We’ve got a handy chart to help you keep everything straight, plus quick links to all the rules & forms.
The time has come yet again to update your appeals know-how. CMS announced several changes to the appeals process effective Aug. 3, 2009, in Transmittal 1762.
Focus on Higher Dollar Amounts
CMS has changed the dollar amount in controversy to file certain levels of appeals. For level-three appeals (administrative law judge hearing), requests filed on or after Jan. 1, 2009, must have at least $120 in controversy.
(The old amount was $100.) For level-five appeals (federal court review), requests filed on or after Jan. 1, 2009, must have at least $1,220 in controversy. (The old amount was $1,180.)
Other changes were more directed toward Medicare contractors and included the following:
• Overpayment cases involving multiple beneficiaries;
• Misrouted appeals requests; and
• Paid claim appeals template.
Get to Know the Appeals Process
You should make sure you know the five steps in the Medicare appeals process:
1. Redetermination. CMS formerly referred to the first level of the appeal process as “post payment review” or “carrier review.” This is the only level in the appeals process that does not involve independent review. Use form CMS 20027.
2. Reconsideration. If Medicare denies your claim during redetermination, the next step is “reconsideration,” formerly known as a “fair hearing.” A qualified independent contractor (QIC) is in charge of all reconsideration requests. Use form CMS 2033.
3. Administrative Law Judge (ALJ). If the QIC denies your claim appeal, the next level that the appeal can go to is the ALJ.
This hearing may be conducted in person, by video conference, or over the phone, says Michael Lee, Esq., in Atlanta. Use form CMS 2034A-B when a QIC performed the reconsideration and form CMS 5011A-B when a fiscal intermediary, carrier, MAC, or QIO performed the reconsideration.
4. Medicare Appeals Council (MAC). If the ALJ denies your appeal as well, you can then request review by the MAC, also known as the departmental appeals board (DAB).
5. Federal court. The final step in the appeals process is bringing your case to federal court. The new CMS transmittal did not change the steps in the appeals process, so you still need to follow these five. But make sure you’re applying the proper time constraints and the new dollar thresholds. You can find Medicare appeals information online here.
Increase Your Potential for Successful Appeals
The importance: “It’s very important for healthcare providers and billers to know what the thresholds set by Medicare are,” explains Cyndee Weston, executive director of the American Medical Billing Association in Sulphur, Okla. “If you know the rules going into it, your chances for a successful appeal are much greater. And, now that Medicare can no longer correct minor errors or omissions on claims through the appeals process, you really have to be prepared and submit clean appeals.”
More information: You may want to read the new Medicare Learning Network brochure on the Medicare appeals process.
Make it easy: See how your appeals will flow after this CMS change with the chart below.
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