Denial appeal time limit - Prestige health insruance

3. Request for Standard Determination
In the event a provider wishes to file an appeal on behalf of a member, the provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to request a standard determination. Prestige Health Choice will make a determination and provide written notice of the resolution of the Appeal within 45 calendar days from the date of receipt of the standard request.

4. Request for Retrospective Determination

The provider and member must complete an Appointment of Representative statement, which can be found in the Forms section of the Provider Manual, to file a request for a retrospective determination.

Prestige Health Choice will make a determination and provide written notification within 45 calendar days from the date of receipt of the retrospective request.

5. 14-Day Extension

The Expedited, Standard and Retrospective Determination periods may be extended by up to 14 calendar days, if the member requests an extension or if Prestige Health Choice justifies a need for additional information and documents how the extension is in the interest of the member. If an extension had not been requested by the member, Prestige Health Choice will provide the member with written notice of the reason for the delay.

Denial upheld and reversal of denial

6. Denial Upheld
If Prestige Health Choice upholds its initial action and/or  denial, then the member, member’s representative or provider will be notified in writing of the decision as well as any additional appeal rights that are available.

7. Reversal of Denial

If Prestige Health Choice overturns its initial action and/or denial, it will notify the member and provider verbally and in writing. Prestige Health Choice will authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires, if the services were not furnished while the appeal was pending and the decision is to reverse a decision to deny, limit, or delay services. Prestige Health Choice also will pay for disputed services, in accordance with state policy and regulations, if the services were furnished while the appeal was pending and the disposition reverses a decision to deny, limit or delay services.

Appeals Submission Process - Prestige insurance

1. A member or provider (acting on behalf of the member)
must submit a request either verbally or in writing within
thirty (30) calendar days of the date of the notice of action
to Prestige Health Choice.

2. If Prestige Health Choice did not issue a written notice of
action, then the member or provider (acting on behalf of
the member) may file an appeal within one (1) year of the
date of the action.

3. If filed verbally, the request must then be followed up with a
written, signed appeal submitted to Prestige Health Choice
within 10 working days.

4. For verbal filings, the time frames for resolution begin on
the date the verbal filing was received by Prestige Health
Choice.

5. If the member wishes to use a representative (including the
physician), then he/she must complete an Appointment of
Representative statement. This form is located in the Forms
section of this manual.

6. The member and the person who will be representing the
member must sign the statement.

Prestige Health Choice will make a determination on an appeal
within the following time frames:

• Expedited Request: 72 hours
• Standard Request: 30 calendar days
• Retrospective Request: 45 calendar days

Appeals must be submitted in writing to:
Prestige Health Choice
Grievance and Appeal Department
P.O. Box 19709
Charlotte, North Carolina 28219-9709
Or by Toll-free Telephone to:
888-611-0786
Or by Toll-free Fax to:
800-338-4195

Insurance Appeal for medical necessity for additional service denial

Practice address

Phone# 789-123-4567

_______________________________________________________________________



05/07/2010 



BCBS

Attn: Medical Review Department

PO BOX 1798

Jacksonville

FL  32231



Re: Appeal of Medical Claim



Patient Name:

Health Insurer Identification Number: XJBH3012008490

Claim Number: Q100000188728928

Call Reference Number: 1-17554020352

Service Date: 11/22/2009



Dear Sir/Madam:



We are appealing your decision and requesting reconsideration of the attached claim that was denied on 04/18/2010 as "MP907 – Documentation related to the date of service is needed from your physician to support medical necessity for the additional services.”



When we had a discussion with the BCBS customer service, the representative suggested us to file an appeal with the supporting Medical documents. Herewith I have attached the claim with supporting Medical documents.



Now we are requesting you to reconsider our claim and reimburse Dr. (Provider name) for the same.



Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 123-456-7890 between the hours of 8:00 a.m-5:00 p.m.



Sincerely,





Henry Samuel

(Account Receivable – Reimbursement Specialist)

Horizon NJ Health Denial Code List

Remark and Denial Codes

Remark	Denial	Description
CDD		DEFINITE DUPLICATE CLAIM
CRS		CODE SUPERCEDED-AMA CPT GUIDELINES
CRT		CODE SUPERCEDED-AMA CPT GUIDELINES-DENIED
F47		PAYMENT REFLECTS COB, IF $0, MAXIMUM LIABILITY WAS MET
F50		CLAIM ADJ - THIRD PARTY DENIED OR BENEFITS EXHAUSTED
I02	X02	ILLEGIBLE RECORDS SUBMITTED; REFILE
I04	X04	CORRECT NDC CODE REQUIRED FOR CONSIDERATION
I05	X05	INVALID/DELETED CODE, MODIFIER OR DESCRIPTION
I06	X06	ITEMIZED BILL/DATES OF SERVICE/CHARGES/ INVOICE REQUIRED
I08	X08	DIAGNOSIS INVALID/MISSING/DELETED REQUIRED 4TH/5TH DIGIT
I10		E-CODE CANNOT BE USED AS PRIMARY DIAGNOSIS
I11	X11	EOB FROM PRIMARY CARRIER REQUIRED
I18		PAID BILLED CHARGES
I19	X19	CARRIER OF SERVICE-HORIZON HEALTHCARE DENTAL SERVICE
I22	X22	RESUBMIT WITH VISIT CODES & CHARGES
I24	X24	CARRIER OF SERVICE-DAVIS VISION
I26	X26	EXHAUSTION OF BENEFITS
I27	X27	SUBMIT MEDICAL RECORDS TO HORIZON NJ HEALTH APPEALS UNIT
I28		REPROCESSED-CLAIM SUBJECT TO INTEREST
I30	X30	SERVICE EXCEEDS LIFETIME LIMITATION
I37	X37	RESUBMIT WITH APPROPRIATE MODIFIER AND/OR TIME UNITS
I42	X42	ILLEGIBLE/INCOMPLETE/INAPPROPRIATE REFERRAL RECEIVED
I43	X43	BI-LATERAL PROCEDURE PREVIOUSLY PAID WITH MODIFIER “50”
I44	X44	RESUBMIT WITH ICD/9 PRINCIPLE PROCEDURE CODE
I47	X47	NON CONTRACTED LEVEL OF CARE
I48	Z48	RESUBMIT TO PRIMARY CARRIER FOR APPEALS PROCESS
I64	X64	CAPITATED TO ANOTHER PROVIDER
I65		DUPLICATE CLAIM-PREVIOUSLY DENIED APPROPRIATELY
I68		INVALID PLACE OF SERVICE FOR PROCEDURE
I83	X83	MOTHER’S BILL NOT RECEIVED – REFILE
I98		TOTAL BILLED STILL UNDER CONSIDERATION
	N02	REDUNDANT PROCEDURE DISALLOW
	N06	ASSISTANT SURGEON DISALLOW
	Q17	ADMINISTRATIVE OVERTURN
R00	X00	PAYMENT INCLUDED IN OTHER BILLED SERVICES
R01	X01	NO PRECERT/AUTHORIZATION OR REFERRAL
R07	X07	RECEIVED AFTER TIMELY FILING TIME LIMIT
R09	X09	REQUESTED HOSPITAL DOCUMENTS NOT RECEIVED
R10	X10	NOT ENROLLED ON DATE OF SERVICE
R15		SUBSET/INCIDENTAL PROCEDURE DISALLOW
R18		RESUBMIT WITH ICD PRINCIPAL PROCEDURE, HCPCS OR CPT CODE
R37		COMBINED PAYMENT-MOTHER & BABY
R38		CONTRACTED FEE
R39	X39	DUPLICATE CLAIM PREVIOUSLY PAID AT CORRECT RATE OR CAPITATION
R40	X40	DUPLICATE CLAIM-ORIGINAL STILL UNDER CONSIDERATION
R42		DRG PAYMENT
R43		INTERIM BILL PAYMENT
R44		MULTIPLE SURGICAL REDUCTION
R45	X45	COMPLETE MED RECORDS REQUIRED FOR CONSIDERATION; REFILE
R46	X46	OVER MAX PROCEDURE/BENEFIT LIMIT (All LOBs)
R47		PAYMENT REFLECTS COORDINATION OF BENEFITS, IF $0, MAX LIABILITY MET
R49	X49	PREVIOUS PYMTS EQUAL TO PURCHASE PRICE
R50	X50	SAME PROCEDURE PAID TO A DIFFERENT PROVIDER
R51	X51	SERVICE NOT COVERED
R53	X53	SERVICES WERE NOT PROVIDED
R55		BILLED INFORMATION REFLECTS LOWER DEGREE ACUITY/TREATMENT
R56		ADMINISTRATIVE APPROVAL
R59	X59	AUTHORIZATION/REFERRAL EXPIRED
R60	X60	DATES AND/OR SERVICES OUTSIDE REFERRAL/AUTHORIZATION
R61	X61	NO PCP REFERRAL
R65		INTERIM BILL 2ND CYCLE PAYMENT
R66	Z34	INTERIM BILL FINAL CYCLE PAYMENT
R67	X67	DISCREPANCY WITH LEVEL OF CARE-APPEAL REQUIRED
R70	X70	EPSDT SCREENING DID NOT COMPLY WITH PERIODICITY SCHEDULE
R71	X71	DUPLICATE OF PREVIOUSLY SUBMITTED EPSDT SCREENING
R72	X72	PROVIDER WAS NOT MEMBER’S PCP
R78	R78	MEMBER’S AGE NOT VALID FOR PROCEDURE CODE
R79	X79	SPECIAL PROJECT-ADJUSTMENT
R81	X81	CHARGES CONSIDERED INCLUDED IN INPATIENT ADMISSION
R84	X84	PLEASE OBTAIN INDIVIDUAL PROVIDER ID #
R86	X85	INVALID/MISSING REVENUE CODE ON CLAIM
R89		AUTHORIZATION ON FILE FOR TECHNICAL COMPONENT
R91	X91	INAPPROPRIATE CODING FOR CONTRACT AGREEMENT
R95	X95	CLAIM SUBMITTED WITHOUT PHYSICIAN NAME
R96	X96	EOB/ATTACHMENTS WERE INCOMPLETE/ILLEGIBLE
R97	X97	DATE OF SERVICE CANNOT BE GREATER THAN THE RECEIVED DATE
	X12	MOTOR VEHICLE ACCIDENT - AUTO CARRIER PRIMARY
	X13	WORKERS COMPENSATION PRIMARY CARRIER
	X21	BILL THROUGH PHARMACY PROGRAM
	X25	INCLUDED IN SETTLEMENT PAYMENT
	X32	APPEAL – DENIAL UPHELD
	X33	APPEAL – ORIGINAL CLAIM PAYMENT UPHELD
	X35	AUTHORIZATION DENIED FOR THIS DATE OF SERVICE
	X55	MEMBER AGE NOT VALID FOR DIAGNOSIS CODE
	X56	CLINIC CLAIM SUBMITTED WITHOUT PHYSICIAN NAME
	X57	THIS “V” DIAGNOSIS CANNOT BE BILLED ALONE
	X62	INVALID/MISSING DRG
X68	X68	INVALID UNITS SUBMITTED
	X77	INCORRECT PROVIDER NAME/TIN IDENTIFICATION # SUBMITTED
	X94	PROVIDER NUMBER SUBMITTED VIA EDI INCORRECT/TERMINATED
X78	X78	COMBINED PAYMENT – MOTHER AND BABY
Z19	Z19	CARRIER FOR SERVICE-HORIZON BLUE
Z47	Z47	SUBMIT CHARGES TO MA FEE-FOR-SERVICE PROGRAM
	Z50	SUBMIT CHARGES TO MEDICAID FEE FOR SERVICE PROGRAM
	Z92	INVALID OR MISSING PLACE OF SERVICE
Z99	Z99	CODE NOT PAYABLE FOR PROVIDER SPECIALTY NO FEE ON FILE
	Z55	NOT AUTHORIZED UNDER CONTRACT TO PROVIDE THIS SERVICE

These explanation codes represent the current set of codes that are returned to the hospital, physician or health care professional on the remittance advice. Please review the translation grid above before calling the Physician & Health Care Hotline for questions about remittance advice codes.

Railroad Medicare denial

Denials: Top Reasons and Procedures

The Palmetto GBA Denial Finder tool includes resources for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you pick up the phone.

• Access denial reasons in plain language
• Scroll through the titles to locate your procedure
• Use the Palmetto GBA search engine to search by remark code

Following are five of the top reasons that services submitted to Palmetto GBA are denied:

• The patient is enrolled in hospice care. Services of the patient’s designated attending physician and services that are unrelated to the patient’s terminal condition may be paid separately, but modifiers are required to note these exceptions
•  'Noncovered services' - these services are never covered, including eye refraction, 'well person' exams, and hot/cold packs used in physical therapy
• Bundling due to 'Correct Coding Initiative' - services denied most often for these reasons include: pulse oximetry; heparin; creatinine (blood); and some supplies
• Medicare is secondary, but the claim was submitted as primary. The MSP Lookup Tool can help guide you as to whether another insurer may be involved.
• Pre- and post-op visits are included in the global surgery package. Tip: access the CMS Medicare Physician Fee Schedule Database (MPFSDB) to determine the global period for surgical procedures. The Palmetto GBA Modifier Lookup tool provides step-by-step instructions for accessing the MPFSDB as well as guidance on how to submit 'exceptions' to the global surgery package.

EOB terms

DEFINITION OF TERMS

SERV DATE: Service date. Refers to the date services were rendered.

CPT CODE: Current Procedure Terminology. A 5 digit code, assigned for each procedure perform by physicians to communicate specific services rendered.

DESCRIPTION Describes the medical procedure performed at the time of visit.

QTY: Quantity. Refers to the number of times a particular service was performed.

BILLED Al’s/IT: Billed amount. The fee charged for a specific medical procedure.

MAX AMT: Maximum amount. Based upon the data gathered by the Health Insurance Association of America and/or other sources, the maximum amount fee is arrived at the compiling the prevailing fees in a geographical area and applying the reimbursement percentage purchased by a group/member. Provides are then reimbursed according to this percentile.

DEDUCTIBLE AMT: Refers to the amounts a Member must contribute on an annual basis before he/she is reimbursed for out-of-network services.

%: Refers to the percentage of the Maximum Amount fee for which the Member is responsible.
COPAY/CO-INS AMT: Copayment/coinsurance amount. The amount that the member is responsible for paying for the services rendered.

ADJ CODE: Adjustment code. A code that shows a correction, adjustment or denial has been made to a claim.

COB AMT: Coordination of Benefits. Refers to the amount covered by the Members alternative insurance carrier when that carrier is the “primary” insurance carrier.

PAYMENT AMT: The total amount that is reimbursed to the vendor.

PATIENT ACCT #: Patient account number. Refers to the provider’s account number or invoice number for the patient or claim.

DATE RECEIVED: The date received is the date that Oxford Health Plans received the claim; the date is reflected in the first four digits of a claim number. (e.g., 9049234568 - The first digit (9) indicated the year
1999 and the following three digits (049) indicated the day of the year the form was received (in
Julian date format). In this example, the claim was received on the 49th day of the year is
February 18, 1999.

Chest X-ray or EKG: Duplicate Denials

Denial Reason, Reason/Remark Code(s)

• M-80, CO-18 - Duplicate Service(s): Same service submitted for the same patient, same date of service by same doctor will be denied as a duplicate
• CPT codes: 93010, 71010, 71020

Resolution/Resources
First: Verify the status of your claim before resubmitting. You can determine the status of a claim by calling the Palmetto GBA Interactive Voice Response unit (IVR):

• Jurisdiction 1: (866) 931-3903 begin_of_the_skype_highlighting              (866) 931-3903      end_of_the_skype_highlighting
• Ohio and West Virginia: (877) 567-9232 begin_of_the_skype_highlighting              (877) 567-9232      end_of_the_skype_highlighting
• South Carolina: (866) 238-9654 begin_of_the_skype_highlighting              (866) 238-9654      end_of_the_skype_highlighting
  
• Submit multiple 'identical' services on the same claim. Use the quantity field to reflect the number of services. If the services cannot be submitted on a single claim, use CPT modifier 76 and specify the exact times of each service.
• If you need to make a correction to a claim that was incorrectly denied as a duplicate, you may request a Telephone Reopening
  
  • Jurisdiction 1: (866) 669-5543 begin_of_the_skype_highlighting              (866) 669-5543      end_of_the_skype_highlighting. We can assist you with up to three requests per call.
  • Ohio and West Virginia: (866) 308-5441 begin_of_the_skype_highlighting              (866) 308-5441      end_of_the_skype_highlighting. We can assist you with up to three requests per call.
  • South Carolina: (866) 815-7891 begin_of_the_skype_highlighting              (866) 815-7891      end_of_the_skype_highlighting. We can assist you with up to three requests per call. 
• Access specific instructions for documenting and submitting CPT modifier 76 through the Palmetto GBA Modifier Lookup:
• Jurisdiction 1: Select 'Articles' on the left side of the Palmetto GBA Web page
• Ohio, South Carolina, and West Virginia: Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.

CCI Bundling Denials

Denial Reason, Reason/Remark Code(s)

• M-80: Not covered when performed during the same session/date as a previously processed service for the patient
• CO-B15: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

Correct Coding Initiative: The Correct Coding Initiative (CCI) packages, or 'bundles', reimbursement for some services under Medicare. CCI identifies code pairs that are never reimbursed separately and code pairs that can only be reimbursed separately in certain circumstances (identified by the appropriate modifier).

Resolution/Resources

• Check CCI edits prior to claim submission; edits are updated quarterly. CCI edits are available at www.cms.hhs.gov/NationalCorrectCodInitEd/
• For specific information on modifiers that may be used to denote exceptions to CCI (including CPT modifiers 24, 25, 59, 76, and 91), refer to the Palmetto GBA Modifier Lookup tool:
  
  • Jurisdiction 1: Select 'Articles' on the left side of the Palmetto GBA Web page
  • Ohio, South Carolina, and West Virginia: Select 'Browse by Topic' on the left side of the Palmetto GBA Web page.
  Question # 1
  

• Is the CCI indicator '0'?

Answer

• These code pairs will not be reimbursed if submitted for the same date of service. Exceptions to CCI edits cannot be made for code combinations with an indicator of '0'

Question # 2

• Is the code indicator '1'?

Answer

• Submit the appropriate modifier to show the service should be separate. Documentation is required in the patient's medical record. Exceptions to CCI edits can be made for code combinations with an indicator of '1'.
• Examples of separate, distinct services include situations in which bundled service was performed a different patient encounter

Anesthesia Services: Bundling Denials

Denial Reason, Reason/Remark Code(s)

• B15 - Bundling: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
• 
  
• CPT code: 99100

Resolution/Resources

• This code is listed as 'Status B' in the Medicare Physician Fee Schedule Database (MPFSDB), which means that payment for this service is always included in payment for other services performed on the same date that are reimbursed under the Medicare Physician Fee Schedule

Multiple Anesthesia Services:

According to the ASA, when multiple surgical procedures are performed during a single anesthesia administration, only the single anesthesia code with the highest Base Unit Value is reported. The time reported is the combined total for all procedures performed on the same patient on the same date of service by the same or different physician or other qualified health care professional. Add-on anesthesia codes (01953, 01968 and 01969) are exceptions to this and are addressed in the Anesthesia Services section and Obstetric Anesthesia Services section of this policy. UnitedHealthcare Community Plan aligns with these ASA coding guidelines. Specific reimbursement percentages are based on the anesthesia modifier(s) reported.

Duplicate Anesthesia Services:

When duplicate (same) anesthesia codes are reported by the same or different physician or other qualified health care professional for the same patient on the same date of service, UnitedHealthcare Community Plan will only reimburse the first submission of that code. Specific reimbursement percentages are based on the anesthesia modifier(s) reported.

In the event an anesthesia administration service is provided during a different operative session on the same day as a previous operative session, UnitedHealthcare Community Plan will reimburse one additional anesthesia administration appended with modifier 59, 76, 77, 78, 79 or XE. As with the initial anesthesia administration, only the single anesthesia code with the highest Base Unit Value should be reported.

Sample appeal letter - Not covered when performed during the same session - denial

Practice Address

Phone# 407-123-4567

_______________________________________________________________________

05/07/2010   

Medicare
Attn: Appeals Department
PO BOX 2360
Jacksonville, FL, 32231

Re: Appeal of Medical Claim

Patient Name:
Health Insurer Identification Number: 4732123456
ICN: 02101066656101234
Service Date: 04/10/2010

Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that was denied on 04/29/2010 as “M80 - Not covered when performed during the same session/date as a previously processed service for the patient.”

We feel this charge should be allowed for the following reason(s):
  
•    The technical component of Baseline Polysomnogram and CPAP titration sleep study are performed on the dates 03/24/2010 and 03/28/2010 respectively. Both the procedures were interpreted by Dr. (Name) on 04/10/2010. Hence Dr. (Name) is due and eligible to get paid for the professional services that he had rendered.

Herewith I have attached the appeal pertaining for this claim with supporting Medical documents.

Now we are requesting you to reconsider our claim and reimburse Dr. (Name) for the same.

Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.

Sincerely,

(Account Receivable – Reimbursement Specialist)

Wrong usage of Modifier 25

Improper Use of -25 Modifier

• -25 modifier not used when needed
• -25 modifier overuse

• 3 uses of -25
    – NP E/M with procedure
    – EST PT E/M with procedure for a new diagnosis
    – Unrelated E/M and procedure