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.

Medicare Reopening request- Second level appeal request

Second Level Appeal Request: 

Reopening If the reopening request is the result of medical review decision (N102 on your Remittance Advice-RA), please attach a copy of the RA and any supporting documentation. If you are unsure whether to request a redetermination or a reopening, request a redetermination as there are specific time limits for submitting redetermination requests.

You can request a Reopening from Palmetto GBA to reopen the claim and correct the following minor errors or omissions:
= Mathematical or computational mistakes 4 If you submitted the incorrect units (i.e., 1 instead of 2 in item 24G or its electronic equivalent), adjust the charge accordingly

= Transposed procedure or diagnostic codes

= Inaccurate data entry = Misapplication of a fee schedule

= Computer errors

= Duplicate denials - When you believe that the 'duplicate' denial is incorrect (e.g., ambulance trip denied as duplicate, but there were two identical trips on the same day)

= Incorrect data items such as a modifier or date of service (month and day only)

= Adjustments to claims that were submitted in error that will result in an overpayment. Palmetto GBA will initiate the overpayment process when you notify us that this situation has occurred.

Related Links :

• Medicare first level appeal

• Administrative law judge hearing third

• Reconsideration by QIC second level of appeal

Redetermination request how to receive successful decision

How to receive a successful decision on Redetermination request

To ensure that you receive a successful decision on single or multiple-claim appeal requests, review the six key items listed below:

1. Requests submitted without all appropriate signed documentation might result in an unfavorable decision for the provide

2. All applicable claim lines and claim details are reviewed for medical necessity, correct coding and supportive documentation

3. Additional claims pertaining to the questioned service are subject to review and possible adjustment

4. The number of claims can be reduced by ensuring that you submit all appropriate supporting medical record documentation, including applicable modifiers and ICD-9 codes, with the initial claim

5. All requests must contain the name and legible signature of the person requesting the appeal 6. If a claim is submitted and denied multiple times, the time limit to request a redetermination starts with the first claim determination Second Level Appeal Request: Reopening

Related Links :

• When to use medicare redetermination

•  Medicare appeal redetermination

• One important message from medicare