Guide to EHR s Governmental Appeals Management. Updated: November

Transcription

1 Guide to EHR s Governmental Appeals Management Updated: November

2 Introduction to EHR s Appeals Management Services EHR is committed to helping your hospital respond to the increase in appeals volume associated with the Recovery Audit Contractor (RAC) program, and other Medicare and Medicaid Fee for Service denials. EHR Physician Advisors have extensive experience with all stages of the governmental payor appeals process and have achieved unmatched success in identifying and obtaining the reversal of thousands of inappropriate Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), Medicaid Integrity Contractor (MIC), and Quality Improvement Organization (QIO) medical necessity denials at all levels of appeal. EHR's methodology combines expert physician clinical expertise, focused on medical necessity, with legal and regulatory arguments so all appeal avenues are explored. Governmental payor medical necessity denial appeals require specialized skills and extensive experience in order to achieve optimal results. To that end, EHR utilizes teams of specially trained Government Appeal Physician Advisors, MD/JDs, and JDs. This team brings experience and an intimate knowledge of Medicare and Medicaid appeals processes to the process. EHR appeals RAC, MAC, MIC, and QIO denials based upon the evidence based EHR Logic TM approach to medical necessity, payment rules, regulatory and guidance underpinnings, and points of law. These four pillars of the EHR appeal are the hallmark of the EHR approach and the reason for EHR s singular success. EHR has vast experience managing the entire appeals process through multiple levels of appeal including preparing memoranda and representing hospitals at Administrative Law Judge (ALJ) hearings. EHR has successfully appealed thousands of Medicare and Medicaid related government Intermediary denials. A critical component in the appeals process is timely and complete submission of all appropriate data and documentation associated with the denial. The purpose of this guide is to consolidate the process, forms, and instructions you will need to submit appropriate appeal information to EHR. This guide provides information about the data you will need to submit for each denial, the methods you can select to send that information to EHR, points of contact at EHR, and additional information about what to expect throughout the appeals process. If you have questions regarding EHR s appeals management services, please do not hesitate to contact your EHR Director of Strategic Accounts. We look forward to a continued successful denials and appeals management partnership with you! - 2 -

3 Key Success Factors in the Appeals Process 1. When to Send an Appeal To ensure appropriate appeals preparation time, all denials information should be submitted to EHR 30 calendar days before the appeal due date. In the case where you d want to prevent recoupment, please make sure that EHR is provided with the complete case file within 15 calendar days of the appeal due date. 2. Things You Can Do to Improve the Likelihood of Success Send all requested data. It may seem like a lot of information, but the materials we include on our checklist are the same data we need to make the best appeal on your behalf. Complete the Denial Cover Form. The information in this form allows EHR to quickly assess the denial and prepare your appeal. In the case of an electronic submission through EHR Integrated, the Denial Cover Form is not necessary, unless you want EHR to engage in the Discussion Period, because all of this data is embedded into the EHR Integrated RAC Tracking system. Send any responses you receive within three (3) business days of receipt. In order to keep the appeal process moving as quickly as possible, send appeal responses or any other correspondence from your payors immediately. If you receive this information, please assume that EHR did not receive it and we cannot preserve your rights to the next level of appeal without it. 3. A Few Items of Significance AOR (Appointment of Representation) EHR cannot submit an appeal on behalf of your hospital/ provider without a completed AOR form. This form can be stamped/electronically signed and has to be dated. The date should reflect the date that you are submitting the case to EHR for appeal. Denial Cover Form (or completed EHR Integrated submission outside of Discussion) The Denial Cover Form contains a checklist of required documents and also summarizes key information that allows EHR to expedite assignment of the appeal. Although a combination of documents you provide may contain the information, it is often difficult to locate and will help you make a complete submission each time. Dates on Forms EHR cannot use a Denial Cover Form or AOR Form that has been dated longer than 30 days prior to the date of your case submission. Please make every effort to sign the date on the form and submit to EHR on that same day. Complete Correspondence Each document sent by your payor is significant to our review of the denial and submission of your appeal. Do not assume that the payor provided the same letters, requests, or information to EHR. Timing In order to preserve the full extent of your rights on appeal, it is essential to conduct each appeal action within the prescribed timelines. The best way to assure we meet deadlines is to send complete case information as soon as possible. Personnel Changes Please notify EHR of any personnel changes as soon as possible so we can update our notifications and reports recipient distribution lists

4 Process for Submitting a Medicare Fee for Service Denial to EHR 1. Prepare the copies of the following materials for each denial for submission to EHR: EHR Denial Cover Form (access form in EHR s Compliance Library at Signed AOR Form can be stamped/electronically signed (access form in EHR s Compliance Library at Entire medical record Copies of all written correspondence sent to or received from payor regarding the case Applicable Denial Information: o Denial Letter required for QIO, Medicaid, Commercial Payor, and Managed Medicare/Medicaid Denials o Remittance Advice or FISS Screens MAP 1881 and MAP 1741 required for Pre Pay FI/MAC Denials and all PIP Providers o Demand Letter and Review Results Letter required for RAC, Post Pay FI/MAC, or ZPIC/PSC Denials Note on Recoupment: EHR will not appeal within the appropriate timeframes to automatically stop recoupment or request that the CMS contractor stop recoupment unless specifically requested to do so by the hospital on the EHR Denial Cover Form or otherwise. There is a significant financial impact surrounding the decision to stop recoupment and that decision must be made by the hospital. Note on Redacting of Documents to Preserve Patient Confidentiality (including RAC/Audit Pull Lists): EHR prefers to not receive RAC/Audit Pull Lists from hospital clients as the information on those lists is contained elsewhere in your submission to EHR. However, if the hospital supplies a Pull List or any other documentation that contains information for more than just the patient for whom you are appealing, as a part of the denial information, EHR requires that the hospital black out or delete patient names, HIC numbers, dates of birth and any other identifiable information for all patients in that documentation other than that of the specific patient that is the subject of the appeal as each individual appeal record can only contain information for that particular patient. This will help the hospital and EHR ensure compliance with the requirements that Protected Health Information only be disclosed to authorized parties. The redacting also applies to those hospitals submitting cases through EHR Integrated

5 Hospital Information: Denial Cover Form Please complete all applicable fields below for each denial that is being referred to EHR. Be sure to submit all of the requested documents listed at the bottom of this form to EHR, along with this completed cover form. Patient Information: Facility Number (EHR Assigned): Hospital Name: Health System Name: Hospital Address Line 1: Hospital Address Line 2: Hospital City, State, Zip: Your Name: Your Title: Your Phone Number: Your Address: Denial Information: Type of Denial: RAC FI/MAC QIO ZPIC/PSC Medicaid Managed Medicare Managed Medicaid Commercial Patient Name: Admission Type: Select One Select All That Apply Adult Med/Surg Rehab or LTAC OB/GYN Ped Psych Short Stay Surgery Admit and Discharge Dates: Insurance Policy Number/Member ID: Billing Account Number: Claim Number: Amount Billed: $ Amount Paid: $ Was this case reviewed concurrently by an EHR Physician Advisor? Yes No Level of Care Details: List level of care given by payor for each day of service within admission: Payor/Contractor Name: Appeals Address Line 1: Appeals Address Line 2: Appeals City, State, Zip: Additional Notes/Information: DRG/Case Rates Apply? Yes No Unknown DRG Code: Do you want to prevent recoupment on this case?: Yes No (Medicare and Medicaid Fee-for-Service Only) Do you want EHR to engage the RAC with the Discussion Period?: Yes No Are you a Periodic Interim Payment (PIP) Provider?: Yes No (If yes, please make sure to include the RA showing denial) Please indicate the type of Denial you would like EHR to perform on your behalf: Medical Necessity Coding/DRG Validation Please provide any additional details that would be helpful to EHR: Document Submission Checklist: EHR Denial Cover Form For cases where the Denial is received verbally: Entire Medical Record Denial Issue Date: Signed AOR Form Date of Appeal Deadline: Copies of all written correspondence sent to or received from the federal or state agency, commercial payor or contractor Denial Information see bolded language for specific requirements Denial Information should include: Denial Letter-required for QIO, Medicaid, Commercial, and Managed Medicare/Medicaid Denials Remittance Advice or FISS Screens MAP 1881 and MAP 1741-required for Pre-Pay FI/MAC Denials; and all PIP Providers Demand Letter and Review Results Letter-required for RAC, Post-Pay FI/MAC, or ZPIC/PSC Denials Last Updated: 11/22/11-5 -

6 Helpful Tips for Completing Your EHR Denial Cover Form: Hospital Information Block: Patient Information Block: - 6 -

7 Denial Entity Information Block: Level of Care Details: - 7 -

8 Additional Notes/Information: Document Submission Checklist: - 8 -

9 Medicare Appointment of Representation Beneficiary Name HIC Number Claim Number/Appeal Number Dates of Service Provider (Appellant) Name Provider Address I do hereby swear that I am the above-mentioned provider or have the legal authority to appoint a representative to act on behalf of the above-mentioned provider. Accordingly, I do hereby appoint of Executive Health Resources, Inc. to act as our Representative regarding the appeal of a service for which Medicare has denied/reduced payment or authorization. has accepted this appointment as a Representative, evidence of which can be found in the appeal request on the Medicare Acceptance of Appointment of Representation page. I understand that may be delegating his appointment to a Designee. Provider Signature Date Provider Phone Provider Number SAMPLE Printed Name Executive Health Resources, Inc. MedicareApptRep0211SAG - 9 -

10 Process for Submitting a Medicare Fee for Service Denial to EHR Cont d 2. Submit all of the above materials to EHR via one of the following methods: Mail/Carrier (UPS, FedEx, etc.) Mail all required documentation to EHR using any postal service. EHR will accept hard copy documents or CD/DVD with all required documentation for an appeal. If you are sending multiple patients please include a packing list. Hospitals are encouraged to use a carrier that allows for tracking of delivery. Please send to: Executive Health Resources 1351 N. Belcrest, Suite 100 Springfield, MO If planning to provide documentation on CD/DVD, please follow these guidelines: 1. The name of the facility must be written on the front of the CD. 2. All documents should be in PDF format. 3. The medical record must be in one PDF document and all other documents in separate PDFs. 4. DO NOT secure or password protect the individual PDF documents and/or files on the disc. 5. DO password protect access to the entire CD/DVD and instructions for how to unlock the CD to [email protected]. 6. If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD. Secure File Transfer Protocol (SFTP) Submit required documentation to EHR via Secure File Transfer Protocol (SFTP). If interested in this option, please contact your Strategic Account Director with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, , and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure to ensure the strictest security and compliance with HIPAA regulations. Release Of Information (ROI) Vendor Portal Submit required documentation to EHR for appeal via the hospital s ROI vendor. EHR has established relationships with some ROI vendors. If interested in this option, please contact your Strategic Account Director to determine if EHR is currently working with your ROI vendor. EHR Integrated Submit your appeal request, including required data and documentation via a certified EHR Integrated partner s solution. View a list of certified solutions on EHR s website at

11 Process for Submitting a Medicare Fee for Service Denial to EHR Cont d EHR econnect Portal Submit your appeal request, including required data and documentation through the EHR econnect portal. The portal will also allow you to obtain real time status of all of your open cases. If you d like to use the econnect portal for referring appeals cases, please contact your Director of Strategic Accounts. 3. Following receipt of the denial, EHR will begin its appeals management process. Throughout the active appeals process, if an appeal response is mistakenly sent to the hospital instead of EHR, the response should be immediately sent to the attention of EHR Government Appeals and Regulatory Affairs via fax or For Medicare denials Fax to (610) OR to [email protected] Please add Medicare Appeals Documents in the subject line of your Note on Destruction of Patient Records: EHR does not destroy electronic records unless they are duplicative or incorrectly sent. All case related data is kept indefinitely, with sustained indefinite access control. No unnecessary data are captured, therefore no extraneous data need be destroyed. Hard copy medical records are stored in a secure location until the first level of appeal is submitted or 3 months, whichever is first. The documents are then shredded

12 Overview of EHR s Medicare Appeals Management Process Once a case is referred to EHR for appeal management, EHR will: 1. Review all of the documentation submitted for each denial. If the case is missing key elements required for appeal submission, the client will be notified via . EHR will also be sending a weekly report at the end of the week showing what appeal submissions the hospital has made to EHR that week. 2. Create an appeal letter which addresses medical necessity and/or coding as appropriate, CMS requirements regarding inpatient hospital admissions, coding guidance, any applicable regulation and guidance, applicable evidence based data and expert guidance, and published medical literature. 3. Mail the appeal letter to the appropriate payor, state or Federal agency or contractor by traceable means. All letters are sent to meet the designated deadlines. 4. the remittance advice (RA), appeal result or payor response letter to the hospital when received by EHR. If the hospital receives an appeal results letter, it should be sent to EHR as soon as possible so that EHR can update our records. Note on the Redetermination Level of Appeal Outcome: If the decision is favorable at the Redetermination level of appeal, EHR will not receive notification from the MAC. The hospital will receive the favorable result through a paid RA. The hospital should immediately forward a copy of the paid RA to EHR. 5. Proceed to next level of appeal, if appeal was not successful at prior level. Note on Administrative Law Judge Appeal and Departmental Appeals Board Levels: EHR will notify the hospital before moving on to the Administrative Law Judge (ALJ) and Departmental Appeals Board (DAB) levels of appeal and provide 5 business days for the hospital to consult with EHR or opt out of this appeal level. 6. Prepare memoranda and represent the hospital client at any level of appeal that requires an external or judicial hearing. 7. Prepare and send the hospital client: Notifications when action was taken by EHR and/or is required by the hospital client Electronic copies of all completed letters of appeal and appeal response letters Appeals status reports weekly and monthly Note on Timing and Appeals Status: The timeframe for an appeal that goes full term can be up to 24 months. The status of the appeal may not change for months while each appeal agency reviews the appeal

13 Medicare Appeals Process Overview

14 EHR Key Contacts Government Appeals and Regulatory Affairs Medicare Appeals Team 15 Campus Boulevard Newtown Square, PA Phone: (610) Toll free: (866) Fax: (610) If you are sending cases (hard copy documents or CD) by Mail/Carrier (UPS, FedEx, etc.), please send to the following address: Executive Health Resources 1351 N. Belcrest, Suite 100 Springfield, MO About EHR s Appeals Client Services Teams: The Appeals Client Management Team is the first point of contact for any client questions or concerns regarding retrospective appeals. The team provides a designated resource for clients and EHR associates with questions regarding specific appeals or the EHR appeals process. Client Management Specialists, who are specially trained to answer process questions, check on the status of a retrospective appeal, and to can quickly refer complex questions to the Appeal Management Liaisons. Appeal Management Liaisons work directly with clients to proactively identify and address any questions regarding the retrospective appeal process and provide ongoing education in respect to the appeals process

15 Process for Submitting a Medicaid Fee for Service Denial to EHR 1. Prepare the copies of the following materials for each denial for submission to EHR: EHR Denial Cover Form (access form in EHR s Compliance Library at Signed AOR Form can be stamped/electronically signed (access form in EHR s Compliance Library at Entire medical record Copies of all written correspondence sent to or received from payor regarding the case Applicable Denial Information: o Denial Letter required for QIO, Medicaid, Commercial Payor, and Managed Medicare/Medicaid Denials o Remittance Advice or FISS Screens MAP 1881 and MAP 1741 required for Pre Pay FI/MAC Denials and all PIP Providers o Demand Letter and Review Results Letter required for RAC, Post Pay FI/MAC, or ZPIC/PSC Denials Note on Redacting of Documents to Preserve Patient Confidentiality (including RAC/Audit Pull Lists): EHR prefers to not receive RAC/Audit Pull Lists from hospital clients as the information on those lists is contained elsewhere in your submission to EHR. However, if the hospital supplies a Pull List or any other documentation that contains information for more than just the patient for whom you are appealing, as a part of the denial information, EHR requires that the hospital black out or delete patient names, HIC numbers, dates of birth and any other identifiable information for all patients in that documentation other than that of the specific patient that is the subject of the appeal as each individual appeal record can only contain information for that particular patient. This will help the hospital and EHR ensure compliance with the requirements that Protected Health Information only be disclosed to authorized parties. The redacting also applies to those hospitals submitting cases through EHR Integrated

16 Hospital Information: Denial Cover Form Please complete all applicable fields below for each denial that is being referred to EHR. Be sure to submit all of the requested documents listed at the bottom of this form to EHR, along with this completed cover form. Patient Information: Facility Number (EHR Assigned): Hospital Name: Health System Name: Hospital Address Line 1: Hospital Address Line 2: Hospital City, State, Zip: Your Name: Your Title: Your Phone Number: Your Address: Denial Information: Type of Denial: RAC FI/MAC QIO ZPIC/PSC Medicaid Managed Medicare Managed Medicaid Commercial Patient Name: Admission Type: Select One Select All That Apply Adult Med/Surg Rehab or LTAC OB/GYN Ped Psych Short Stay Surgery Admit and Discharge Dates: Insurance Policy Number/Member ID: Billing Account Number: Claim Number: Amount Billed: $ Amount Paid: $ Was this case reviewed concurrently by an EHR Physician Advisor? Yes No Level of Care Details: List level of care given by payor for each day of service within admission: Payor/Contractor Name: Appeals Address Line 1: Appeals Address Line 2: Appeals City, State, Zip: Additional Notes/Information: DRG/Case Rates Apply? Yes No Unknown DRG Code: Do you want to prevent recoupment on this case?: Yes No (Medicare and Medicaid Fee-for-Service Only) Do you want EHR to engage the RAC with the Discussion Period?: Yes No Are you a Periodic Interim Payment (PIP) Provider?: Yes No (If yes, please make sure to include the RA showing denial) Please indicate the type of Denial you would like EHR to perform on your behalf: Medical Necessity Coding/DRG Validation Please provide any additional details that would be helpful to EHR: Document Submission Checklist: EHR Denial Cover Form For cases where the Denial is received verbally: Entire Medical Record Denial Issue Date: Signed AOR Form Date of Appeal Deadline: Copies of all written correspondence sent to or received from the federal or state agency, commercial payor or contractor Denial Information see bolded language for specific requirements Denial Information should include: Denial Letter-required for QIO, Medicaid, Commercial, and Managed Medicare/Medicaid Denials Remittance Advice or FISS Screens MAP 1881 and MAP 1741-required for Pre-Pay FI/MAC Denials; and all PIP Providers Demand Letter and Review Results Letter-required for RAC, Post-Pay FI/MAC, or ZPIC/PSC Denials Last Updated: 11/22/

17 Helpful Tips for Completing Your EHR Denial Cover Form: Hospital Information Block: Patient Information Block:

18 Denial Entity Information Block: Level of Care Details:

19 Additional Notes/Information: Document Submission Checklist:

20 Medicaid Appointment of Representation Beneficiary Name Medicaid Identification Number Claim Number/Appeal Number Dates of Service Provider (Appellant) Name Provider Address Provider Number Provider Phone Medicaid Contractor I do hereby swear that I am the above-mentioned provider or have the legal authority to appoint a representative to act on behalf of the above-mentioned provider. Accordingly, I do hereby appoint, of Executive Health Resources, Inc. to act as our Representative regarding the appeal of a service for which Medicaid has denied/reduced payment or authorization. has accepted this appointment as a Representative, evidence of which can be found in the appeal request on the Medicaid Acceptance of Appointment of Representation page. I understand that may be delegating his appointment to a Designee. SAMPLE Provider Signature Date Printed Name Executive Health Resources, Inc. MedicaidApptRep0211SAG

21 Process for Submitting a Medicaid Fee for Service Denial to EHR Cont d 2. Submit all of the above materials to EHR via one of the following methods: Mail/Carrier (UPS, FedEx, etc.) Mail all required documentation to EHR using any postal service. EHR will accept hard copy documents or CD/DVD with all required documentation for an appeal. If you are sending multiple patients please include a packing list. Hospitals are encouraged to use a carrier that allows for tracking of delivery. Please send to: Executive Health Resources 1351 N. Belcrest, Suite 100 Springfield, MO If planning to provide documentation on CD/DVD, please follow these guidelines: 1. The name of the facility must be written on the front of the CD. 2. All documents should be in PDF format. 3. The medical record must be in one PDF document and all other documents in separate PDFs. 4. DO NOT secure or password protect the individual PDF documents and/or files on the disc. 5. DO password protect access to the entire CD/DVD and instructions for how to unlock the CD to [email protected]. 6. If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD. Secure File Transfer Protocol (SFTP) Submit required documentation to EHR via Secure File Transfer Protocol (SFTP). If interested in this option, please contact your Strategic Account Director with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, , and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure to ensure the strictest security and compliance with HIPAA regulations. Release of Information (ROI) Vendor Portal Submit required documentation to EHR for appeal via the hospital s ROI vendor. EHR has established relationships with some ROI vendors. If interested in this option, please contact your Strategic Account Director to determine if EHR is currently working with your ROI vendor. EHR Integrated Submit your appeal request, including required data and documentation via a certified EHR Integrated partner s solution. View a list of certified solutions on EHR s website at

22 Process for Submitting a Medicaid Fee for Service Denial to EHR Cont d EHR econnect Portal Submit your appeal request, including required data and documentation through the EHR econnect portal. The portal will also allow you to obtain real time status of all of your open cases. If you d like to use the econnect portal for referring appeals cases, please contact your Director of Strategic Accounts. 3. Following receipt of the denial, EHR will begin its appeals management process. Throughout the active appeals process, if an appeal response is mistakenly sent to the hospital instead of EHR, the response should be immediately sent to the attention of EHR Government Appeals and Regulatory Affairs via fax or For Medicaid denials Fax to (610) OR to [email protected] Please add Medicaid Appeals Documents in the subject line of your Note on Destruction of Patient Records: EHR does not destroy electronic records unless they are duplicative or incorrectly sent. All case related data is kept indefinitely, with sustained indefinite access control. No unnecessary data are captured, therefore no extraneous data need be destroyed. Hard copy medical records are stored in a secure location until the first level of appeal is submitted or 3 months, whichever is first. The documents are then shredded. Note on Medicaid Appeals: States have demonstrated significant variability in managing appeals. This includes different documentation requirements, appeal timelines, appeal levels available, and responsiveness. The EHR team will work directly with the hospital to obtain any addition information necessary to successfully file each Medicaid appeal

23 Overview of EHR s Medicaid Appeals Management Process Once a case is referred to EHR for appeal management, EHR will: 1. Review all of the documentation submitted for each denial. If the case is missing key elements required for appeal submission, the client will be notified via . EHR will also be sending a weekly report at the end of the week showing what appeal submissions the hospital has made to EHR that week. 2. Create an appeal letter which addresses medical necessity and/or coding as appropriate, CMS requirements regarding inpatient hospital admissions, coding guidance, any applicable regulation and guidance, applicable evidence based data and expert guidance, and published medical literature. 3. Mail the appeal letter to the appropriate payor, state or Federal agency or contractor by traceable means. All letters are sent to meet the designated deadlines. 4. the appeal result or payor response letter to the hospital when received by EHR. If the hospital receives an appeal results letter, it should be sent to EHR as soon as possible so that EHR can update our records. 5. Proceed to next level of appeal, if appeal was not successful at prior level. Note on Administrative Law Judge and Other Hearing Level Appeal: EHR will notify the hospital before moving on to the Administrative Law Judge (ALJ) and other Hearing levels of appeal and provide 5 business days for the hospital to consult EHR or opt in to this appeal level. 6. Prepare memoranda and represent the hospital client at any level of appeal that requires an external or judicial hearing. 7. Prepare and send the hospital client: Notifications when action was taken by EHR and/or is required by the hospital client Electronic copies of all completed letters of appeal and appeal response letters Appeals status reports weekly and monthly Note on Timing and Appeals Status: The timeframe for an appeal that goes full term can be lengthy. The status of the appeal may not change for months while each appeal agency reviews the appeal

24 EHR Key Contacts Government Appeals and Regulatory Affairs Medicaid Appeals Team 15 Campus Boulevard Newtown Square, PA Phone: (610) Toll free: (866) Fax: (610) If you are sending cases (hard copy documents or CD) by Mail/Carrier (UPS, FedEx, etc.), please send to the following address: Executive Health Resources 1351 N. Belcrest, Suite 100 Springfield, MO About EHR s Appeals Client Services Teams: The Appeals Client Management Team is the first point of contact for any client questions or concerns regarding retrospective appeals. The team provides a designated resource for clients and EHR associates with questions regarding specific appeals or the EHR appeals process. Client Management Specialists, who are specially trained to answer process questions, check on the status of a retrospective appeal, and to can quickly refer complex questions to the Appeal Management Liaisons. Appeal Management Liaisons work directly with clients to proactively identify and address any questions regarding the retrospective appeal process and provide ongoing education in respect to the appeals process

25 Helpful Definitions Levels of Appeal Redetermination The first level of the Medicare appeals process handled by the Medicare Administrative Contractor (MAC), the entity responsible for processing the Medicare claim. In some jurisdictions, this entity is still called a Fiscal Intermediary (FI). The MAC has 60 days to render a decision from the date they receive the Redetermination request. If an appeal is upheld at this level, the hospital has the right to request a Reconsideration within 180 days of receipt of the decision, unless they want to prevent recoupment (the take back of money). Reconsideration Administrative Law Judge (ALJ) This is the second level of the Medicare appeals process handled by the Qualified Independent Contractor (QIC)(currently MAXIMUS Federal Services). The QIC has 60 days to render a decision from the date they receive the Reconsideration request. If an appeal is upheld at this level, the hospital has the right to request a hearing with an Administrative Law Judge (ALJ) within 60 days of receipt of the decision. There is no opportunity to prevent recoupment at the ALJ level. This is the third level of the Medicare appeals process and can involve a hearing. It is the first opportunity for the hospital to actually speak with a person that will render a decision as to whether the claim should be paid, unless the judge decides in the hospital s favor without the need for a hearing. The ALJ usually takes more than 90 days to render a decision. Departmental Appeals Board (DAB) This is the fourth level of the Medicare appeals process and involves a review of the documents from the prior appeal levels. There is generally no opportunity for a hearing. This level of appeal is generally reserves to attack a judge s decision that the judge applied the wrong guidelines, regulations or laws, failed to apply the correct guidelines, regulations or laws, or improperly applied the correct guidelines, regulations or laws

26 Helpful Definitions Cont d Appointment of Representation (AOR) This form is required by the Centers for Medicare and Medicaid Services (CMS) to allow EHR to represent the hospital in the appeals process. It is partially completed by the hospital and then submitted to EHR for completion. It is submitted with each appeal request. Demand Letter The letter the hospital receives from the RAC requesting repayment based upon the findings of the Review Results Letter. This document triggers the formal appeals process. The hospital has to file an appeal within 120 days of receipt of the decision, unless the want to prevent recoupment (the take back of money). Departmental Appeal Board (DAB) This is a division under the Department of the Health and Human Services that is responsible for overseeing the fourth level of the appeals process. Discussion Period This period is triggered by the hospital s receipt of the Review Results Letter and continues until CMS recoups (takes back) the money from the hospital. It is an opportunity for the hospital to ask the RAC to review the case and perhaps have a discussion with the RAC Medical Director, but is not part of the formal appeals process. If you would like EHR to engage in Discussion on your hospital s behalf, you will need to state this on the EHR Denial Cover Form. If you decide not to engage in Discussion, you can still appeal once you receive a Demand Letter. In this case, please send the appeal to EHR after you have received the Demand Letter. EHR Denial Cover Form This form is completed by the hospital and submitted along with the entire appeal file from the hospital. It sets forth what services the hospital is requesting that EHR perform and serves as a checklist of documents and information that should be submitted. Fiscal Intermediary Shared System (FISS) This is a database of claims and beneficiary information used by the Medicare Administrative Contractors

27 Medicare Administrative Contractor (MAC) Formerly known as the Fiscal Intermediary, this is the entity under contract with CMS to process claims, reopen and revise paid claims based upon data analysis and medical review, and determine whether payment was proper. They are the first level of appeal, or Redetermination. Office of Medicare Hearings and Appeals (OMHA) This is a division under the Department of the Health and Human Services that is responsible for overseeing the Administrative Law Judges (ALJ) and the third level of appeal. Qualified Independent Contractor (QIC) This is the entity under contract with CMS to process the second level of appeal, or Reconsideration. Quality Improvement Organization (QIO) This is the entity under contract with CMS to review claims for quality issues relating to care and medical necessity. They review claims based upon data analysis and medical review, and determine whether payment was/is proper. Recoupment The recovery by CMS of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the amount due. It does not include the hospital sending a check to CMS that is considered a voluntary payment. Recovery Audit Contractor (RAC) This is the entity under contract with CMS to reopen and revise paid claims based upon data analysis and medical review, and determine whether payment was proper. If they find that initial payment was not proper, they either seek repayment (through the MAC) in the case of an overpayment determination, or they refund monies (also through the MAC) in those cases where they determine an underpayment

28 Remittance Advice This is an electronic form that the hospitals obtain from CMS as a result of submitting a claim for payment. Pertinent information about the claim is found on this form, including all beneficiary information, claim payment status, denial information, and appeal rights. Review Results Letter The letter the hospital receives from the RAC advising them of the findings of their review, but does not request repayment. This document triggers the Discussion Period (not part of the formal appeals process). Teleconference Notification A notification of a peer to peer review or a hearing by teleconference to review payment on an admission. Zone Program Integrity Contractor (ZPIC) Also known as Program Safeguard Contractors These entities are under contract with CMS to process referrals of fraud and abuse from the MAC or other contractor