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 increase in appeals volume associated with the Recovery Auditor (RA) program and other Medicare and Medicaid Fee-for-Service denials. EHR Physician Advisors have extensive experience with all stages of the governmental payer appeals process and achieved unmatched success in identifying and obtaining the reversal of thousands of inappropriate Recovery Auditor (RA), Medicare Administrative Contractor (MAC), Medicaid Integrity Contractor (MIC), and Quality Improvement Organization (QIO) medical necessity denials at all levels of appeal. Governmental payer medical necessity denial appeals require specialized skills and extensive experience in order to achieve optimal results. EHR utilizes teams of specially trained clinical professionals with experience and intimate knowledge of Medicare and Medicaid appeals processes. EHR appeals RA, MAC, MIC, and QIO denials utilizing EHR Logic TM, its evidence-based approach to medical necessity, payment rules, and regulatory and guidance underpinnings. These four pillars of the EHR approach is the reason for its success. 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, 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-
EHR Key Contacts EHR Appeals Management Client Services 15 Campus Boulevard Newtown Square, PA 19073 Toll-free: (866) 873-5029 Fax: (610) 557-4729 Email: AppealSupport@ehrdocs.com If you are sending cases (hard copy documents by mail/carrier (UPS, FedEx, etc.), please send to the following address: Executive Health Resources, Inc. 1351 N. Belcrest, Suite 100 Springfield, MO 65802 If you are sending cases via CD/DVD, please send to the following address: Executive Health Resources, Inc. 17 Campus Blvd. Attn: DCG Newtown Square, PA 19073 About EHR s Appeals Management Client Services The Appeals Management Client Services department 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 are specially trained to answer process questions, check on the status of a retrospective appeal, and 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 with respect to the appeals process. -3-
1. When to Send an Appeal Key Success Factors in the Appeals Process To ensure appropriate appeal preparation time, all denial information should be submitted to EHR as soon as all of the required information is available but with a minimum of 15 calendar days prior to either an appeal due date or a recoup due date, if stopping recoupment is desired. Cases submitted with less than 15 calendar days to process may utilize a general appeal model if needed to ensure due date is met. 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 EHR 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 TM, the Denial Cover Form is not necessary. If you wish for EHR to participate in the Discussion period, then the EHR Denial Cover Form is required. Send any responses you receive within three (3) business days of receipt. In order to keep the appeal process moving as quickly as possible, immediately send appeal responses or any other correspondence from your payers. If you receive this information, please assume 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. The form must be completed with the very first case submitted to EHR. An electronic copy of the AOR form can be found in the EHR Compliance Library at www.ehrdocs.com/library. Please note: As CMS periodically updates its guidance and policies, the AOR form may be subject to change and require client hospitals to submit a new version. EHR will communicate any changes as soon as we are notified. EHR 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. -4-
Complete Correspondence Each document sent by your payer is significant to our review of the denial and submission of your appeal. Do not assume that the payer provided the same letters, requests, or information to EHR. If you completed any lower level appeals yourself on this case, be sure to include both a copy of the appeal as well as the results letter from each level of appeal. 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. Cases sent less than 15 days before the appeal due date may impact our ability to file timely clinical appeals. Be advised we will continue to process these cases. Personnel Changes Please notify EHR of any personnel changes as soon as possible so we can update our notifications and reports recipient distribution lists. 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 Signed AOR Form Entire Medical Record Written Correspondence from Payer Denial Letter Remittance Advice or FISS Screens MAP 1714 and MAP 1741 Demand Letter and Review Results Letter Copies of Duplicate Documents (For multiple case submissions) Access form in EHR s Compliance Library at www.ehrdocs.com/library Access form in EHR s Compliance Library at www.ehrdocs.com/library See Note on Page 8 regarding patient confidentiality Copies of all written correspondence sent to or received from payer regarding the case Required for QIO, Medicaid, FFS Medicare, Commercial Payer, and Managed Medicare/Medicaid Denials Required for Recovery Auditors (RA) (if no Demand is issued), Pre-Pay FI/MAC Denials and all PIP Providers Required for RA, Post-Pay FI/MAC, or ZPIC/PSC Denials. If no Demand provided, please provide Post-RA Remittance Advice If you send multiples cases at one time to EHR, please provide separate copies of documents such as audit pull lists for each denial. -5-
Be advised that should you (the provider) opt to send only the post-audit Remit Advice for your overpayment claim (and not the Demand Letter), we cannot guarantee the Medicare Appeals Contractor (MAC) will accept the appeal as valid. The MAC may dismiss the appeal as incomplete due to lack of Demand Letter, which ultimately may negatively impact your overall appeal timeliness. 2. Submit all of the above materials to EHR via one of the following methods: EHR Exchange Submit your appeal request, including required data and documentation, via the EHR Exchange. Through EHR s online portal, client hospitals can submit cases securely for all retrospective appeals. The online portal also provides real-time status of all of your open cases. If you d like to use the portal for referring appeals cases, please contact your Director of Strategic Accounts. 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 www.ehrdocs.com. EHR Enhanced File Transfer Enhanced File Transfer (EFT) allows the hospital to submit appeal files via two secure methods: Secure File Transfer Protocol (SFTP) and Web-based Electronic Transfer using Hyper Text Transfer Protocol Secure (HTTPS). EFT ensures the highest levels of compliance with data security allowing for fast, secure, simple and reliable transfer of files. Both methods meet HIPAA and HITECH security requirements. If interested in this option, please contact your Director of Strategic Accounts with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, email, and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure email 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 Director of Strategic Accounts to determine if EHR is currently working with your ROI vendor. -6-
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. Hard Copy Documents 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 65802 Electronic Documents on CD/DVD If planning to provide documentation on CD/DVD, please follow these guidelines: The name of the facility must be written on the front of the CD. All documents should be in PDF format. The medical record must be in one combined PDF document and all other documents saved as individual PDFs. DO NOT secure or password-protect the individual PDF documents and/or files on the disc. DO password protect access to the entire CD/DVD and email instructions for how to unlock the CD to AppealSupport@ehrdocs.com If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD. Multiple medical records can be placed in one CD/DVD. Mail the disc to the following address: Executive Health Resources 17 Campus Blvd. Attn: DCG Newtown Square, PA 19073 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 EHR via EHR Exchange or to the attention of EHR Government Appeals and Regulatory Affairs via fax or email: For Medicare denials Fax to (610) 557-4729 - OR - Email to AppealSupport@ehrdocs.com Please add Medicare Appeals Documents in the subject line of your email -7-
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. There is a significant financial impact surrounding the decision to stop recoupment and the decision must be made by the hospital. Note on Redacting of Documents to Preserve Patient Confidentiality (including RA/Audit Pull Lists): Other than the patient that is the subject of the appeal, EHR requires the hospital to black out or delete patient names, dates of birth and any other identifiable information for all other patients listed in any documentation submitted to EHR such as audit pull lists. 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. 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 three (3) months, whichever is first. The documents are then shredded. -8-
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 email or posted on the EHR Exchange. At the end of each week, EHR will also send a report of submitted cases from the prior 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 any other pertinent information. 3. Send the appeal letter to the appropriate payer, state or federal agency or contractor by traceable means. All letters are sent according to the designated deadlines. 4. Upon receipt, review and forward the appeals results letter to the hospital. 5. If the hospital receives an appeal results letter, it should be sent to EHR as soon as possible so EHR can update the records. Proceed to next level of appeal, up through reconsideration level and will extend client opt out communication at ALJ level and beyond. 6. Prepare memoranda, if appropriate or required, 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 Final Determination Notice and Case Received reports on weekly basis -9-
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 remittance advice. The hospital should immediately forward a copy of the paid remittance to EHR. 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) level of appeal and provide 14 calendar days to opt out of this appeal level. Conversely, EHR will notify the hospital of the Administrative Law Judge decision and provide 14 calendar days for the hospital to opt in to the Department of Appeals Board (DAB) level of appeal. Note on Timing and Appeals Status: In EHR s experience, the timeframe for an appeal that goes full-term can exceed 24 months. The status of the appeal may not change for months while each appeal agency reviews the appeal. -10-
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 Signed AOR Form Entire Medical Record Written Correspondence from Payer Denial Letter Copies of Duplicate Documents (For multiple case submissions) Access form in EHR s Compliance Library at www.ehrdocs.com/library Access form in EHR s Compliance Library at www.ehrdocs.com/library See Note on Page 14 regarding patient confidentiality Copies of all written correspondence sent to or received from payer regarding the case Required for QIO, Medicaid, FFS Medicare, Commercial Payer, and Managed Medicare/Medicaid Denials If you send multiples cases at one time to EHR, please provide separate copies of documents such as audit pull lists for each denial. 2. Submit all of the above materials to EHR via one of the following methods: EHR Exchange Submit your appeal request, including required data and documentation through the EHR Exchange. Through EHR s online portal, client hospitals can submit cases securely for all retrospective appeals. The online portal also provides real-time status of your open cases. If you would like to use the portal for referring appeals cases, please contact your Director of Strategic Accounts. EHR Integrated EHR is committed to the efficiency and accuracy of the appeal tracking process and, to this end, published an inbound/outbound data exchange interface for appeal tracking providers to access at no cost. EHR has validated that an exclusive group of appeal tracking and workflow/data management solutions integrate with EHR technology and reporting. Working with an EHR Integrated solution enables EHR and the hospital to exchange appeals data and status updates seamlessly. This avoids time-intensive, costly data entry that the hospital would otherwise incur. Furthermore, utilizing an EHR Integrated solution reduces the hospital's administrative processing efforts and optimizes data integrity and completeness throughout the RAC appeals status and data tracking process. View a list of certified solutions on EHR s website at www.ehrdocs.com. -11-
EHR Enhanced File Transfer Enhanced File Transfer (EFT) allows the hospital to submit appeal files via two secure methods: Secure File Transfer Protocol (SFTP) and Web-based Electronic Transfer using Hyper Text Transfer Protocol Secure (HTTPS). EFT ensures the highest levels of compliance with data security allowing for fast, secure, simple and reliable transfer of files. Both methods meet HIPAA and HITECH security requirements. If interested in this option, please contact your Director of Strategic Accounts with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, email, and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure email 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 Director of Strategic Accounts to determine if EHR is currently working with your ROI vendor. 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. Hard Copy Documents 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 65802-12-
Electronic Documents on CD/DVD 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 combined PDF document and all other documents saved as individual 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 email instructions for how to unlock the CD to AppealSupport@ehrdocs.com 6. If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD. 7. Multiple medical records can be placed in one CD/DVD. Mail the disc to the following address: Executive Health Resources 17 Campus Blvd. Attn: DCG Newtown Square, PA 19073 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 EHR via EHR Exchange or to the attention of EHR Government Appeals and Regulatory Affairs via fax or email: For Medicaid denials Fax to (610) 557-4729 - OR - Email to AppealSupport@ehrdocs.com Please add Medicaid Appeals Documents in the subject line of your email -13-
Note on Redacting of Documents to Preserve Patient Confidentiality (including RA/Audit Pull Lists): Other than the patient that is the subject of the appeal, EHR requires the hospital to black out or delete patient names, dates of birth and any other identifiable information for all other patients listed in any documentation submitted to EHR such as audit pull lists. 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. 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 and other appeal related documents are stored in a secure location until the first level of appeal is submitted or three (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 additional information necessary to successfully file each Medicaid appeal. -14-
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 email. EHR will also send a report on Wednesday of submitted cases from the prior week (Sunday to Saturday) 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 any other pertinent information. 3. Send the appeal letter to the appropriate payer, state or federal agency or contractor by traceable means. All letters are sent to meet the designated deadlines. 4. Email the appeal result or payer 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 EHR can update the records. 5. Proceed to next level of appeal, if appeal was not successful at prior level. 6. Prepare memoranda, if appropriate or required, 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 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 14 calendar days for the hospital to opt in to this appeal level. 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. -15-
Key Provider Responsibilities Submit all denial information as soon as all required information is received. Information must be received with a minimum of 15 calendar days prior to the appeal or recoupment (if applicable) due date. Submit all required documentation Copy of complete medical record as submitted to state, federal agency or contractor. Assignment of Representation (AOR) signed. Denial cover form with all pertinent fields completed, including denied amount. Copy of all correspondence sent to or received from the state, federal agency or contractor. Copy of all applicable denial information. Demand/denial letter/review results letter Remittance advice or FISS Screens Map 1714 and MAP 1741 Response letters Utilize current version of all forms located in the EHR Compliance Library (www.ehrdocs.com/library). Review all notifications, documents and reports sent from EHR via secure email and/or available on EHR Exchange, EHR s online portal for case submission and real-time status reports. NOTIFICATIONS Incomplete Information Incomplete Follow Up Clinically Insufficient Denial Information Missing Demand Letter Expedited Case Hearing Recommendation Scheduled Conference Call Response Required X X X X X Review and Reconciliation Validation Recommended -16-
REPORTS Weekly Case Received Report Weekly Chart Request Report (Concurrent Denials Only) Weekly Final Determination Report Monthly Status Reports Monthly Program Results Response Required Review and Reconciliation Validation Recommended X X X X X DOCUMENTS Appeal Letters Payer Acknowledgement Letters Response Letters Payer Requests for Additional Information Payer Warning and Delinquent Letters Hearing Notifications Hearing Memo Response to Notice of Hearing Response Required X Review and Reconciliation Validation Recommended -17-
Frequently Asked Questions What is the turnaround time for case processing? Our goal is to send all appeals in a timely fashion to meet your appeal deadline once we receive all required documentation. There are variations in turnaround times based on volumes and payers. Our target is 30 days or less for EHR turnaround time. Why is there no clinical information in my appeal letter? There may be instances when we received your appeal request too close to the appeal deadline. In these instances, we will expedite the appeal with a non-clinical appeal letter to preserve the appeal rights. A clinical review will be included at subsequent levels of appeal. After the initial appeal level, do I need to follow up for subsequent levels? The Appointment of Representation Form authorizes EHR as a representative of the provider. The payer should send all correspondence directly to EHR. However, this does not always occur. If the payer sends the outcome response directly to the provider, the provider must send the outcome response to EHR. Without the outcome response, EHR will not know that the case requires an additional appeal or the deadline associated with the next level of appeal. Can you expedite our cases? We make every effort to expedite all appeals well in advance of the appeal deadline. However, this will be impacted by the timeliness of receipt of the appeal. What is your appeal follow up process? We send delinquent notices on day 75. If the case is still unresolved at day 120 we reach out telephonically to the payer. If the payer indicates that it is still in process, we set a follow-up based on information from the payer on when it will be resolved. If it is resolved, we request a copy of the decision. Will you appeals all cases sent to you? The appeals department will appeal your case if we find, after review, that we can present a defensible argument. -18-
Where can I obtain the latest version of EHR forms? You can register on line for EHR s Compliance Library to access the most current version of EHR forms, guides and continuing education information. To register for the Compliance Library go to www.ehrdocs.com. Who do I contact with appeal questions? You can contact our Client Management Specialists via email at appealsupport@ehrdocs.com or by telephone at 866-873-5029 What is the best way to check the status of my appeals? EHR Exchange is an online portal that provides real-time status of all open cases. Providers can also submit appeal cases securely via EHR Exchange. Contact your assigned Appeals Management Liaison for access. -19-
Helpful Definitions Redetermination Reconsideration Administrative Law Judge (ALJ) Departmental Appeals Board (DAB) LEVELS OF APPEAL The first level of the Medicare appeals process is 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). 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. 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. There is no opportunity to prevent recoupment at the ALJ level. 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 allows clients to appeal an administrative law 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. -20-
Appointment of Representation (AOR) Demand Letter Discussion Period EHR Denial Cover Form Fiscal Intermediary Shared System (FISS) Medicare Administrative Contractor (MAC) Office of Medicare Hearings and Appeals (OMHA) 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. The letter the hospital receives from the MAC 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 they want to prevent recoupment (the take-back of money), which requires filing of the appeal within 30 days of the receipt of the decision. This period is triggered by the hospital s receipt of the Review Results Letter. It is an opportunity for the hospital to ask the RA to review the case and perhaps have a discussion with the RA 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 or post-audit remit advice. In this case, please send the appeal to EHR after you have received the Demand Letter. 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. This is a database of claims and beneficiary information used by the Medicare Administrative Contractors. 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. 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. -21-
Qualified Independent Contractor (QIC) Quality Improvement Organization (QIO) Recoupment Recovery Auditor (RA) Remittance Advice This is the entity under contract with CMS to process the second level of appeal, or Reconsideration. 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. 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. 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. 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 Teleconference Notification Zone Program Integrity Contractor (ZPIC) Also known as Program Safeguard Contractors The letter the hospital receives from the RA 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). A notification of a peer-to-peer review or a hearing by teleconference to review payment on an admission. These entities are under contract with CMS to process referrals of fraud and abuse from the MAC or other contractor. -22-
Patient and Hospital Information EHR Appeals Denial Cover Form Please complete all applicable fields below for each denial that is being referred to EHR. The information in Green is optional. Submitted By: Submitter Phone: Submission Date: Patient Name: Hospital Name: Hospital Address: Hospital City: Hospital State: Zip: Facility Number (EHR Assigned): Admit and Discharge Dates: Start of Service Date: Time: Source: How was this billed? o IP o OBS o OP Was EHR Physician recommendation followed? o Yes o No o Not Concurrently Reviewed If concurrently reviewed, what was the EHR recommendation? o IP o OBS o OP o Other Type of Denial: o RA Medicare Pre-Payment Rev. o FI/MAC o QIO o ZPIC/PSC o Medicaid o Managed Medicare o Managed RECOUPMENT Medicaid o Commercial EHR does not automatically prevent Recoupment: recoupment. That is a decision for Do you want to prevent recoupment the client on to this make. case?: o Yes o No (Medicare and Medicaid Fee-for-Service Only) REQUIRED FOR MEDICAID FEE FOR SERVICE AND COMMERCIAL DENIALS List Dates Denied/Downgraded and Level of Care by Payor: o Per Diem o DRG o Unknown DRG Code: Please indicate the type of Denial you would like EHR to perform on your behalf: o Medical Necessity o Coding/DRG Validation Please provide any additional details that would be helpful to EHR: Insurance Policy Number/Member ID: Billing Account Number: Claim Number: Amount Billed: $ Amount Paid: $ Amount Denied $ FOR COMMERCIAL DENIALS ONLY Payer/Contractor Name: COMMERCIAL DENIALS Appeals Address Line This 1: information is for commercial Appeals Address Line payers 2: only including Managed Appeals City, State, Zip: Medicare and Medicaid Appeal Due Date: Does Payer Have External Appeals Level? o Yes o No o Unknown Do you want EHR to engage the RA with the Discussion Period?: o Yes o No DISCUSSION Please be advised the Discussion is Are you a Periodic Interim Payment (PIP) Provider?: o Yes o No not peer to peer but written form. (If yes, please make sure to include the RA showing denial) For cases where the Denial is received verbally: Denial Issue Date: Date of Appeal Deadline: Document Submission Checklist SELECT ONE o Adult o Ped CHECK ALL THAT APPLY FOR REHAB DENIALS o OPTIONAL NCD/LCD o INFORMATION Pre-Admission o IRF- Patient o While Psych the information Screening is not required, Assessment o it LTAC will allow EHR to provide more Instrument detailed reports o Post and analytics o on Individualized the effectiveness of Admission your retrospective Comprehensive appeal programphysician Plan of Care Evaluation o EHR Denial Cover Form AOR FORMS o Entire Medical Record Submit with first denial to EHR o Signed AOR Form o Copies of all written correspondence sent to or received from the federal or state agency, commercial payor or contractor o Denial Information should include: Denial Letter-at a minimum is needed for QIO, Medicaid, Commercial, and Managed Medicare/Medicaid Denials Remittance Advice or FISS Screens MAP 1714 and MAP 1741-required for RAC (if no Demand is issued), Pre-Pay FI/MAC Denials and PIP Providers Demand Letter recommended for RA, Post-Pay FI/MAC, or ZPIC/PSC Denials. If no Demand provided, please provide Post-RA Remittance Advice Review Results Letter required for Discussion Be advised that should you (the provider) opt to send only the post-audit Remit Advice for your overpayment claim (and not the Demand Letter), we cannot guarantee the Medicare Appeals Contractor (MAC) will accept the appeal as valid. The MAC may dismiss the appeal as incomplete due to lack of Demand Letter, which ultimately may negatively impact your overall appeal timeliness.
Appointment of Representation Provider (Appellant) Name Provider Phone Number Provider Address 10-digit National Provider Identifier (NPI) Date pl Provider Signature e 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 Godffery Tang, MD, of Executive Health Resources, Inc. to act as our Representative regarding the appeal of items or services for which payment or authorization has been denied/reduced. Dr. Tang has accepted this appointment as a Representative, but I understand that Dr. Tang may be delegating his appointment to one or more Designees, and I consent to that delegation. Printed Name Sa m Godffery Tang, M.D., of Executive Health Resources, Inc., a Business Associate of the above-mentioned provider, hereby accepts the appointment as a Representative of said provider for the appeal of items or services for which payment or authorization has been denied/reduced. Dr. Tang hereby delegates his appointment to the Designee listed below (if completed), who accepts the delegation and agrees to comply with the requirements of representation. Representative Signature Date Godffery Tang, M.D. Printed Name Designee Signature Date Printed Name 17 Campus Blvd.; Newtown Square, PA 19073 Address of Representative/Designee Executive Health Resources, Inc. ApptRep1013-24- (610) 557-4900 Representative/Designee Phone Number