ) is a not-for-profit, private, public service
Please make the check payable to Medicare and send it with a copy of this letter to the following address:
SAMPLE Demand Letter INSERT RAC LOGO Region Recovery Audit Contractor (RAC) Date RAC Point of Contact Provider Name Address 1 Address 2 Re: Provider Name #123456789 Dear Medicare Provider, The Centers
Comprehensive Health Insurance Billing Coding Reimbursement
Comprehensive Health Insurance Billing Coding Reimbursement SECOND EDITION CHAPTER 17 Refunds, Follow-up, and Appeals Key Terms and Abbreviations administrative law judge (ALJ) hearing documentation Employee
December 5, 2014. Submitted Electronically
December 5, 2014 Submitted Electronically Ms. Nancy J. Griswold Chief Administrative Law Judge Office of Medicare Hearings and Appeals U.S. Department of Health and Human Services 1700 N. Moore Street
Recovery Audit Contractor Program
Recovery Audit Contractor Program What is a RAC? Recovery Audit Contractor RAC Mission Detect and correct past improper payments so that future improper payments can be prevented: Providers can avoid submitting
How To Appeal A Medicare Recovery Claim
APPLICABLE PLAN APPEALS Appealing a Medicare Secondary Payer Recovery Claim where Medicare pursues recovery from insurers or workers compensation entities. Presented by: The Division of Medicare Secondary
Jane Snecinski, FACHE Post Acute Advisors, LLC P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors.com
Jane Snecinski, FACHE P.O. Box 12078 Atlanta, GA 30355 www.postacuteadvisors.com RAC Demonstration Project 3 year demonstration project Greatest impact to IRF from California Issue with greatest impact
Demand Letter. Date. RAC Point of Contact Provider Name Address 1 Address 2 City, State Zip
Demand Letter Date RAC Point of Contact Provider Name Address 1 Address 2 Re: Letter ID: XXXXXX Issue: (Issue Name) Dear Medicare Provider, The Centers for Medicare & Medicaid Services (CMS) has retained
Overview of appeals process Tip sheet Sample appeals letter Sample doctor s letter
Date: Dear Helpline Caller: The Medicare Rights Center is a national, nonprofit organization. We help older adults and people with disabilities with their Medicare problems. We support caregivers and train
Enclosed is information to help guide you through the Part D appeals process.
Date: Dear Helpline Caller: The Medicare Rights Center is a national, nonprofit organization. We help older adults and people with disabilities with their Medicare problems. We support caregivers and train
Chapter 15 Claim Disputes and Member Appeals
15 Claim Disputes and Member Appeals CLAIM DISPUTE AND STATE FAIR HEARING PROCESS (FOR PROVIDERS) Health Choice Arizona processes provider Claim Disputes and State Fair Hearings in accordance with established
MANAGING MEDICARE IN 2014: Fighting Back-Managing Claims. California Orthopaedic Association May 30, 2014
MANAGING MEDICARE IN 2014: Fighting Back-Managing Claims California Orthopaedic Association May 30, 2014 Healthcare System Changing Current orthopedic practices are evolving Only thing constant is change
MEDICARE RECOVERY AUDIT CONTRACTORS AND CMS S ACTIONS TO ADDRESS IMPROPER PAYMENTS, REFERRALS OF POTENTIAL FRAUD, AND PERFORMANCE
Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE RECOVERY AUDIT CONTRACTORS AND CMS S ACTIONS TO ADDRESS IMPROPER PAYMENTS, REFERRALS OF POTENTIAL FRAUD, AND PERFORMANCE Daniel
Table of Contents (Rev. 105, Issued: 04-20-12)
Medicare Managed Care Manual Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment
BlueAdvantage SM Health Management
BlueAdvantage SM Health Management BlueAdvantage member benefits include access to a comprehensive health management program designed to encompass total health needs and promote access to individualized,
VI. Appeals, Complaints & Grievances
A. Definition of Terms In compliance with State requirements, ValueOptions defines the following terms related to Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial
Appeals and Provider Dispute Resolution
Appeals and Provider Dispute Resolution There are two distinct processes related to Non-Coverage (Adverse) Determinations (NCD) regarding requests for services or payment: (1) Appeals and (2) Provider
Department of Health and Human Services DEPARTMENTAL APPEALS BOARD. Civil Remedies Division
Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Civil Remedies Division Eileen M. Rice, M.D., Petitioner, v. Centers for Medicare and Medicaid Services. Docket No. C-12-162 Decision
Using Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered
Using Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered SPRING 2009 9 www.yourpharmacybenefit.org Table of Contents How does it work?............................................ 1 When
2. What authority does CMS have to do this type of settlement? 3. What is the deadline for a hospital to submit the signed administrative agreement?
Last Updated: 10/31/14 A. GENERAL QUESTIONS: 1. Why is CMS offering a settlement? CMS believes that the changes in Final Rule 1599-F, 1 the so called the 2 midnight rule, (published in August 2013) will
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD. DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-10-452
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-10-452 In the case of Home Care 4 U, Inc. (Appellant) Claim for Hospital Insurance
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL In the case of Claim for Supplementary Medical Robert Markman M.D. Insurance Benefits (Part B) (Appellant)
FRANCHISE AND PERSONAL INCOME TAX APPEALS
STATE BOARD OF EQUALIZATION FRANCHISE AND PERSONAL INCOME TAX APPEALS If you disagree with a Franchise Tax Board decision about your liability for franchise or personal income taxes, or about your eligibility
12/4/2014. The Auditor s Role In The Appeals Process. Issues Leading to Denied Claims. Understanding How to Win
The Auditor s Role In The Appeals Process Presented By: Sean M. Weiss, Partner Vice President & Chief Compliance Officer Issues Leading to Denied Claims Incident-to and Split/Shared Billing Locum and Reciprocal
LESSONS LEARNED AND INSIGHT INTO HANDLING PART D APPEALS, GRIEVANCES AND COVERAGE DETERMINATIONS
LESSONS LEARNED AND INSIGHT INTO HANDLING PART D APPEALS, GRIEVANCES AND COVERAGE DETERMINATIONS By Lisa A. Hathaway. Esq. Blue Cross and Blue Shield of Florida 1 Part I-The Basics to Understand Part D
SIXTH CIRCUIT GUARDIAN FEE ISSUES
SIXTH CIRCUIT GUARDIAN FEE ISSUES Billing to leave/receive messages, then billing again when they connect with the person Reductions may be recommended if there are an extraordinary number of such billing
Health Care Insurer Appeals Process Information Packet
{PAGE} Health Care Insurer Appeals Process Information Packet CAREFULLY READ THE INFORMATION IN THIS PACKET AND KEEP IT FOR FUTURE REFERENCE. IT HAS IMPORTANT INFORMATION ABOUT HOW TO APPEAL DECISIONS
Introduction...3 Why would you need to appeal?...4. Before you begin your appeal...4
Table of Contents Introduction...3 Why would you need to appeal?...4 Before you begin your appeal...4 Part D Appeals: An outline...5 Pre-Appeal: Requesting a coverage determination...6 Beginning the appeals
Table of Contents. Procedural Screening, Generally Appealable Decision. Amount in Controversy Timely Request for Hearing Complete Request for Hearing
Chapter 3 Section V-3-1 V-3-2 V-3-3 V-3-4 V-3-5 V-3-6 PROCEDURAL SCREENING Table of Contents Title Procedural Screening, Generally Appealable Decision Standing Amount in Controversy Timely Request for
CMS Referral for Own Motion Review by DAB/MAC. 1-991166855 and 2 others Beneficiary (if not the Appellant) List attached ALJ Decision Date
Appellant at ALJ Level CMS Referral for Own Motion Review by DAB/MAC Fondren Orthopedic Group, L.L.P. ALJ Appeal Number 1-991166855 and 2 others Beneficiary (if not the Appellant) List attached ALJ Decision
DEPARTMENT PROCEDURE. Purpose
DEPARTMENT PROCEDURE Subject: MAP Appeals of Adverse Determinations Primary Department: Secondary Department(s): Prior Procedure Reference(s): 4.001 Effective Date of Procedure: Date Procedure Last Reviewed:
HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER
CONSUMER'SGUIDE A Consumer s Guide to HEALTH INSURANCE UTILIZATION REVIEW, APPEALS AND GRIEVANCES YOUR RIGHTS AS A HEALTH INSURANCE CONSUMER from your North Carolina Department of Insurance A MESSAGE
MEDICAL AUDITS: TOP TEN TIPS FOR PHYSICIANS TO ANTICIPATE, RESPOND AND PROTECT THEIR PRACTICES
MEDICAL AUDITS: TOP TEN TIPS FOR PHYSICIANS TO ANTICIPATE, RESPOND AND PROTECT THEIR PRACTICES The pressure on both governmental and private payers to reduce the cost of healthcare and the often mistaken,
How and When to Disclose and Refund Overpayments
How and When to Disclose and Refund Overpayments Darrell D. Zurovec American Health Lawyers Association Long Term Care and the Law February 25 27, 2013 Medicare and Medicaid providers and suppliers have
How to Prepare a Winning RAC Appeal
How to Prepare a Winning RAC Appeal Craneware InSight Consulting Copyright 2011, CRANEWARE INSIGHT. All rights reserved. www.cranewareinsight.com p.1 Introduction Introductions Karen Bowden, RHIA, Senior
Ancillary Providers General Billing Requirements
Introduction... 2! Claims Settlement Practices and Provider Dispute Resolution Mechanism Regulations (Assembly Bill 1455)...2 Claim Submission Instructions... 2 Dispute Resolution Process for Contracted
Recovery Audit Contractor Audits: What You Need to Know
Recovery Audit Contractor Audits: What You Need to Know August 19-21, 2009 Gulfport Hattiesburg Meridian Jackson Kosciusko Presented by: Jeff Moore Phelps Dunbar LLP jeff.moore@phelps.com Materials PowerPoint
Telephone Teach-in: Appealing Medicare Patient Observation Status
1 Telephone Teach-in: Appealing Medicare Patient Observation Status Presenter: Sarah Jane Blake New York StateWide Senior Action Council, Inc. July 26, 2013 2 Agenda What is Observation Status? Discussion
NEW JERSEY ADMINISTRATIVE CODE Copyright 2013 by the New Jersey Office of Administrative Law
5:23A-1.1 Title; authority; scope; intent (a) This chapter, which is promulgated under authority of N.J.S.A. 52:27D-124, 52:17D-198, 40A:14A-43, 40A:14B-76 and 40:55D-53.2a, shall be known as, and may
How To Get A Medicare Payment
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD ORDER OF MEDICARE APPEALS COUNCIL REMANDING CASE TO ADMINISTRATIVE LAW JUDGE Docket Number: M-11-2222 In the case of Eagle Air Medical
Dated 29 February 2016. Flood Re Limited. Payments Dispute Process. Version 1.0
Dated 29 February 2016 Flood Re Limited Payments Dispute Process Version 1.0 1. General 1.1 The following provisions will apply to all disputes referred to and conducted under this Payments Dispute Resolution
Appealing Medical Assistance or Waiver Denials (or Don t t take no for an answer) David Gates PA Health Law Project
Appealing Medical Assistance or Waiver Denials (or Don t t take no for an answer) David Gates PA Health Law Project 1 Who can appeal? Individual in whose name benefits are sought Parent of child under
DISPUTE RESOLUTION AND ADMINISTRATIVE CLAIM PROCESS
City of Cincinnati Proposal Note 025 10/15/2004 DISPUTE RESOLUTION AND ADMINISTRATIVE CLAIM PROCESS The Contractor must follow this process in order to resolve disputes on the project and to seek additional
005. Independent Review Organization External Review Annual Report Form
Title 210 NEBRASKA DEPARTMENT OF INSURANCE Chapter 87 HEALTH CARRIER EXTERNAL REVIEW 001. Authority This regulation is adopted by the director pursuant to the authority in Neb. Rev. Stat. 44-1305 (1)(c),
Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number
Claims and Billing Process AHCCCS Provider Identification Number and NPI Number All United Healthcare Community Plan providers requesting reimbursement for services must be properly registered with AHCCCS
Services Available to Members Complaints & Appeals
Services Available to Members Complaints & Appeals Blue Cross and Blue Shield of Texas (BCBSTX) resolves complaints and appeals related to any aspect of service provided by itself or any subcontractor
Medicare Advantage and Other Medicare Plans 1
2015 National Training Program Module 11 Medicare Advantage and Other Medicare Health Plans Session Objectives This session should help you to Define Medicare Advantage (MA) Plans Describe how MA Plans
Chapter 8: IFSP Implementation and Review
Chapter 8: IFSP Implementation and Review... 1 Flow Chart for No Shows for Service Visits... 6 IFSP Reviews... 11 Annual IFSP... 17 Transition... 26 Discharge and Determination of Child Progress at Exit...
Health care insurer appeals process information packet Aetna Life Insurance Company
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Health care insurer appeals process information packet Aetna Life Insurance Company Please read this notice carefully
How to Request an Initial Evaluation for Special Education Eligibility
2222 West Braker Lane Austin, Texas 78758 MAIN OFFICE 512.454.4816 TOLL-FREE 800.315.3876 FAX 512.323.0902 How to Request an Initial Evaluation for Special Education Eligibility If you or someone you know
ifuse Implant System Patient Appeal Guide
ifuse Implant System Patient Appeal Guide Table of Contents PURPOSE OF THIS BOOKLET...................................................... 2 GUIDE TO THE APPEALS PROCESS..................................................
Compensation and Claims Processing
Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance
General Information on Representing Yourself in a Workers Compensation Case
General Information on Representing Yourself in a Workers Compensation Case Idaho Industrial Commission PO Box 83720 Boise, ID 83720-0041 Telephone: (208) 334-6000 Fax: (208) 332-7558 www.iic.idaho.gov
Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers
Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers Table of Contents Introduction... 5 Prior Authorization... 7 Overview... 7 Step Therapy... 7 Quantity Limits... 7 The Prior Authorization
RAC Preparation 7 Key Steps and Best Practices
McGuireWoods Health Care practice is ranked 6th largest in the country by the American Health Lawyers Association. RAC Preparation 7 Key Steps and Best Practices Elissa K. Moore, Associate 704.343.2218
External Breast Prosthesis. 2012 Copyright, CGS Administrators, LLC.
External Breast Prosthesis 1 Agenda Coverage Criteria Modifier Use Documentation Cert Findings Cert Requirements Jurisdiction C Resources 2 Coverage 3 Coverage Criteria A breast prosthesis can be made
Hon Nikki Kaye Minister for ACC December 2015
Currently accident compensation appeals before the District Court have an average age of 669 days. This is far too long for people waiting for their accident compensation claim to be resolved. As part
Physical Medicine Services Registration and Authorization Program Guide for Prevea360 Providers
Physical Medicine Services Registration and Authorization Program Guide for Prevea360 Providers Introduction... 3 Authorization Program Overview... 3 Prevea360 Health Plans Affected... 3 The Authorization
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD. DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-10-1929
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-10-1929 In the case of Claim for E.M.P. (Appellant) Medicare Secondary Payer ****
The Medical Inquiry and Conciliation Panel Office of Administrative Hearings Department of Commerce and Consumer Affairs State of Hawai`i
A Guide to the Medical Inquiry and Conciliation Panel The Medical Inquiry and Conciliation Panel Office of Administrative Hearings Department of Commerce and Consumer Affairs State of Hawai`i THIS GUIDE
AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT
AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Aetna Medicare Open Plan s terms and conditions 3. Provider
Injured on-the-job? Know Your Workers' Compensation Rights in New Jersey
Page1 Injured on-the-job? Know Your Workers' Compensation Rights in New Jersey HPAE members who are injured or made ill on-the-job may be entitled to cash benefits, medical care, and other benefits under
Key Provisions of Tennessee Senate Bill 200 Effective July 1, 2014, through July 1, 2016
2014 Construction of Statute Definition of Injury (Causation) Revises Section 50-6-116, Construction of Chapter, to indicate that for dates of injury on or after July 1, 2014, the chapter should no longer
HOUSE BILL NO. HB0110. Sponsored by: Representative(s) Jaggi, Harvey and Senator(s) Dockstader A BILL. for
0 STATE OF WYOMING LSO-00 HOUSE BILL NO. HB00 Workers' compensation-attorney fees. Sponsored by: Representative(s) Jaggi, Harvey and Senator(s) Dockstader A BILL for AN ACT relating to workers compensation;
Crime Victim Compensation Application 7 th Judicial District 1140 North Grand Ave, Suite #200, Montrose, CO 81401
Crime Victim Compensation Application 7 th Judicial District 1140 North Grand Ave, Suite #200, Montrose, CO 81401 All claims are reviewed by the Crime Victim Compensation Board (CVC). The CVC board meets
GUARDIANSHIP / CONSERVATORSHIP: What Do I Need to Know?
GUARDIANSHIP / CONSERVATORSHIP: What Do I Need to Know? What is a Guardian? A guardian is a person who is responsible for your personal affairs. A guardian is appointed by a judge after he or she determines
Class Action Settlement Notice Long Form Notice From the United States District Court for the Northern District of Ohio
Class Action Settlement Notice Long Form Notice From the United States District Court for the Northern District of Ohio YOU COULD GET MONEY FROM A CLASS ACTION SETTLEMENT RELATED TO THE REMOVAL OF SPARK
Your Right To Question A Decision Made On Your Supplemental Security Income (SSI) Claim
Your Right To Question A Decision Made On Your Supplemental Security Income (SSI) Claim Your Right To Question A Decision Made On Your Supplemental Security Income (SSI) Claim W e want to be sure that
Notice of Imposition of Civil Money Penalty for Medicare Advantage-Prescription Drug Contract Number: H5985
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PARTS C AND D OVERSIGHT AND ENFORCEMENT GROUP November 6,
Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C
Subscriber Agreement PLAN 65 Medicare Supplement Plan SELECT C MEDICARE SUPPLEMENT SUBSCRIBER AGREEMENT This agreement describes your benefits from Blue Cross & Blue Shield of Rhode Island. This is a Medicare
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD. DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-11-944
DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL Docket Number: M-11-944 In the case of Kaiser Foundation Health Plan/Kaiser Permanente Senior Advantage
A M SA HOUSEHOL D GOOD S DISPUT E SET TLEMENT P R O G R A M
A M SA HOUSEHOL D GOOD S DISPUT E SET TLEMENT P R O G R A M Program Rules for the AMSA Household Goods Dispute Settlement Program As Amended and Effective October 1, 2010 INTRODUCTION The arbitration procedures
The Health Insurance Marketplace: Know Your Rights
The Health Insurance Marketplace: Know Your Rights You have certain rights when you enroll in a Marketplace health plan. These rights include: Getting easy-to-understand information about what your plan
Rules of Arbitration
Rules of Arbitration [Binding] The name Better Business Bureau is a registered trademark of the Council of Better Business Bureaus, Inc. 2010 by the Council of Better Business Bureaus, Inc. Arlington,
FAMILY LAW SECTION, STATE BAR OF NEVADA THE STANDARDS FOR BOARD CERTIFIED SPECIALIZATION IN FAMILY LAW
FAMILY LAW SECTION, STATE BAR OF NEVADA THE STANDARDS FOR BOARD CERTIFIED SPECIALIZATION IN FAMILY LAW 1.0 DURATION OF BOARD CERTIFICATION OF SPECIALIZATION IN FAMILY LAW 1.1 Board Certification of Specialization
SOCIAL SECURITY BENEFITS
SOCIAL SECURITY BENEFITS Social Security is a federal program that pays monthly payments to aged, blind and disabled people. In some cases, dependents and survivors also get benefits. The Social Security
Medicare Program; Pre-Claim Review Demonstration for Home Health Services. AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
This document is scheduled to be published in the Federal Register on 06/10/2016 and available online at http://federalregister.gov/a/2016-13755, and on FDsys.gov CMS-6069-N DEPARTMENT OF HEALTH AND HUMAN
The Real Cost of the Inefficient Medicare RAC Program
HOSPITAL SURVEY REPORT: The Real Cost of the Inefficient Medicare RAC Program The Recovery Audit Contractor (RAC) program was created by Congress to audit providers Medicare claims to identify overpayments
Fraud & Abuse: Part 2
Fraud & Abuse: Part 2 This article was developed from a presentation by Stephen M. Levine, PT, DPT, MSHA, a partner in Fearon & Levine Consulting, at the 2013 FSBPT annual meeting. How some therapists
Medicare Part B - Current Updates October 2015
Medicare Part B - Current Updates October 2015 Disclaimer Every reasonable effort has been made to ensure the accuracy of this information. However, the provider has the ultimate responsibility for compliance
Federal Register / Vol. 80, No. 39 / Friday, February 27, 2015 / Rules and Regulations
Federal Register / Vol. 80, No. 39 / Friday, February 27, 2015 / Rules and Regulations 10611 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 405 [CMS 6055 F]