How to check Medicare appeal status online and RR Medicare

Appeal status lookup – Part B help guide

The appeals status lookup tool enables providers to check the status on active redeterminations to confirm if the appeal has been received by First Coast Service Options.

When using the appeals status lookup, all fields are required.

http://medicare.fcso.com/Appeals/271084.asp

1. First, select your line of business (Part A or Part B) for the Medicare Plan field. Note: If you do not select your line of business first, the remaining dropdown menus for each field will be unavailable.

2. Next select your location (Florida, Puerto Rico, or the U.S. Virgin Islands).

3. Select the third drop down to search by Case Control Number (CCN), Provider Transaction Access Number (PTAN), or PTAN and Internal Control Number (ICN). The appropriate numbers should be entered into the Value field or PTAN/ICN for that option.


How do I submit an Appeal online?

Answer:
You can submit an Appeal online through our eServices tool. If you have an EDI Agreement on file with Medicare, you can register for eServices. If you are already a registered user in eServices you can immediately begin submitting Appeals through our 'Secure Forms' section of the tool.

The 'Secure Forms' section is on the 'Messaging/Forms' tab. This is on the menu once you successfully log in. You should see the 'Secure Forms' button to access available forms. Answer the questions on the page, and the forms available will appear as links at the bottom of the page.

Once you select the option to submit a 'Secure Form,' a pre-populated form will appear with the information we have on file from your registration record. This will save you several steps. Then fill in all the information that is required for an appeal request (they are highlighted with red 'asterisks'). Be sure to add attachments to support your appeal request. You may attach an unlimited number of PDF attachments to each form. Each attachment can be up to 40 MB in size. The total size of all attachments on each ADR form can be no more than 150 MB.  

If you have any difficulties in uploading attachments or submitting the form, view our FAQ 'How do I upload attachments to an Appeal request' for more information.

How do I upload attachments to an Appeal request?

Answer:
You may add attachments up to 40 megabytes (MB) each to a form. While there is no longer a limit to the number of files that can be attached to this form, the combined size of all attachments cannot exceed 150 MB. All attachments must be PDF documents. Most scanners have the ability to save documents in the PDF format. If you receive an error when uploading the file, your form will refresh with the error listed at the top of the page, and the PDF will no longer be attached. Errors can occur if the PDF is corrupt or if it was not created using PDF software. For example, you cannot change a file extension to PDF. It will not be in the correct PDF format and you will be unable to upload it.

If your file is over 40 MB, you will want to break it down into smaller files in order to attach it to your form. You can do this through your PDF software or by changing your original files and creating the PDFs again.

How can I check the status of my Appeal request submitted through eServices?

Answer: 
When you are logged into eServices, you can use the Document Control Number (DCN) that is assigned to your request to look up form processing status and view your submitted forms. When you open the confirmation email that has the DCN, you can click on the DCN in the message to look up the status of your form. In addition, you may view the documents you submitted by clicking on the View Documentation button.

When you are logged into eServices, you can also access the status look-up by clicking the 'Get Status' button on the Messaging/Forms tab. You will need to input the DCN to view the status through this screen.

Where do I find the CCN?

• CCNs may be obtained through searching the tool by PTAN
OR
• You may call the Interactive Voice Response (IVR) follow the prompts to select status information followed by claim status.

Where do I find the ICN?
• ICNs may also be obtained from your remittance advice.
OR
• You may call the Interactive Voice Response (IVR) follow the prompts to select status information followed by claim status.

4. Once all fields have been completed click the Submit button. Note: Providers with multiple appeal records may experience a slower loading time. Please allow up to 30 seconds for the results to load. We appreciate your patience.


To search using another value, click the Search Again link above the results.

Results are sorted by case received date. You may sort by any category, ascending or descending, by clicking on the column header. To change the order, simply click the column header again.

If multiple pages of results are found, use the scrolling menu bar to view the bottom results. You may also use the page number and/or arrow links found at the top or bottom of the results to view different pages. Note: You may experience a slight delay when changing pages. We appreciate your patience.
Important reminders

• Please allow 15 days after you have submitted your appeal request before checking its status in the lookup tool or contacting customer service.

• Appeals involving multiple claims may be identified by searching on the first claim listed on your request for redetermination. There will not be a separate listing for each claim on the redetermination.

• Once the request has been received, First Coast may take up to 60 days to issue a written decision on the redetermination request.

• Please keep in mind that the status tool is only as accurate as the data supplied to First Coast on the

Redetermination Request form. Status cannot be located if data was missing from your redetermination.

• Appeals which have been finalized will no longer display in the tool.


Check the status of your appeal

Once your redetermination request has been finalized, you may use SPOT to check the status of your claim. Be sure to use the new internal control number (ICN) number you received when you submitted your request. You may also use the Interactive Voice Response (IVR) system to check the status of your claim once your appeal has been finalized.

If a claim appeal has been finalized, it will not display in the appeal status search tool. Providers will receive correspondence within 15 days notifying them of the results of their appeal.

Claim reconsideration

If a provider is not satisfied with First Coast’s redetermination decision, they may take the claim to the second level of appeal: reconsideration. A qualified independent contractor (QIC) conducts all claim reconsideration requests. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request reconsideration. First Coast offers online forms for providers to contact the QIC to review their reconsideration request.

Medicare Appeal time limit - Five level of appeal

When to file an appeal

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

The five levels of appeals, listed in order, are:

Appeal level Time limit for filing request Where to file an appeal


First level: Redetermination 120 days from the initial claim determination Medicare administrative contractor (MAC

Second level: Reconsideration 180 days from the redetermination decision Qualified independent contractor (QIC)

Third level: Administrative law judge hearing (ALJ) 60 days from the date of the reconsideration decision Office of Medicare Hearings and Appeals

Fourth level: Medicare Appeals Council 60 days from the date of the ALJ decision Departmental Appeals Board

Fifth level: Judicial review: 60 days from the date of the Medicare Federal District Court

Submit request by:

Monetary threshold for requests made on or after January 1, 2015: $1,460. For requests made on or after January 1, 2016, the threshold is $1,500.


Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Common reason for adjusting and reopening claims FAQ

Q: What are some common situations when I can or cannot adjust or reopen claims?

A: Providers are responsible in determining when it is appropriate to make corrections to paid (status/location P/B9997) or rejected (status/location R/B9997) claims. Listed below are some helpful hints in determining when you can or cannot correct

Clerical or minor claim error corrections

• Mathematical or computational mistakes
• Transposed providers or diagnostic codes
• Inaccurate data entry
• Misapplication of fee schedule
• Computer errors
• Denial of clams as duplicates which the party believes were incorrectly identified as a duplicate
• Incorrect data items, such as provider number, use of a modifier or date of service

Tolerance guidelines for adjusting hospitals and skilled nursing facilities (SNF) claims

• Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non-covered days)
• Blood deductible
• Change in the Part B cash deductible of more than $1.00
• Inpatient hospital cash deductible of more than $1.00
• Servicing hospital or SNF provider number
• Hospital outlier payment
• Discharge status

Adding charges or services

• Providers may adjust claims (TOB xx7) to add charges or services when the claim is within the timely filing period.

• Providers are not permitted to add charges or services on an initial bill after the expiration of the time limitation for filing a claim.

• Click here for additional information on the timely filing guidelines.


Hospital diagnosis related group (DRG) claim adjustments

• Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.

• Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.
Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments

• SNF adjustments to change in HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.

Medically denied claim

• It is not appropriate to adjust claims that have medical review (MR) denials (status/location D/B9997), or paid claims with line item(s) denials.

• Medicare administrator contractors (MACs) will not allow claim lines that have been denied through a MR process (for example, MR, recovery audit contractor (RAC), comprehensive error rate testing (CERT), office inspector general (OIG), quality improvement organization (QIO), etc.) to be reopened.

• Click here to review the process on how to determine when a claim was medically reviewed and how to make changes.

• Providers must submit appeal request for claim denials based on medical records, including failure to respond to medical record requests.



Additional reminders

• Do not adjust claims in status/location P/B9996 (payment floor) until they have reached final disposition.
• Claims in status/location P/B7516 or R/B7516 (Medicare secondary payer post pay) will be held for at least 75 days (CMS cost avoidance savings), and cannot be adjusted until they have reached final disposition.
• Third party payer error in making primary payment does not constitute “good cause” for the purpose of reopening a claim beyond one year of the initial determination.
• A contractor’s decision to reopen or not reopen a claim, regardless of the reason for the decision, is not subject to an appeal.
• A reopening will not be granted if an appeal decision is pending or in process.

Q: What is the difference between a claim reopening and an adjustment?

A: Reopening’s are different from adjustment bills based on the following rules:

• Adjustment bills are subject to normal claims processing timely filing requirements (that is, filed within one year of the date of service).

• Reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed (for example, claim determinations may be reopened within one year of the date of receipt of the initial determination for any reason, or within one to four years of the date of receipt of the initial determination upon a showing of good cause). Reopening’s are only allowed after the normal timely filing period has expired.
Providers that need to correct or supplement information on paid (status/location P/B9997) and/or rejected (status/location R/B9997) claims may refer to the following:

Claim adjustment guidelines

• Providers may submit adjustment claims (type of bill (TOB) xx7) to correct errors or supplement a claim when the claim remains within the timely filing limits.

• Examples of timeliness for filing claim adjustments:

Timely filing period – Use TOB xx7

Claim “through” date Remittance advice date Adjustment period (based on “through” date)

10/01/14 11/01/14 11/02/14 – 09/30/15

10/01/14 03/31/15 04/01/15 – 09/30/15

10/01/14 09/30/15 N/A – timely filing period has elapsed

Claim reopening guidelines

• Prior to January 1, 2016, providers submitted the timely filing exception form for preapproval on claim(s) requiring correction that were beyond the timely filing limit.

• Effective on/after January 1, 2016, providers billing electronic media (EMC) or direct data entry (DDE) claims must utilize the new reopening process (TOB xxQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill is not allowed.

• In an effort to streamline and standardize the process for claim reopening with the ‘Q” frequency code and adjustment reason codes (ARC), the Centers for Medicare & Medicaid Services (CMS) issued

• Examples of timelines for filing claim reopenings:

Beyond timely filing period – Use TOB xxQ

Claim “through” date Remittance advice date Reopening period – ARC=R1 (based on RA date) Reopening period – ARC=R2 (based on RA date) Reopening period – ARC=R3 (based on RA date)

10/01/14 11/01/14 10/01/15 - 10/31/15 11/01/15 - 10/31/18 11/01/18 and beyond

10/01/14 03/31/15 10/01/15 – 03/30/16 03/31/16 – 03/30/19 03/31/19 and beyond

10/01/14 09/30/15 10/01/15 – 09/30/16 10/01/16 – 09/29/19 09/30/19 and beyond

Claim reopening Guidelines

Q: What is the difference between a claim reopening and an adjustment?

A: Reopening’s are different from adjustment bills based on the following rules:

• Adjustment bills are subject to normal claims processing timely filing requirements (that is, filed within one year of the date of service).

• Reopenings are subject to timeframes associated with administrative finality and are intended to fix an error on a claim for services previously billed (for example, claim determinations may be reopened within one year of the date of receipt of the initial determination for any reason, or within one to four years of the date of receipt of the initial determination upon a showing of good cause). Reopening’s are only allowed after the normal timely filing period has expired.

Providers that need to correct or supplement information on paid (status/location P/B9997) and/or rejected (status/location R/B9997) claims may refer to the following:

Claim adjustment guidelines

• Providers may submit adjustment claims (type of bill (TOB) xx7) to correct errors or supplement a claim when the claim remains within the timely filing limits.

• Click here for additional information on the timely filing guidelines.

• Click here to review the claim data elements required for adjusting and/or canceling claims.

Claim reopening guidelines

• Prior to January 1, 2016, providers submitted the timely filing exception form for preapproval on claim(s) requiring correction that were beyond the timely filing limit.

• Effective on/after January 1, 2016, providers must utilize the new reopening process (TOB xxQ) when the need for correction is discovered beyond the claim timely filing limit; an adjustment bill is not allowed.

• CMS released special edition MLN Matters® article SE1426 external pdf file, to assist providers with coding instructions and billing scenarios for submitting requests to reopen claims that are beyond the claim filing timeframe.

Examples of timelines for filing adjustments and reopenings:

Timely filing period – Use TOB xx7

How to appeal against PQRS payment adjustment ?

2016 PQRS Payment Adjustment and Informal Review Process

On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.

If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:

• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.

https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

• See the fact sheet and Analysis and Payment web page for more information

For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.

When to file an appeal - Big question in Medical billing

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

Appeal level	Time limit for filing request	Where to file an appeal
First level: Redetermination	120 days from the initial claim determination	Medicare administrative contractor (MAC)
Second level: Reconsideration	180 days from the redetermination decision	Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)	60 days from the date of the reconsideration decision               Submit request by: Monetary threshold for requests filed before December 31, 2014: $140 Monetary threshold for requests filed on or after January 1, 2015: $150	Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council	60 days from the date of the ALJ decision	Departmental Appeals Board
Fifth level: Judicial review:	60 days from the date of the Medicare Appeals Council decision                                 Submit request by: Monetary threshold for requests made before December 31, 2014: $1,430. Monetary threshold for requests made on or after January 1, 2015: $1,460.	Federal District Court

Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

Part B clerical reopening

A clerical error could occur when one of the following happens to your claims:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service

There are two options for conducting a clerical reopening of a claim:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
• For the IVR reopening request help sheet, click here .
• For reopening requests in writing, use the clerical reopening .

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to the an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.
• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.



Difference between appeal and Grievance

Appeal: A type of complaint a member (or an authorized representative) makes when the member disagrees with an action taken or wants Amerigroup to reconsider a decision. Complaint: Any expression of dissatisfaction to a Medicare health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made orally or in writing. This can include concerns about the operations of providers or Medicare health plans such as: waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to enrollees, the claims regarding the right of the enrollee to receive services or receive payment for services previously rendered. It also includes a plan’s refusal to provide services to which the enrollee believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievance and/or appeal process.

Grievance: Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare  health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

An Appointment of Representative (AOR) Form is required if someone other than the member is filing a complaint or appeal on behalf of the member. There are some exceptions: Medical Doctors are not required to fill out an AOR when initiating an appeal for a Part C (Medical Appeal). However, The Centers for Medicare & Medicaid Services (CMS) require an AOR from Medical Doctors for Part D (Pharmacy) appeals, except for expedited Part D appeals. Personal Representative Forms will not be accepted in lieu of an AOR. The appeal timeframe will start once the AOR is signed by the member and representative and returned to the Medicare Complaints Appeals and Grievances (MCAG) department.



Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim
Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?
A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.
Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.
The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.


Additional records submission during appeals FAQ

Q: During the appeal process, at what point can additional records be submitted?
A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery auditor (RA) determination, the RA will forward the medical records they receive to the affiliated contractor, or First Coast Service Options Inc.

Departmental appeals board (DAB) FAQ
Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?
A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.

Amount in controversy (AIC) FAQ
Q: What does the term "amount in controversy" mean?
A: The amount in controversy (AIC) is the minimum threshold amount in dispute you must have in order to request the administrative law judge (ALJ) and judicial review levels in the appeal process. Click here external link for the current AIC for the ALJ level; click here external link for the current AIC for the Federal judicial review.

What is considered a relevant appeal FAQ
Q: Is there a resource for providers or beneficiaries that outlines what services or items can be appealed?
A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.

Resubmission of denied claim FAQ
Q: Can we resubmit a claim that was denied by the recovery auditor (RA) if we determine the incorrect code was submitted?
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.

Reason codes for denied claims FAQ
Q: What are the reason code ranges for claims when they have denied?
A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a "5". If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a "7", which is a non-medical denial.
Click here for the description of a Medicare Part A reason code. Enter the reason code into the box and click the submit button.


Appeals FAQs
Q: Can I resubmit or adjust a claim when an appeal is processing?

A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.

Filing claim to Medicare after offset from Medicare advantage plan (HMO)

Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:
• prior enrollment of the beneficiary in an MA plan or PACE provider organization;
• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;
• the effective date of the disenrollment; and,
• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.
(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.
(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

Medicare incarceration recoupment and appeal option

RECOUPMENTS 

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue? 

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest? 

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction? 

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid? 

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim? 

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

RECOUPMENTS

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue?

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest?

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction?

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid?

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim?

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

Q2: Once CMS reprocesses the inappropriate claim denials/cancellations, will there be a way for providers to appeal denied claims that were deemed appropriate even if the time limits for filing appeals expired?

A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.
A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.

DEFINITIONS - Complaint, Grievance, Appeal, reconsideration , Quality improvment organization (QIO)

Complaint:
Any expression of dissatisfaction by a Member, including dissatisfaction with the administration, claims practices, or provision of services, which related to the quality of care provided by a provider pursuant to the organization’s contract and which is submitted to the organization or to a state agency.  

Grievance:
Any complaint or dispute, other than one involving an organization/coverage determination, expressing dissatisfaction  with  the  manner  in  which  CarePlus  or  delegated  entity  provides  health  care  services, regardless of whether any remedial action can be taken.  An enrollee or their representative may make the complaint or dispute, either orally or in writing, to CarePlus, provider or facility.  An expedited grievance may also include a complaint that CarePlus refused to expedite an organization/coverage determination, reconsideration or redetermination or invoked an extension to an organization/coverage determination or reconsideration/redetermination time frame.

In  addition,  grievances  may  include  complaints  regarding  the  timeliness,  appropriateness,  access  to, and/or  setting  of  a  provided  health  service,  procedure,  or  item.    Grievance  issues  may  also  include complaints  that a  covered health service procedure or item  during  a course of treatment  did not  meet accepted standards for delivery of health care.

Quality Improvement Organization (QIO):
Organizations comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare enrollees.  QIOs review complaints raised by  enrollees  about  the  quality  of  care  provided  by  physicians,  inpatient  hospitals,  hospital  outpatient department, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans,  and  ambulatory  surgical  centers.  The  QIOs  also  review  continued  stay  denials  for  enrollees receiving care in acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs, and CORFs.

Initial determination (Organization Determination):
A member must ask for a standard organization determination by making a request with the Plan, or if applicable, the entity responsible for making the determination (as directed by the Plan), in accordance with the following: the request may be made orally or in writing, except where the request is for payment.

An  organization  determination  is  any  determination  made  by  the  Plan  with  respect  to  any  of  the following:

** Payment for temporarily out of the area renal services, emergency services, post-stabilization care or urgently needed services.
** Payment for any other health services furnished by a provider or supplier other than CarePlus, that the Member or former Member believes are covered under Medicare; or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by CarePlus.
** A refusal by CarePlus to provide or pay for services in whole or in part, including the type or level of services that the Member believes should be furnished or arranged for by CarePlus.
** Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment.
** Failure of CarePlus to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

Appeal:  
Any of the procedures that deal with the review of adverse organization determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the member), or any amounts the enrollee must pay for a service as defined in 42 CFR 422.566 (b).  These procedures include reconsideration by the Health plan and if necessary, an independent review entity, hearings before Administrative  Law  Judges  (ALJ’s),  review  by  the  Medicare  Appeals  Council  (MAC),  and  judicial review.

Reconsideration:   

A member’s first step in the appeals process after an adverse organization determination; the health plan or independent review entity may re-evaluate an adverse organization determination, the findings upon which it was based, and any other evidence submitted or obtained.

What is Expedited Appeals Expedited Appeals

An expedited appeal is a review of a time-sensitive adverse organization determination or coverage determination that a member believes that he/she is entitled to receive, including:

** Any delay in provding, arranging for, or approving health care services/medications that would adversely affect the health of the member

** Reduction or stoppage of treatment or services that would adversely affect the member’s health

Note: Time-sensitive is defined as a situation in which applying the standard decision time frame could seriously jeopardize a member’s life, health, or ability to regain maximum function.

Members, their representatives, or any treating or prescribing physician (regardless of whether the provider is affiliated with Tufts Medicare Preferred HMO) can request an expedited appeal. Verbal and written requests for expedited appeals are accepted. If the request meets the necessary time-sensitive criteria, a decision will be made within 72-hours of receipt of the request, unless an extension is needed. Extensions of up to 14 calendar days can be granted if in the best interest of the member.

Note: Extensions are not allowed for expedited Part D appeals.

Time limit for Medicare appeals

Carrier appeals process for redeterminations and Over payment appeal address


The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.

For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.

The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.

There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.



The five levels of appeal are as follows:

1st Level - Redetermination

Time limit to file request: 120 days from date of receipt of the initial determination notice

Monetary threshold: None

Request is sent directly to the carrier



2nd Level - Reconsideration

Time limit to file request: 180 days from date of receipt of the redetermination

Monetary threshold: None

Request is sent directly to the QIC

3rd Level - Administrative Law Judge (ALJ) Hearing

Time limit to file request: 60 days from the date of receipt of the reconsideration

Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).


4th Level - Departmental Appeals Board (DAB) Review

Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision

Monetary threshold: None

5th Level - Federal Court Review

Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB

Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.


Overpayment appeals address

The address for overpayment appeals is as follows:

First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248

Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.

Minor errors or omissions outside the appeals process FAQ

Can minor errors or omissions be corrected outside of the appeals process?

 Yes. A clerical error reopening can be initiated via the telephone or in writing; or, in many cases, the denied service(s) can simply be resubmitted. Resubmitting claims to correct minor clerical errors or omissions is the most efficient method for addressing certain denied services.*

*Resubmit the denied service(s) ONLY - resubmitting an entire claim will create a duplicate denial.

If these issues are received via written and telephone requests, it may take up to 60 days to process and finalize an adjustment, versus 14-30 days for a resubmitted claim. Ensure that you review the type of clerical error or omission you are attempting to correct and select the most efficient option available.

Note: Single-line clerical reopenings can now be requested through the Part B Interactive Voice Response unit (IVR).

Determine if the error can be corrected and resubmitted prior to writing in or calling to request a clerical error reopening.

• Minor clerical errors or omissions that can be corrected and resubmitted:

• Change of diagnosis codes

• Add, change, or delete modifiers (e.g., 24, 25, 50, 59, 78, 79, RT, LT)

• Incorrect place of service

• Written or telephone clerical error reopenings are appropriate only for services that were processed and received an approved amount, and could include the following types of situations:

• Number of services (NB) billed

• Submitted charge amount

• Date of service (DOS)

• Add, change or delete certain modifiers

• Procedure code; excluding codes requiring documentation on the initial submission or codes being upcoded

Medicare appeal - some basic questions

Appeals process FAQs


Q: During the appeal process, at what point can additional records be submitted?

A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records to the affiliated contractor, or First Coast Service Options Inc.


Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?

A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.


Q: What does the term “amount in controversy” mean?

A: The amount in controversy (AIC) is the amount in dispute, at a minimum, that you must have for the administrative law judge (ALJ) and judicial review levels in the appeal process.



Q: Is there a resource that highlights for providers or beneficiaries what would be considered a relevant appeal to submit?

A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the Centers for Medicare & Medicaid Services (CMS), Internet only manuals (IOM).


Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?

A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.



Q: What are the reason code ranges for claims when they’ve denied?

A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.

Appeal process on PQRI - review of determination

Appeals Process

Sec. 3002 (f)(2) of ACA requires the Secretary to establish by not later than January 1, 2011, an informal appeals process so that physicians can seek review of the determination that the physician did not satisfactorily submit data on quality measures under the PQRI. CMS proposes to base the informal process on its current inquiry process whereby a physician can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and e-prescribing incentive program information, information on PQRI feedback report availability and access, and/or information on PQRI Portal password issues.

The AMA supports a PQRI appeals process, which is critical for re-evaluating the participation status of a physician who may have been incorrectly deemed not successful. We have strong concerns, however, with use of the current structure of the Quality Net Help Desk. Physicians have had many difficulties in accessing and obtaining reliable information from the Quality Net Help Desk. At times, they could not get through, or worse, the Help Desk representative was ill-equipped to answer their specific questions, which has led to frustration among physicians who are attempting to successfully participate in the PQRI. Therefore, the AMA urges that CMS significantly improve the Quality Net Help Desk by adding more telephone lines and hiring more trained and experienced, qualified staff. If the Quality Help Desk is not adequately resourced to handle the additional processes related to an informal PQRI appeals process, CMS’ efforts will not be viewed as sincere in trying to add a successful informal PQRI appeals process. We also urge that CMS post on its Web site the names of physicians who have been determined to be a successful participant upon appeal.

TOP ten ways to avoid appeal

Ways to AVOID an Appeal

   1. Verify all data pertaining to the service is correct. Correct data allows the service to process as is intended, eliminating the need to make corrections after the claim has processed.

   2. Become familiar with Local Coverage Determinations (LCD).

   3. Become familiar with National Coverage Determinations (NCD).

   4. Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.

   5. Document a repeat or duplicate service to reflect it is as a distinct and separate service. Failure to document a repeat or duplicate service will result in a denial.

   6. Submit supporting documentation with the claim when certain modifiers e.g. 52 or 22 are appended to the service or when a LCD or NCD indicates documentation is required. Failure to submit the documentation will result in a denial.

   7. Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.
   8. The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.

   9. Enter the concise description of an unlisted procedure code (an NOC code) or a “not otherwise classified” code. Failure to describe the NOC or other scenarios listed below will result in a denial.

  10. When Medicare is the secondary payer (MSP) the claim must include information from the primary insurer. Failure to include this information will result in a denial.
 

When Medicare appeal request rejected

Withdraw of an Appeal Request
 

A request for a redetermination may be dismissed under the following circumstances.

• 
  
  At the Request of the Party
  
  A request for redetermination may be withdrawn at any time prior to the mailing of the redetermination upon the request of the party or parties filing the request for redetermination.  You must submit the request in writing. A letter documenting your request to withdraw the appeal will be issued and will provide you with the criteria that must be met if you wish to review the service at another time.
  
  
• 
  
  Failure to File Timely
  
  When a request for a redetermination is not filed within the required time limit (120 days from the date of the initial determination) and good cause for failure to file timely was not found by the FI or MAC, the request will be dismissed.  It is the responsibility of the individual filing the request to provide information to support the late filing request.
  
  
  
• Party Failed to Make a Valid Request
  When it is determined that the provider failed to submit a valid request for redetermination as identified in Section 1.1, the request will be dismissed.  You may file your request again with the required information if it has been 120 days or less since the date of receipt of the initial determination.
  
  
• Appeal Rights for Dismissals
  You may request that we vacate our dismissal within 6 months of the date of the mailing of the dismissal notice if you think you have good and sufficient reason to dispute the dismissal.  You also have the right to appeal a dismissal to the Qualified Independent Contractor (QIC) if you believe it was incorrect.  The reconsideration request to the QIC must be filed within 60 days of the date of the dismissal.  The dismissal letter will provide you with detailed information regarding your options and the time frames for each option.

Medicare appeal time limit

Reconsideration (Second Level Appeal) by a Qualified Independent Contractor (QIC)
 

A second level appeal is called a Reconsideration.  Requests for a Reconsideration must be filed with a Qualified Independent Contractor (QIC).  The name and address of the QIC will be specified in each Redetermination notice.  Requests should be submitted in writing with a copy of the Redetermination Notice to the following address:

Maximus QIC Part A East Project

1040 First Avenue, Suite 400
King of Prussia, PA 19406

A Reconsideration request form should be used and will be provided with each Redetermination notice issued.  A Reconsideration Request Form can be downloaded from the forms section of our website.  In lieu of the form, the Reconsideration request must include the following items:
The beneficiary’s name;

• Medicare health insurance claim number
• The specific service(s) and items (s) for which the reconsideration is requested and the specific date(s) of service;
• The name and signature of the party or representative of the party; and
• The name of the contractor that made the Redetermination  

A request for reconsideration must be filed within 180 days of the date of receipt of the notice of the Redetermination.  The date of filing for request filed in writing is defined as the date received by the QIC in their corporate mailroom

Medicare Cert Appeals vs. Claim Adjustments

B. Cert Appeals vs. Claim Adjustments

Some Part A providers are cancelling claims and resubmitting adjusted claims when CERT alerts them via a Tech Stop or Non-Response Contact that documentation is missing or that a coding error has occurred.  Because these claims have been medically reviewed by the CERT contractor, providers are instructed to cease the practice of cancelling and adjusting claims that are selected in the CERT review process.

At the time of the Tech Stop or Non-Response Contact, the claim has been medically reviewed, but has not yet been denied.  Highmark Medicare Services will initiate the adjustments for any necessary denials.  When the CERT adjustment has been made in the FISS system, it will appear as an XXH type of bill.  If you need to make a correction or addition to the claim, providers may appeal the denials on the XXH type of bill.  The proper appeals process should be followed.

Providers should continue the practice of submitting an adjustment claim for an incorrectly billed line item, when the provider identifies the error outside of the medical review or CERT process.

Medicare Redetermination and Reconsideration Processing

Redetermination and Reconsideration Processing

Generally, a redetermination decision will be issued within 60 days of receipt of the redetermination request.  For fully favorable decisions, the parties will receive notice of effectuation via a Medicare Summary Notice (MSN) or Remittance Advice (RA).

For partially favorable decisions and unfavorable decisions, the parties will receive a written redetermination decision with the rationale for the decision as well as notice of effectuation via a MSN or RA.  If you do not agree with the decision, you will be provided instructions on how to pursue the next level of appeal, reconsideration by the QIC.  The decision will also include a Reconsideration Request Form that is to be submitted to the QIC if you wish to appeal the redetermination decision.

A. Letter of Written Assurance

Prior to paying a provider for fully favorable or partially favorable cases where the beneficiary was previously liable, the MAC must ascertain whether the provider has been reimbursed for the previously denied services from another source.  The MAC will withhold the Medicare reimbursement until the party has assured, in writing, that any prior payment has been refunded.
Returning a Letter of Assurance promptly will result in quicker payment to you.  Only after the Letter of Assurance has been received will a claim adjustment be initiated to make payment. If no Letter of Assurance is received, no payment will be made.

Documentation should inculde with appeal request

Documentation to include with your Appeal Request

Redetermination requests must include all pertinent medical documentation pertaining to the services in question.  The medical record documentation must include the patient’s name and must be complete and legible.  If you are making changes to the claim, include a copy of a revised UB-04 claim form.  In addition, if an Advance Beneficiary Notification (ABN) or other beneficiary notice was issued, include a copy of this document.

Remember that medical record documentation must be legible.  Each page of the record should identify the patient and the date.  A hand written or electronic signature and credentials should follow each record entry (stamp signatures are not acceptable).  The record should be of good copy quality for review purposes.

Effective August 1, 2008, Highmark Medicare Services will not routinely request additional inpatient documentation from providers who failed to submit all the necessary medical records.  The redetermination will be performed based on the medical record documentation that you submitted with your initial claim and appeal request.  Providers, physicians and other suppliers are responsible for providing all the information the contractor requires to adjudicate the claim(s) at issue.

If the service being appealed was denied due to a Local Coverage Determination (LCD), you should review the LCD policy for the documentation requirements that are necessary to support the service.  The LCDs are available on the Highmark Medicare Services internet site.

If the service being appealed was denied due to a National Coverage Determination (NCD), you should review the NCD policy for the documentation requirements that are necessary to support the service.  The NCDs are available on CMS’ website.

The following list may be used as a guideline (not all-inclusive list) when submitting documentation with your redetermination request.

OUTPATIENT RECORDS

Issue	Documentation
Cosmetic Surgery	Surgical report, pathology report, history and physical , physician's progress notes
Dental Services	Dental surgical report, pathology report, history and physical , physician's progress notes, physician orders and laboratory reports
Diagnostic Tests:  Radiology	Physician orders, history and physical, test results, e.g., x-ray reports
Drugs (J codes)	Physician orders, history and physical, medication record, nurses notes
Laboratory Services	Physician orders, laboratory report(s), pathology report
Physical, Occupational, and  Speech therapy	Physician orders, therapy evaluation and progress notes; physician certification/recertification

INPATIENT RECORDS
SKILLED NURSING FACILITY INPATIENT RECORDS

Issue	Documentation
Inpatient Hospital	Complete Hospital Records including emergency room reports, admission history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory  and pathology reports, X-ray reports, operating room and anesthesia report, discharge summary, Advance Notice of Non-Coverage (signed by the beneficiary), denial notification issued by the provider, billing form
Inpatient Rehab Facility	Complete Hospital Records including history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory reports, X-ray reports, therapy evaluation and progress notes, physician certification/recertification, Advance Notice of Non-Coverage(signed by the beneficiary), billing form
SNF Inpatient	Hospital discharge summary, physician certification, progress notes, and orders, nurses notes, medication records, therapy records, if applicable, copy of the MDS, signed Advance notice of non-coverage and denial notification issued by the provider, if applicable

An appeal request for a claim that was denied by Medical Review (MR) for lack of documentation or for insufficient documentation must be submitted with all the medical record documentation that was requested in the additional documentation request (ADR).  The ADRs that you receive requesting additional supporting documentation are very specific regarding the type of information that is required.  Thoroughly review the ADR to be sure that all items requested in the ADR have been submitted with your appeal.

How to do Medicare redetermination request

Filing a Request for a Redetermination

The first level of appeal is a redetermination.  A redetermination is an independent reexamination of an initial claim redetermination.  A redetermination can be requested if you are dissatisfied with the initial processing of your claim.  A redetermination must be filed within 120 days of the date of receipt of the initial claim determination notice.  All requests for redeterminations must be filed in writing.  Regulations dictate that requests for redeterminations may not be filed over the telephone.

Medicare providers who submit claims to Medicare Administrative Contractors (MACs) have the same right to appeal claims as beneficiaries.  This means the provider does not need to submit an Appointment of Representative form with an appeal request.

Highmark Medicare Services has developed the Medicare Part A Redetermination Request Form for your use. A Medicare Redetermination Request form should be completed for each claim in question.  Request forms should be mailed to Highmark Medicare Services using the following address and post office boxes to submit requests for claim redeterminations (first level appeals):

Medicare Appeals
Highmark Medicare Services
PO Box 89XXXX
Camp Hill, PA 17089-XXXX
Substitute the XXXX with the appropriate PO Box number and 4 digit zip from the table below:

State	PO Box Number / 4 Digit Zip
Pennsylvania Part A	0385
Maryland/ District of Columbia Part A	0385
New Jersey Part A	0385
Delaware Part A	0417

All written requests for a redetermination must contain the following items:

• The beneficiary name;
• The beneficiary Medicare number;
• The specific service(s) and/or item(s) for which the redetermination is being requested;
• The specific date(s) of service; and
• The printed name and signature of the requestor.

Your appeal request will be dismissed if any of the above information is not included with the request



Appeals: What happens to an incomplete redetermination request?

Answer:

An incomplete redetermination request is any correspondence received by our redetermination department that does not specifically identify all of the following information:
Beneficiary name
Medicare health insurance claim (HIC) number
The specific service(s) and/or item(s) for which the redetermination is being requested
The specific date(s) of the service
The name and signature of the appellant or the representative of the appellant
You have 120 days from the initial determination (date on the remittance notice) to request a redetermination. The notice of initial determination is presumed to be received 5 days from the date of the notice.  If your request is incomplete and returned to you, your request may be delayed and consequently may not meet the timely redetermination request requirement.

To ensure that your redetermination request contains all of the required information, we strongly encourage you to submit your request on a Railroad Medicare Redetermination request form or through our eServices portal. Redetermination request forms can be found by accessing 'Forms' under the Top Links section of our home page. For more information on submitting a redetermination request through eServices see the following article 'More Appeals Forms Now Available in eServices'.