Thursday, July 8, 2010

When we need to appal and how to appeal the claims

The Appeals Process

When an insurer denies or underpays a claim, first examine the original claim and the Explanation of
Benefits (EOB) to determine whether there is inaccurate or insufficient information. Claims denied for
these reasons can simply be resubmitted with the corrected or additional data required.

Should a payer deny a claim for some other reason, consider filing an appeal. Industry sources indicate
that only 10% of claims are appealed, but that 90% of appeals are successful. In fact, according to an
Office of the Inspector General report, there has been an increase in appeals to Medicare at the
Administrative Law Judge (ALJ) level (99% increase); in these appeals, 81% of the initial denials
were overturned.

By law, all payers must have a procedure for filing appeals. Below is the process for filing an appeal for
claims submitted under Medicare Part B. The process begins with a request to review the claim and, if
needed, can progress to a hearing at various levels. Note time and claim limits on various levels of the
appeal process.

The Medicare Part B Fee-for-Service Appeals Process

Providers who disagree with a determination on a Part B claim have the right to appeal the claim.
When appealing a claim, the following information should be submitted:

> Beneficiary name
> Medicare Health Insurance Claim (HIC) number
> Date of initial determination
> Date(s) of service for which the initial determination was issued
> An explanation of why you have requested a review
> A copy of the claim and the EOB or remittance notice
> Supporting documentation
> Signature of the requester

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a
process for the correction of minor errors or omissions without pursuing an appeal. Requests for
adjustments to claims resulting from clerical errors shall be handled and processed by the contractor
through telephone reopenings.

The Part B appeals process consists of 5 levels, as listed below. Each level must be completed prior to
proceeding to the next level of appeal. An appeal cannot be made until the provider receives an initial
determination from the Medicare carrier. Keep in mind that specific time constraints, as well as minimum
dollar amounts in controversy, exist at the various appeal levels

Appeal Level                            Time Limit                                                        Amount in Controversy

1. Redetermination*     120 days from date of receipt of the notice of initial determination     None    

2. Reconsideration by Qualified Independent Contractor (QIC)     180 days from date of receipt of the redetermination     None    

3. Administrative Law Judge (ALJ) Hearing     60 days from date of receipt of the reconsideration     At least $110    

4. Departmental Appeals Board (DAB) Review     60 days from date of receipt of the ALJ hearing decision     None    

5. Federal Court Review     60 days from date of receipt of DAB decision or declination of review by DAB     At least $1,090   

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