Medicare top ten errors

This Claim is rejected for relational field due to Billing Provider’s submitter not approved for electronic claim submissions on behalf of this Billing Provider (A8:496:85)

   
This Claim is rejected for Invalid Information for a Subscriber’s contract/member number (A7:164:IL)

   
This Claim is rejected for relational field Billing Provider’s NPI (National Provider ID) and Tax ID (A8:562:85 – A8:128:85)

   
This Claim is rejected for relational field Information within the Detailed description of service (A8:306)

   
This Claim is rejected for Invalid Information for the Subscriber's Postal/Zip Code(A7:500:IL)
   

   
This Claim is rejected for relational field Information within the HCPCS (A7:507)
   
   
This Claim is rejected for Invalid Information in the Billing Provider's NPI (National Provider ID) (A7:562:85)
   
   
This Claim is rejected for Invalid Information for a Rendering Provider's National Provider Identifier (NPI). (A7:562:82)

   
This Claim is rejected for relational field due to Billing Provider's submitter not approved for electronic claim submissions on behalf of this Billing Provider .(A7:562:85)

   
This Claim is rejected for Invalid Information within the Diagnosis code (A7:254)

PR B9 Denail code and Action - Enrolled in hospice

PR B9 Patient is enrolled in a hospice

(THESE SERVICES ARE DENIED BECAUSE THE PATIENT IS IN A HOSPICE)

Resources/tips for avoiding this denial

Specific guidelines exist pertaining to Medicare hospice benefits. Certain Medicare coverage does not apply to a beneficiary enrolled in a hospice program.

• View the document titled Medicare Hospice Benefits , detailing guidelines applying to hospice cases

Before submitting a patient's claim to Medicare Part B, contact the Part B interactive voice response (IVR) system to determine if the patient is enrolled in a hospice program. The following beneficiary information can be obtained:

• Hospice effective date

• Hospice termination date (if applicable)

• Servicing contractor number



Certain modifiers apply when services or providers are not related to hospice:

• Modifier GV: Attending physician not employed or paid under agreement by the patient’s hospice provider

• Modifier GW: Services not related to the hospice patient’s terminal condition

• If a modifier is applicable to the claim, apply the appropriate modifier prior to submitting the claim.



Tips to correct the denied claim

If you have submitted the claim without an appropriate modifier, refer to the modifier guidelines above.

• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim.

If you have submitted the claim with a GV modifier, double-check the patient's file to ensure the attending physician is in fact not employed by the hospice provider.

• If the system suspected a match when cross-referencing the performing provider with the list of hospice providers, this denial may have been assessed.

If you have submitted the claim with a GW modifier, double-check the primary diagnosis on the claim to ensure the services are not related to the hospice patient's terminal condition.

• Ensure the correct diagnosis is submitted on the claim.

• For example, if the patient's terminal condition is pancreatic cancer and the primary diagnosis on the claim is cancer-related, this can be considered related and would cause the denial.

If the modifier has been applied appropriately, it may be necessary to appeal the decision.



Hospice: Non-Attending Physician Denials

Denial Reason, Reason/Remark Code(s)

PR-B9: Patient is enrolled in a Hospice

Procedures: All

Resources/Resolution

Prior to submitting claims to Medicare, determine whether the patient has elected hospice benefits

You may verify eligibility through the Palmetto GBA Interactive Voice Response (IVR) unit or online though an ANSI 270/271 transaction
If the patient has elected hospice benefits, refer to 'Hospice Benefits and Medicare Part B' section below


Hospice Benefits and Medicare Part B

Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition


When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner


Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV if the services are related to the terminal illness. HCPCS modifier GV signifies that:

The service was rendered to a patient enrolled in a hospice

The service was provided by a physician or nurse practitioner identified as the patient’s 'attending physician' at the time of that patient’s enrollment in the hospice program


If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted

If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, HCPCS modifier GV may not be submitted

Any covered Medicare services by the attending or rendering provider that are not related to the treatment of a terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be submitted with HCPCS modifier GW. HCPCS modifier GW signifies that the service was not related to the hospice patient's terminal condition

Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare or the MA plan?

A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.

While a hospice election is in effect, certain types of claims may be submitted to the MAC, by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:

• Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice

• Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition

• MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked

Example:

Beneficiary’s hospice election period ended on 1/10/YY
Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY
Bill the MA plan for claims for dates of service 2/1/YY and beyond




Avoiding denial reason code PR B9 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?

Patient is enrolled in a hospice.

A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.
The following situations require a modifier be applied to the claim prior to submission.
• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
• Claim should be submitted with modifier GV.
• If claim was submitted with the GV modifier, check patient's file to verify that the attending physician is not employed by the hospice provider.
• Services not related to the hospice patient’s terminal condition:
• Claim should be submitted with modifier GW.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.
• If claim was submitAvoiding denial reason code PR 49 FAQ
Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?
Routine examinations and related services are not covered.
A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.
• Medicare does not cover diagnostic/screening procedures or evaluation and management (E/M) services for routine or screening purposes, such as an annual physical.
• Before submitting the claim, refer to "Active, Future, and Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.
• Medicare does cover certain preventive services.
• Click here for more information on covered preventive services.
• Click here external pdf file for information on coding and billing for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV), both covered preventive benefits.
Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.
• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.
• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.
list item Please use your browser's back button to return to the referring page.

Denial Group Codes - PR, CO, CR and OA, RARC explanation

Group codes identify the financially responsible party or the general category of payment adjustment. A group code must always be used in conjunction with a CARC.

Group codes are codes that will always be shown with a reason code to indicate when a provider may or may not bill a beneficiary for the non-paid balance of the services furnished.

Payment Adjustment Category Description

• PR (Patient Responsibility).

• CO (Contractual Obligation).

• OA (Other Adjustment).

• CR (Correction or Reversal to a prior decision).


Group Code PR

All denials or reductions from the billed amount with group code PR are the financial responsibility of the beneficiary or his supplemental insurer (if it covers that service).

Due to the frequency of their use, separate columns have been set aside for reporting of deductible and coinsurance, both of which are also the patient’s responsibility.

PR amounts, including deductible and coinsurance, are totaled in the Patient Responsibility field at the end of each claim.



Charges that have not been paid by Medicare and/or are not included in a PR group are:

• Late filing penalty (reason code B4),

• Excess charges on an assigned claim (reason code 42),

• Excess charges attributable to rebundled services (reason code B15),

• Charges denied as a result of the failure to submit necessary information by a provider who accepts assignment,

• Services that are not reasonable and necessary for care (reason code 50 or 57) for which there are no indemnification agreements are the liability of the provider.



Providers may be subject to penalties if they bill a patient for charges not identified with the PR group code.

Group Code OA

Group code OA is used when neither PR nor CO applies, such as with the reason code message that indicates the bill is being paid in full.

Group Code CR

Group code CR - Correction to or reversal of a prior decision is used when there is a change to the decision on a previously adjudicated claim, perhaps as the result of a subsequent reopening.

This group applies whenever there is a change to a previously adjudicated claim. Separate reason code entries must be used in the NSF for the CR group entry and any other groups that apply to the readjudicated claim. At least one reason code is always used with a group code in the NSF. We always enter the reason code(s) and that amount from the initial remittance advice for the service being corrected with the CR, and include any additional reason code that may apply to the subsequent adjustment. If the change does not involve a prior denial/reduction reason code reason code 93 is used

Reminder: Group code CR explains the reason for change and is always used in conjunction with PR, CO or OA to show revised information.



.

Group Code CO

Group code CO- Contractual obligations is always used to identify excess amounts for which the law prohibits Medicare payment and absolves the beneficiary of any financial responsibility, such as:

• Amounts for services not considered being reasonable and necessary.

• Participation agreement violations or Limiting charge violations.

• Assignment amount violations,

• Excess charges by a managed care plan provider,

• Late filing penalties,

• Gramm-Rudman reductions,

• Medical necessity denials/reductions.

The patient may not be billed for these amounts.


Medicare Group Codes

A group code is a code identifying the general category of payment adjustment. A group code must always be used in conjunction with a claim adjustment reason code to show liability for amounts not covered by Medicare for a claim or service. MACs do not have discretion to omit appropriate codes and messages. MACs must use appropriate group, claim adjustment reason, and remittance advice remark codes to communicate clearly why an amount is not covered by Medicare and who is financially responsible for that amount. Valid Group Codes for use on Medicare remittance advice:

• CO - Contractual Obligations. This group code shall be used when a contractual agreement between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally, these adjustments are considered a write off for the provider and are not billed to the patient.

• OA - Other Adjustments. This group code shall be used when no other group code applies to the adjustment.

• PR - Patient Responsibility. This group code shall be used when the adjustment represent an amount that may be billed to the patient or insured. This group would typically be used for deductible and copay adjustments.

Claim Adjustment Reason Codes

Claim Adjustment Reason Codes (CARCs) are used on the Medicare electronic and paper remittance advice, and Coordination of Benefit (COB) claim transaction. The Claim Adjustment Status and Reason Code Maintenance Committee maintains this code set. A new code may not be added, and the indicated wording may not be modified without the approval of this committee. These codes were developed for use by all U.S. health  payers. As a result, they are generic, and there are a number of codes that do not  apply to Medicare. This code set is updated three times a year. MACs shall use only most current valid codes in ERA, SPR, and COB claim transactions. Any reference to  procedures or services mentioned in the reason codes apply equally to products, drugs, supplies or equipment. References to prescriptions also include certificates of  medical necessity (CMNs).

These reason codes explain the reasons for any financial adjustments, such as denials, reductions or increases in payment. These codes may be used at the service or claim level, as appropriate. Current ASC X12 835 structures only allow one reason code to explain any one specific adjustment amount.

There are basic criteria that the Claim Adjustment Status and Reason Code Maintenance Committee considers when evaluating requests for new claim adjustment reason codes:

• Can the information be conveyed by the use or modification of an existing reason code?

• Is the information available elsewhere in the ASC X12 835?

• Will the addition of the new reason code make any significant difference in the action taken by the provider who receives the message? The list of Claim Adjustment Reason Codes can be found at: http://www.wpc-edi.com/codes

The updated list is published three times a year after the committee meets before the ASC X12 trimester meeting in the months of January/February, June, and September/October. MACs must make sure that they are using the latest approved claim adjustment reason codes in ERA, SPR and COB transaction by implementing necessary code changes as instructed in the Recurring Code Update Change Requests (CRs) or any other CMS instruction and/or downloading the list from the WPC website after each update. The Shared System Maintainers shall make sure that a deactivated code (either reason or remark) is not allowed to be used in any original business message, but is allowed and processed when reported in derivative business messages. Code deactivation may be implemented prior to the stop date posted at the WPC web site to follow Medicare release schedule. SSMs shall implement deactivation on the earlier date if the implementation date in the recurring code update CR is different than the stop date posted at the WPC Web site.

The MACs are responsible for entering claim adjustment reason code updates to their shared system and entry of parameters for shared system use to determine how and when particular codes are to be reported in remittance advice and coordination of benefits transactions. In most cases, reason and remark codes reported in remittance advice transactions are mapped to alternate codes used by a shared system. These shared system codes may exceed the number of the reason and remark codes approved for reporting in a remittance advice transaction. A particular ASC X12 835 reason or remark code might be mapped to one or more shared system codes, or vice versa, making it difficult for a  MAC to determine each of the internal codes that may be impacted by remark or  reason code modification, retirement, or addition.

Shared systems must provide a crosswalk between the reason and remark codes to the shared system internal codes so that a MAC can easily locate and update each internal code that may be impacted by a remittance advice reason/remark code change to eliminate the need for lengthy and error prone manual MAC searches to identify each affected internal code. Shared systems must also make sure that 5-position remark codes can be accommodated at both the claim and service level for ASC X12 835 version 4010 onwards.

The effective date of programming for use of new or modified reason/remark codes applicable to Medicare is the earlier of the date specified in the CMS manual transmittal or CMS Recurring Code Update change request or the Medicare Claims Processing Manual transmittal that implemented a policy change that led to the issuance of the new or modified code. MACs must notify providers of the new and/or modified codes and their meanings in a provider bulletin or other instructional release prior to issuance of remittance advice transactions that include these changes. Some CARCs are so generic that the reason for adjustment cannot be communicated clearly without at least one remark code. These CARCs have a note added to the text for identification. A/B MACs and DME MACs must use at least one appropriate remark code when using one of these CARCs.

Remittance Advice Remark Codes

Remittance Advice Remark Codes (RARCs) are used in a remittance advice to further explain an adjustment or relay informational messages that cannot be expressed with a claim adjustment reason code. Remark codes are maintained by CMS, but may be used by any health plan when they apply. MACs must report appropriate remark code(s) that apply. There is another type of remark codes that does not add supplemental explanation for a specific adjustment but provides general adjudication information. These “Informational” remark codes start with the word “Alert” and can be reported without Group and Claim Adjustment Reason Code. An example of an “Informational” RARC would be:

MA01: Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late. Remark codes at the service line level must be reported in the ASC X12 835 LQ segment.

Remark codes that apply to an entire claim must be reported in either an ASC X12 835 MIA (inpatient) or MOA (non-inpatient) segment, as applicable. Although the IG allows up to 5 remark codes to be reported in the MOA/MIA segment and up to 99 remark codes in the LQ segment, system limitation may restrict how many codes MACs can actually report.

The remark code list is updated three times a year, and the list is posted at the WPC website and gets updated at the same time when the reason code list is updated. Both code lists are updated on or around March 1, July 1, and November 1. MACs must use the latest approved remark codes as included in the Recurring Code Update CR or any other CMS instruction or downloading the list from the WPC Website after each update. MAC and shared system changes must be made, as necessary, as part of a routine release to reflect changes such as retirement of previously used codes or newly created codes that may impact Medicare.


Group codes definition from BCBS

What are group codes and how does BCBSF use them? Group codes are used to identify specific types of adjustments. There are five group codes that can be used with the 835 ERA according to the Washington Publishing Website:

• CO (Contractual Obligations) is used when a contractual agreement between the payer and payee or a regulatory requirement requires an adjustment. Generally, these adjustments are considered a write-off for the provider.

• CR (Corrections and Reversals) is used for correcting a prior claim when there is a change to a previously adjudicated claim.

• OA (Other Adjustments) is used when no other group code applies to the adjustment.

• PI (Payer Initiated Reductions) is used by payers when it is believed the adjustment is not the responsibility of the patient but there is no supporting contract between the provider and payer.

• PR (Patient Responsibility) is used for deductible and copay adjustments when the adjustments represent an amount that should be billed to the patient or insured. What does code OA 23 followed by an adjustment amount mean?

This code is used to standardize the way all payers report coordination of benefits (COB) information. Whenever COB applies, this code combination is used to represent the prior payer’s impact fee or sum of all adjustments and payments affecting the amount BCBSF will pay.

What codes display on the 835 ERA?

Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) display on the 835 ERA. They identify standard reasons why payment may be different than the submitted charge.

CARCs and RARCs are mandated by HIPAA-AS and the code definitions cannot be changed by BCBSF or any payer. CARC definitions tend to be generic while RARC definitions provide more information related to adjudication of the claim. HIPAA-AS requires that for every five CARCs displayed on the 835 ERA at least one RARC must be returned as well to provide clearer information when claim payments are denied or reduced.

What recent updates have been made to CARCs and RARCs?

In November, an additional 98 BCBSF proprietary codes will be mapped to more appropriate CARCs and RARCs to ensure accurate and clear messaging is received on the 835 ERA. This updates makes a total of 300 proprietary codes mapped to more descriptive codes. In addition, codes for capitated claims on both the 835 ERA and paper remittances will change. For example, if applicable, you may see code CO*24 (Payment for charges denied/reduced. Charges are covered under a capitation agreement) when payment is different than the submitted charge. Why are CARC definitions so generic compared to BCBSF proprietary codes displayed on the

paper remittance advice? HIPAA-AS mandates usage of CARCs and RARCs on the 835 ERA to standardize code definitions industry-wide; therefore, the definitions are generic compared to BCBSF and other payers’ proprietary codes.

Requests for Additional Codes

The CMS has a national responsibility for maintenance of the remittance advice remark codes and the Claim Adjustment Status Code Maintenance Committee maintains the claim adjustment reason codes. Requests for new or modification or deactivation of RARCs and CARCs should be sent to a mail box set up by CMS:

Remittance_Advice.CMS.HHS.GOV.

The MACs should send their requests to this mail box for any change in CARC, RARC or any code combination. Requests for codes must include the suggested wording for the new or revised message, and an explanation of how the message will be used and why it is needed or a justification for the request.

To provide a summary of changes introduced in the previous 4 months, a code update instruction in the form of a CR is issued. These CRs will establish the deadline for Medicare shared system and MAC changes to complete the reason and/or remark code updates that had not already been implemented as part of a previous Medicare policy change instruction.

 ASC X12 Version 4010A1

ASC X12 version 4010A1 was the standard before implementation of the current standard version 5010A1. There could be situations where a claim/service that has been paid and reported using version 4010A1 may need to be corrected. Under this situation, the same codes originally used are used in reversal, and any adjustment for the corrected claim/service would report the new/modified codes, if applicable.

80 – The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Mandated Operating Rules

Section 1104 of the Patient Protection and Affordable Care Act (ACA) establishes the development and implementations of “requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs.” A/B MACs/ CEDI/ and DME MACs are required to conform to the following CAQH Core Operating Rules impacting the transmittals of X12 835 transactions.
A complete list of ACA mandated operating rules are available at http://www.caqh.org/ORMandate_index.php.

Health Care Claim Payment/Advice (835) Infrastructure Rule

This operating rule regulates the transmission of batch 835 transactions including the exchange of security identifiers and communications-level acknowledgments and errors. This rule does not address the content of 835 communications beyond those required by the HIPAA mandated ASC X12 format. This rule designates a standard form of communication to ensure trading partner support by all A/B MACs, DME MACs, and CEDI contractors. A complete list of requirements and technical direction for the Connectivity Rule are available at: http://www.caqh.org/ORMandate_EFT.php

 Version X12/5010X221 Companion Guide

CAQH CORE mandated operating rules require the usage of a companion guide for the ASC X12 835 standard transaction. This companion guide is to correspond with the already existing V5010 ASC X12 Implementation Guide.A companion guide template is available at: 

What are the documents needed for SNF

Documentation needed for Skilled Nursing Facility (SNF), Part A

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    All applicable Minimum Data Set (MDS) assessments for the period billed, including documents to support the number of days of the MDS look-back period.
o    Medical records for 30 days prior to each Additional Documentation Request (ARD).
o    Acute hospital discharge summary and transfer form.
o    History and physical.
o    Admission assessment.
o    Any relevant hospital documentation to support five-day MDS assessment.
o    Physician’s certification and recertification for skilled care.
o    Physician’s orders specifying need for SNF care.
o    Physician’s orders physician/Non-Physician Practitioner (NPP) order/intent.
o    Physician’s progress notes.
o    Care plans.
o    Skill sheets/records.
o    Treatment records.
o    Medication Administration Records (MAR).
o    Nurse’s notes.
o    Intake and output log.
o    Vital sign log.
o    Weight records.
o    Treatment and medication sheets.
o    Rehabilitation notes.
o    Initial therapy evaluation.
o    Therapy evaluation/re-evaluation.
o    Therapy progress notes.
o    Treatment logs to identify therapy minutes.
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the ADR letter.

what is WO - withholding and FB - Forward balance with exapmple

PROVIDER ADJ DETAILS

The provider-level adjustment details section is used to show adjustments that are not specific to a particular claim or service on this SPR.

PLB REASON CODE – This field indicates the various provider-level adjustment reason codes that may be used. Examples include:


• 50 – Late charge – Used to identify Late Claim Filing Penalty.

• L6 – Interest owed – Used for the interest paid on claim on an RA.

• WO – Withholding – Used to recover previous overpayments. A reference number (the original ICN) is applied for tracking purposes. The WO amount is subtracted from the check amount.

• FB – Forwarding Balance – Reflects the difference in the payment between the original claim and the overpayment/adjustment to the original claim. An FB will be on an RA any time a claim has been overpaid/adjusted. This amount does not reflect a withholding on this claim. Providers should receive a letter requesting this amount and instructions for refund. If the refund is not received in approximately 45 days, the amount will be reflected as a “WO” on a future remittance.

When the adjustment shows a corrected payment of less than the original claim payment, an FB reflects a negative amount. When the adjustment shows a corrected payment of more than the original claim payment, the FB reflects a positive amount.

The RA will identify the associated FB with the FCN (ICN).


FCN – Indicates the Financial Control Number (FCN) that this adjustment relates to when the adjustment refers to a claim that appeared on a previous RA. This usually matches the ICN field of a previous claim. If the adjustment in question does not relate to a previous claim, this field is left blank.

AMT – This field indicates the amount of the provider-level adjustment. These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number).



My remittance advice (RA) contained code LE - Levy. What does this mean?


Some adjustments that are made on a RA (remittance advice) are not related to a specific claim or service. These adjustments are made at the provider level, and are described by codes called Provider-Level Adjustment Reason Codes. Provider level reason code LE is assigned to report federally mandated recoupments and/or bonus payments; this can be an additional payment or reduction.

If the LE adjustment code includes a phone number in the description (usually starting with 800), then this is a tax levy and you will need to call that telephone number for more information.

If the LE adjustment code is not accompanied by a telephone number, then the LE adjustment code is detailing an incentive payment (example eRx or PQRS).

For more information, visit the CMS websites on the Physician Quality Reporting System (PQRS) external link  or ePrescribing Incentive Programs external link .

All other inquiries should be directed to the appropriate Provider Contact Center.


What does forwarding balance mean on my remittance notice?
Answer:

Forwarding balance means that a negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous RA. A reference number (the original ICN and HIC) is applied for tracking purposes.

What does that mean?

A negative value represents a balance that will be moved forward to a future remittance payment advice. This means that an overpayment for a specific claim or claims (on this remittance) has been created because Medicare has paid for a service that should not have been allowed or has paid too much for a service. Your remittance notice will show the corrected allowed amounts for the adjusted claim(s).

A positive value represents a balance that is being applied from a previous remittance advice. This means we are notifying you that we have completed an adjustment on a claim or claims (included in this remittance) and we have determined that an additional payment is due in part or in full for a previously processed service(s). Your remittance notice will show the corrected allowed amounts for the adjusted claim(s). A reference number (the original ICN and HIC) will be provided for tracking purposes.

Adjustment Code :FB – Forwarding Balance

Reference Number:Current Check # (TRN02) value

Used when:

*  An overpayment can’t be recovered in full resulting in a forwarding balance to be recovered from a future payment.

* An existing forwarding balance can’t be recovered in full resulting in a new forwarding balance. The TRN02 values will be as defined in the X12 Standards for  Electronic Data Interchange Technical Report Type 3 (TR3).

Example: PLB*123456789*20141231*FB:Check#*-37.5~


Complex Forward Balance Examples

835 Electronic Remittance Advice PLB Segment: TheASC X12 Standards for Electronic Data Interchange Technical Report Type 3 has specific rules for reporting overpayment recovery in the 835. The following information should be referenced to understand the formatting of the PLB segments of the 835 for recoupment of funds and when forward balance situations occur.

The following applies in situations where the recoupment will occur at the time a reversed and corrected claim record populates the 835. When the adjustment is less than the original paid amount, the difference will be subtracted from  the check. When the monies can’t be recovered in full, a forwarding balance (FB) is created in the PLB segment. Per the guide, the FB reference ID must be the current TRN02 (check number) value. The monies unable to be recovered will be identified as a forwarding balance (FB) with the monies expressed as a negative.

PLB*9999999999*20141231*FB|TRN02CheckA*-100


When the monies can be recovered from future payment, the forwarding balance (FB) will be returned with the monies expressed as a positive. (To identify what claims are associated to the PLB where TRN02CheckA is referenced, refer back to the original 835 where TRN02CheckA first occurred.)

PLB*9999999999*20141231*FB|TRN02CheckA*100


If forwarding balance (FB) monies are unable to be recovered in full, a new forwarding balance (FB) will be created with the new balance. (To identify what claims are associated to the PLB where TRN02CheckA and TRN02CheckB  arereferenced, refer back to the original 835 where TRN02CheckA first occurred.

PLB*9999999999*20141231*FB|TRN02CheckA*100
PLB*9999999999*20141231*FB|TRN02CheckB*-50


Additional Complex Forward Balance Examples

Multiple days where claims were adjusted and negative balances occurred in different 835 ERA’s

Day 1: Check A

The provider had previously received an 835 with a correction and reversal where the amount owed was $100. The remit that generated the reversal and correction only had funds available with the check to satisfy $62.50. The FB generated in that remit was for -37.50. A subsequent remit is now being generated and now $37.50 can be used to satisfy the forward balance left in full.

Day 2: Check B

The provider had previously received an 835 with a correction and reversal where the amount owed was $200. The remit that generated the reversal and correction only had funds available with the check to satisfy $75.00. The FB   generated in that remit was for -125.00. A subsequent remit is now being generated and now $125.00 can be used to satisfy the forward balance left in full.

Day 3: Check C

The provider had previously received an 835 with a correction and reversal where the amount owed was $300. The remit that generated the reversal and correction only had no funds available to satisfy $300.00. The FB generated in that remit was for -300.00. A subsequent remit is now being generated and now $200 can be used to satisfy and will create a new FB for -100.00

First initial Remittance where FB occurred:

Day1: Check A
Provider number = 1234
Overpayment = 100.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkA
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKA*-37.5~


Day 2: Check B
Provider number = 1234
Overpayment = 200.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkB
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKB*-125.00~


Day 3: Check C
Provider number = 1234
Overpayment = 300.00
FB = Forward Balance
CLP01 value = PTACCT
TRN02 value - TRN02checkC
The initial remit would have:
Reversal and correction claim
And PLB as follows: PLB*1234*20011231*FB: TRN02CHECKC*-300.00~


DAY 4: Check D
Second subsequent remittance (different day/check/eft):
TRN02 value – TRN02checkD
Balance yet to be satisfied is $37.50, 125.00 and 300.00 = 462.50
The remittance only has sufficient funds to offset $237.50 (CheckA 37.50 and Check B 125.00 and check C 200.00) with
balance left of 100.00
The remittance would ONLY have the following:

PLB*1234*20011231*FB: TRN02CHECKA*37.50*~
PLB*1234*20011231*FB: TRN02CHECKB*125*~
PLB*1234*20011231*FB: TRN02CHECKC*300*FB: TRN02CHECKD*-100~


OVERPAYMENT/ADJUSTMENT


ADJS – Adjustment.

PREV PD – Displays the amount the provider was previously paid on this claim.

INTEREST – Interest amount.

LATE FILING CHARGE – Amount charged to the provider for filing a claim past the claim filing time limits.

PROV PD AMT – The provider paid amount is the total net amount (the amount Medicare owes the provider for this claim) minus any Forwarding Balance (FB).



PROV ADJ AMT – The provider adjustment amount is the total amount of any Withholding (WO) amounts. Provides the amount the check has been adjusted from the provider’s paid amount.

Provider not certified denial - what need to be done

CO B7 Provider was not certified/eligible to be paid for this procedure/service on this date service

(THIS PHYSICIAN/SUPPLIER IS NOT ELIGIBLE TO RECEIVE PAYMENT)



Resources/tips for avoiding this denial

Services were denied because the date of service(s) on the claim is prior to the effective date or after the termination date of the Medicare enrollment of the billing provider who appears on the claim.


• Ensure to submit only claims for services during which the provider had active Medicare billing privileges.

• If services were provided prior to or after a provider's Medicare billing privileges were active, this denial will be received.


Tips to correct the denied claim

Verify the correct date of service(s) appears on your Medicare Remittance Advice (RA).

• If the date of service(s) on the RA is not correct, the procedures for correcting claims errors should be followed.

• Clerical error reopening requests to correct the date of service can be performed.

• If the date of service(s) is correct, there may be an issue with the effective or termination date of the provider’s Medicare billing number.


0732 Servicing Provider Invalid 

Verify the 10 digit number entered for the servicing provider.


0022 Servicing Provider is Not Eligible to Bill this Payment Request Type

The servicing provider billed on the claim is not eligible to bill this claim.

1357 NPI Servicing Provider Not on File

Verify the 10 digit NPI entered for the servicing provider.


0731  Servicing Provider Not Eligible on DOS

The servicing provider was not eligible on the date of service. Contact Provider Enrollment Unit.



0757 Servicing Provider Can Not be a Group Provider

The servicing provider number used on your claim can’t be a group NPI number.



0756 Billing Provider is not a Group Provider

The billing provider must be enrolled as a group provider. Contact Provider Enrollment



0730 Servicing Provider Not a Member of the Group

The servicing provider is not a member of the group provider, Contact Provider Enrollment



0480 Not CLIA Certified to perform procedure

check that the CLIA number used on the claim is certified to perform the procedure.

Eligibility/Coverage related Denials - How to avoid

If claims are denied for eligibility reasons, the following steps should help resolve the denial and obtain reimbursement for covered dates of service for eligible recipients.

Step 1—Check for Errors on the Claim

Compare the recipient’s eligibility information to the information entered on the claim.

If the information on the claim and the recipient’s eligibility information do not match, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, request a time limit override by submitting the claim and a completed Medicaid Resolution Inquiry form. Include a copy of the Remittance and Status Report (RA) or other documentation of timely filing.

• If the claim was originally received and processed within the 365-day claim filing time limit, resubmit the claim on paper or electronically as a new day claim, ensuring that the recipient’s MID number, provider number, “from” date of service, and total billed match the original claim exactly.

Step 2—Check for Data Entry Errors

Compare the RA to the information entered on the claim.

If the RA indicates that the recipient’s name, MID number, or date of service has been keyed incorrectly, correct the claim and resubmit on paper or electronically as a new day claim.

• If the claim is over the 365-day claim filing time limit, follow the instructions in Step 1 for requesting a time limit override.

• If the claim was originally received and processed within the 365-day claim filing time limit, follow the instructions in Step 1 for resubmitting the claim.

Step 3—When All Information Matches

Verify that the recipient’s eligibility information has been updated in the state eligibility file by utilizing the Recipient Eligibility Verification Web Tool or by calling the AVR system.

If the Recipient Eligibility Verification Web Tool or the AVR system indicates that the recipient is ineligible, submit a Medicaid Resolution Inquiry form to DMA Claims Analysis. Include the recipient eligibility information, the claim, and the RA. Mail to claim mailing address

The Claims Analysis unit will review and update the information in EIS and resubmit the claim. Do not mail eligibility denials to HP Enterprise Services, as this will delay the processing of your claim.
For further information, refer to Appendix F, Verifying Recipient Eligibility and Appendix A, Automated Voice Response System.

Submitting adjustment claims

RA Requirements for Paper Adjustments


• Paper adjustment processing procedures require that providers attach a copy of all paper Medicaid RA pages related to the referenced claim.

• A provider-generated RA, or a copy of the electronic RA (835 transaction) is not an acceptable substitute for the paper copy mailed to providers by HP Enterprise Services. Provider-generated RAs have varied formats and do not include all information necessary for manual adjustment processing.

• Paper adjustments that do not include the required RA will be denied with EOB 812, “Adjustment denied. Please refile with all related RA’s, including original processing.” Providers receiving this denial should resubmit a copy of their adjustment with the requested RA.

• If you do not have a copy of the paper RA, contact HP Enterprise Services Provider Services to request a replacement. (There is a per-page charge for RA requests that are more than 10 checkwrites old. RA reprints for the last 10 checkwrites are provided at no charge. Refer to How to Request a Duplicate Remittance and Status Report in Section 9, Remittance and Status Report, for additional information.)

Submitting an Adjustment Electronically

With the implementation of standard claims transactions to comply with the Health Insurance Portability and Accountability Act (HIPAA), adjustments may be filed electronically. Electronic adjustments are the preferred method to report an overpayment or underpayment to NC Medicaid. There are two separate actions that may be filed:

1. Void—in order to file a claim to be voided, the provider must mark the claim as a voided claim using the Claim Submission Reason Field (Dental and CMS-1500) and Type of Bill (UB-04) on the 837 electronic claim transaction. The ICN for the original claim to be voided must also be provided. When processed, the claim associated with the original ICN will be recouped from the patient’s record and the payment will be recouped from the provider’s RA.

2. Replacement—a replacement claim may be filed by completing a corrected electronic claim and marking the claim as a replacement using the Claim Submission Reason Field (Dental and CMS-1500) and Type of Bill (UB04) on the electronic claim transaction. The ICN for the original claim to be replaced must also be provided. The original claim will be recouped from the patient’s record and shown as a recoupment on the RA when the replacement claim processes and pays without error. If the replacement claim is denied, the entire replacement process will be denied, including the recoupment.

N.C. Medicaid will continue to accept and process paper adjustments. Although adjustments may be filed electronically, providers are advised to file adjustments on paper when paper documentation is required.

What are the documents Psychiatry Services needed

Documentation needed for Psychiatry Services

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Physician’s progress notes.
o    Physician orders.
o    Procedure notes.
o    Physician supervision and evaluation.
o    History and physical.
o    Individualized treatment plan for psychiatric services.
o    Daily individual and group therapy notes.
o    Nurse’s notes.
o    Medication records.
o    Initial psychiatric/psychological evaluation/mental status exam.
o    Medical and psychiatric history.
o    Any diagnostic tests and results.
o    Any re-evaluations.
o    All progress notes/summaries.
o    Plan of treatment.
o    Any adjustments or revisions to the plan of treatment.
o    Treatment plan reviews.
o    Patient goals and progress toward goals.
o    Evidence of attempts to decrease frequency of visits and results of those attempts if treatment is ongoing.
o    Signatures/credentials of professionals providing services.
o    Documentation to support type of or timed codes billed.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.

Medicare code denial MA130 and action

MA 130 - Claims returned as unprocessable as appeal requests

There are large volume of appeals have been filed on claims that were returned as unprocessable. An unprocessable claim is one that was filed with incomplete and/or invalid information.

Claims that are unprocessable cannot be appealed. Therefore, when a provider files an appeal on an unprocessable claim, the correspondence is returned to the provider with a letter instructing the provider to refile a new claim. Response letters are typically not generated for at least 30-40 business days after the original request was submitted. To avoid delays in payments, providers must resubmit claims returned as unprocessable. Filing an appeal only delays payment on claims and could result in a timely filing denial if the incomplete/invalid claim is not re-filed with the correct information with the timely filing period.

Identifying an unprocessable claim

Claims returned as unprocessable will typically include the MA130 remittance advice message with a corresponding reason code message to denote why the claim was incomplete or invalid.

Communication letters to top providers that file appeals on unprocessable claims

CMS will be sending communication letters to providers in the future if appeals are continually filed on unprocessable claims. These letters will provide details on the number of appeals requests received on unprocessable claims by the applicable providers and the impacts that such requests have on regular appeal and inquiry inventories.



Code/Modifier Combination Invalid and Modifier Invalid/Missing

Remark Code/ Message Number:

4: The procedure code is inconsistent with the modifier used or a required modifier is missing

MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Resolution

Review the CPT/HCPCS code narratives to determine if a modifier is needed

Verify that the submitted modifier is appropriate to be submitted with the procedure code

Tips for Filing Adjustments

The following tips will assist in completing the adjustment form

• Complete only one adjustment request form per claim; a separate adjustment request form for each line item on a single claim is not necessary.

• Reference only one ICN per adjustment request form.

• If requesting a review of a previously denied adjustment, reference the original ICN and resubmit with all supporting documentation related to the adjustment. Do not reference the ICN for the denied adjustment.

• Include a copy of the appropriate RA with each adjustment request. If multiple RAs were involved in the claim payment process, include copies of each RA.

• Include a copy of the claim that is referenced on the adjustment request.

Note: This is not required for electronically submitted claims.

• When the adjustment request involves a corrected or revised claim, send both the original and revised claim. Do not obliterate previously paid details on the claim.

• Include pertinent information on a separate sheet of paper. Do not write information on the back of the adjustment form, RAs, etc.

• Ensure that all of the information submitted with the adjustment request is legible.

• Send only the medical records that pertain to the services rendered. If it is necessary to send records with other information included, identify the portion of the record that is significant to the adjustment request.

• Only the claim that pertains to the payment or denial in question should be submitted with the adjustment request. Do not submit any other claims with the adjustment request. Claims for service dates that have not been submitted should be filed on a new day claim, including late charges for codes not previously filed.

• When submitting an adjustment to Medicaid due to a Medicare-adjusted voucher, attach both the original voucher and the adjusted Medicare voucher. Reference the ICN of the original voucher.

• If requesting a review of a previous partial payment or a partial recoup adjustment, reference the ICN for the adjustment and resubmit with all supporting documentation related to the adjustment.

• Adjustments equal to or less than $1.00 will be denied.

The most common mistakes that are made when filing adjustments are these:

• Incomplete or invalid MID information or ICNs

• Multiple ICNs on the same form

• Unspecified or too-general reason for the adjustment request

• Missing copy of the RA related to the request

• Missing reference to the original ICN, or use of a denied adjustment ICN

• A partial payment or partial recoupment number is not referenced as the original ICN

• Filing the adjustment after the 18-month time limit

Note: If an adjustment is not filed until the 17th month from the date of service, the original claim may no longer be available in the system for adjustment. Submit adjustments as soon as possible so they can be processed within the 18-month time limit.

• Missing required documentation (Medicare vouchers, medical records, operative records, etc).

• Referencing the NPI on the adjustment request

Note: This form requests the MPN in the blank specified for Provider Number.

Denial and Action for PR 96 and CO 170

CO/PR 96 Non-covered charge(s)

(THE PROCEDURE CODE SUBMITTED IS A NON-COVERED MEDICARE SERVICE)


Resources/tips for avoiding this denial

There are multiple resources available to verify if services are covered by Medicare we can use that resources. Check the Medicare NCCI Edit and make sure that CPT and ICD combination are matching.


Tips to correct the denied claim

This denial is not usually able to be corrected.

• If you are submitting non-covered services to receive a denial for secondary or supplemental insurance, ensure to bill services with the modifier GY, indicating "statutorily non-covered services." Generally secondary insurance would cover these rejection.

 *  Check the possibilities of adding Modifier and changing the DX as per Medical record.



The acutal meaning for this denial is Billing for services not covered under the contract.

This could be differentiated between Providers’ and Patients’ Contract

All carriers have their list of Non-covered services mentioned in the Providers’ & Patients’ handbook / manual.

This also includes about Providers’ participation with the carrier and the insureds' (patients’) choosing of one such provider who participates.

Challenge:  Biggest challenge is to identify and differentiate the exact denial information from the EOBs/ERAs about the claim to handle.

Categories: Non-Covered denial is grouped majorly under the following categories by the carriers

Patient Related Concerns :

When a patient meets and undergoes treatment from an Out-of-Network provider

Action to be taken – Based on Provider’s consent bill patient either for the whole billed amount or the carrier’s allowable. Cross verify in the EOB if the payment has been made to the patient directly. If yes, please bill the patient without any delay.


Preliminary Action to avoid delay in billing patient – Prior verification notes should explain in detail for the front desk executive so that they could inform patient about provider’s participation. In most cases they would avoid seeing those patients except for an emergency need – [Process already in place with Verification Dept]. 


Similarly, cross verify with the insurance if the payment would be made to the patient if the claims are filed. If yes, pls document the same in the notes and alert the front office to collect the calculated (calculate separately based on the CPT's allowed amt) amount from the patient at the time of service

Any services not listed under the patients’ benefit package

Action to be taken – Bill patient directly

Preliminary Action to avoid delay in billing patient – While posting denial set the Denial description to reflect directly on the patient statement format.  And generate either electronic or manual patient statement for despatch immediately

When patients’ age criteria is not met

Action to be taken – Either patient age should have been incorrectly updated in the Demo else we would have picked CPT irrelevant to the patient’s age.  Double confirm the correct and required information with coding team and refile the claim

Preliminary Action to avoid delay in Reimbursement – Set AGE criteria in the CPT Master set up.  This set up will alarm the charge posters while saving the CPT code that is irrelevant to the patient’s age.


{Note:  1. Provider’s may also instruct us to waive the balances for First 2 Cases in that situation we have take write off while posting denial actions or while AR review, with appropriate “Write Off code” as “W/O taken for Non-Covered services based on Provider’s Consent”

2. All the actions should be recorded in the Follow up notes section of your system with received denial, appropriate action to it and a follow up date set (if reqd)}

Coding Related Concerns :

ICD – LCD guidelines not met
Multiple procedures performed on the same day billed
Invalid POS/type billed
When a service is performed within a period of time prior to or after inpatient services
Invalid NDC code
Inclusive to primary procedure billed
Invalid CPT billed and Others

Action to be taken – Initiate claims towards Coding Dept for review.  Based on coders’ response take appropriate action on the claim.

Preliminary Action to avoid action delay in Reimbursement – 

ICD – Valid DX set up within CPT Masters could be enabled and in-turn the CPT code could be tagged within the Insurance Masters.

System will alert us with a warning message stating “CPT already entered for this date – Do you want to continue” Within CPT Set up Master we would specify valid POS (Place of service) and TOS (Type of service) Prior billed services could be viewed under “Bill” from the Charge posting screen

Drug Set up could be utilized in order to fix NDC# specific to plan and procedures.

Modifiers to avoid Inclusive Denials could be specified in the CPT Master setup
Inactivate all the invalid or deleted CPTs from the CPT masters 

Provider Related Concerns :

When service is not related to Providers’ specialty

Action to be taken – Inform provider about the procedure listed in the superbill and suggests an alternate active CPT code to be billed - to be done during coding and charge entry process itself before claim submission.

Preliminary Action to avoid action delay in Reimbursement –
Coding screening could be done on prior hand so that these could be immediately identified and escalated to the Provider.

Non-covered services listed by the Carriers billed

Action to be taken – List the services which are denied for the given reason from specific carriers and forward it to client for W/O approval.. Note:  Ensure that we have billed the CPTs correctly.

Preliminary Action to avoid action delay in Reimbursement – 

 Procedures listed in the scheduler should be verified prior to charge posting.  So that providers will be aware of the Non-covered services prior to billing.
Same service already been billed and paid to another provider

Action to be taken – Follow up with the carrier and get the details of prior claim which was billed and paid to the other provider.  Ensure to get the information of the other provider billed for the same service.  Also make sure that no component of that claim is payable but missed to be collected by us. Compile the list and forward it to client for approval of W/O

If provider is not participating with the carrier

Action to be taken – Credentialing process to be initiated and affected claims are to be compiled and sent for provider’s approval for W/O

Preliminary Action to avoid action delay in Reimbursement – 

Providers participation details are to be verified during verification process
Front Desk executives are to be alerted through Alerts/Instructions within the system Until credentialing process is completed we could hold our claims to avoid denial on participation.




CO 170 This payment is adjusted when performed/billed by this type of provider.

(THIS SERVICE BY A CHIROPRACTOR IS NOT COVERED BY MEDICARE) . Provider type does not match type required by benefit

Resources/tips for avoiding this denial

Chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered.

This type of provider can't be performed this service hence please check the procedure CPT code and change it if any mistakes happened or else we it should be adjustment.


Tip to correct the denied claim

Services not covered by Medicare should not be billed to Medicare.

• Billing denied services to Medicare for coordination of benefits is allowable.

If our provider keep on doing this procedure means, contact insurance and include this procedure CPT code in the contract.

Appeals process Full review - basic question and answer

How to Know When You Can Appeal

When we do not authorize or approve a service or pay for a claim, we must notify you of your right to appeal that decision. Your notice may come directly from us, or through your treating physician or provider.


Decisions You Can Appeal

You can appeal the following decisions:

1. We do not approve a service that you or your treating physician or provider has requested.

2. We do not pay for a service that you have already received.

3. We do not authorize a service or pay for a claim because we say that it is not "medically necessary."

4. We do not authorize a service or pay for a claim because we say that it is not covered under your insurance policy, and you believe it is covered.

5. We do not notify you, within 10 business days of receiving your request, whether or not we will authorize a requested service.

6. We do not authorize a referral to a specialist.



Decisions You Cannot Appeal

You cannot appeal the following decisions:

1. You disagree with our decision as to the amount of "usual and customary charges."

2. You disagree with how we are coordinating benefits when you have health insurance with more than one insurer.

3. You disagree with how we have applied your claims or services to your plan deductible.

4. You disagree with the amount of coinsurance or copayments that you paid.

5. You disagree with our decision to issue or not issue a policy to you.

6. You are dissatisfied with any rate increases you may receive under your insurance policy.

7. You believe we have violated any other parts of the Arizona Insurance Code.

If you disagree with a decision that is not appeal-able according to this list, you may still file a complaint with the Arizona Department of Insurance, Consumer Affairs Division, 2910 N. 44th, Suite 210, Phoenix, AZ 85018.


Who Can File An Appeal?

Either you or your treating physician or provider can file an appeal on your behalf. At the end of this packet is a form that you may use for filing your appeal. You are not required to use this form, and can send us a letter with the sameinformation. If you decide to appeal our decision to deny authorization for a service, you should tell your treating physician or provider so he/she can help you with the information you need to present your case.


Description of the Appeals Process

There are two types of appeals: an expedited appeal for urgent matters, and a standard appeal. Each type of appeal has 3 levels. The appeals operate in a similar fashion, except that expedited appeals are processed much faster because of the patient's condition.

Expedited Appeals Standard Appeals

(for urgently needed services (for non- urgent services you have not yet received) or denied claims)

Level 1. Expedited Medical Review Informal Reconsideration 1

Level 2 Expedited Appeal Formal Appeal

Level 3 Expedited External Independent External Independent



Medical Review Medical Review

We make the decisions at Level 1 and Level 2. An outside reviewer, who is completely independent from our company, makes Level 3 decisions. You are not responsible to pay the costs of the external review if you choose to appeal level 1-3.

1 Informal reconsideration is not available for a denied claim.


EXPEDITED APPEAL PROCESS FOR URGENTLY NEEDED SERVICES

NOT YET PROVIDED

Level 1. Expedited Medical Review

Your request: You may obtain Expedited Medical Review of your denied request for a service that has not already been provided
if:

• You have coverage with us,

• We denied your request for a requested service, and

• Your treating physician or provider certifies in writing and provides supporting documentation that the time required to process your request through the Informal Reconsideration and Formal Appeal process (about 60 days) is likely to cause a significant negative change in your medical condition. (At the end of this packet is a form that your treating physician or provider may use for this purpose. Your treating physician or provider could also send a letter or make up a form with similar information.) Your treating physician or provider must send the certification and documentation to:

Physical Health Issues

UnitedHealthcare

Central Escalation Unit

P.O. Box 30573

Salt Lake City, UT 84130-0573

Fax: 801-567-5498



To reach us by telephone please call the number listed on the back of your UnitedHealthcare ID card. Our decision: We have 1 business day after we receive the information from the treating physician or provider to decide whether we should change our decision and authorize your requested service. Within that same business day, we must call and tell you and your treating physician or provider, and mail you our decision in writing. The written decision must explain the reasons for our decision and tell you the documents on which we based our decision.

If we deny your request: You may immediately appeal to Level 2.

If we grant your request: We will authorize the service and the appeal is over.

If we refer your case to Level 3: We may decide to skip Level 1 and Level 2 and send your case straight to an independent reviewer at Level 3.



Level 2: Expedited Appeal

Your request: If we deny your request at Level 1, you may request an Expedited Appeal. After you receive our Level 1 denial, your treating physician or provider must immediately send us a written request, at the office specified in the letter informing you of the outcome of your Level 1 review, to tell us you are appealing t Level 2. To help your appeal, your treating physician or provider should also send us any more information (that the treating physician or provider hasn't already sent us) to show why you need the requested service. Our decision: We have 3 business days after we receive the request to make our decision.

If we deny your request: You may immediately appeal to Level 3. If we grant your request: We will authorize the service and the appeal is over. If we refer your case to Level 3: We may decide to skip Level 2 and send your case straight to an independent reviewer at Level 3 Level 3: Expedited External, Independent Review Your request: You may appeal to Level 3 only after you have appealed through Levels 1 and 2. You have only 5 business days after you receive our Level 2 decision to send us your written request for Expedited External Independent Review.

Appeals/Grievance Coordinator

P.O Box 30978

Salt Lake City, UT 84130

To reach us by telephone please call the number listed on the back of your UnitedHealthcare ID card. Neither you nor your treating physician or provider is responsible for the cost of any external independent review. The process: There are two types of Level 3 appeals, depending on the issues in your case:


(1) Medical necessity

These are cases where we have decided not to authorize a service because we think the services you (or your treating physician or provider) are asking for, are not medically necessary to treat your problem. For medical necessity cases, the independent reviewer is a provider retained by an outside independent review organization ("IRO"), that is procured by the Arizona Insurance Department, and not connected with our company. The IRO provider must be a provider who typically manages the condition under review.

(2) Contract coverage

These are cases where we have denied coverage because we believe the requested service is not covered under your insurance policy. For contract coverage cases, the Arizona Insurance Department is the independent reviewer.

Medical Necessity Cases: Within 1 business day of receiving your request, we must: 1. Mail a written acknowledgement of the request to the Director of Insurance, you, and your treating physician or provider. 2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar document; all medical records and supporting documentation used to render our decision; a summary of the applicable issues including a statement of our decision; the criteria used and  linical reasons for our decision; and the relevant portions of our utilization review guidelines. We must also include the  name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.


Within 2 business days of receiving our information, the Insurance Director must send all the submitted information to an external independent reviewer organization (the "IRO").

Within 72 hours of receiving the information the IRO must make a decision and send the decision to the Insurance Director.

Within 1 business day of receiving the IRO's decision, the Insurance Director must mail a notice of the decision to us, you, and your treating physician or provider.

The decision (medical necessity): If the IRO decides that we should provide the service, we must authorize the service. If the IRO agrees with our decision to deny the service, the appeal is over. Your only further option is to pursue your claim in Superior Court. Contract Coverage Cases: Within 1 business day of receiving your request, we must:

1. Mail a written acknowledgement of your request to the Insurance Director, you, and your treating physician or provider.

2. Send the Director of Insurance: the request for review, your policy, evidence of coverage or similar document, all medical records and supporting documentation used to render our decision, a summary of the applicable issues including a statement of our decision, the criteria used and any clinical reasons for our decision and the relevant portions of our utilization review
guidelines.

Within 2 business days of receiving this information, the Insurance Director must determine if the service or claim is covered, issue a decision, and send a notice to us, you, and your treating physician or provider.


Referral to the IRO for contract coverage cases: The Insurance Director is sometimes unable to determine issues of coverage. If this occurs, the Insurance Director will forward your case to an IRO. The IRO will have 5 business days to make a decision and send it to the Insurance Director. The Insurance Director will have 1 business day  after receiving the IRO's decision to send the decision to us, you, and your treating physician or provider. The decision (contract coverage):If you disagree with Insurance Director's final decision on a contract coverage issue, you may request a hearing with the Office of Administrative Hearings ("OAH"). If we disagree with the Director's final decision, we may also request a hearing before OAH. A hearing must be requested within 30 days of receiving the Director's decision. OAH must promptly schedule and complete a hearing for appeals from expedited Level 3 decisions.


STANDARD APPEAL PROCESS FOR NON-URGENT SERVICES AND DENIED CLAIMS 

Level 1 Informal Reconsideration

Your request: You may obtain Informal Reconsideration of your denied request for a service if:

• You have coverage with us,

• We denied your request for a requested service,

• You do not qualify for an expedited appeal, and

• You or your treating physician or provider asks for Informal Reconsideration within 2 years of the date we first deny the requested service by calling, writing, or faxing your request to: Physical Health Issues UnitedHealthcare Central Escalation Unit P.O. Box 30573 Salt Lake City, UT 84130-0573 Fax: 801-567-5498 Mental Health Issues United Behavioral Health  Appeals Coordinator 1900 East Golf Road, Suite 300 Schaumburg, IL 60173 Fax: 1-800-322-9104 Dental IssuesAppeals/Grievance Coordinator Grievance & Appeals Department P.O. Box 30569 Salt Lake City, UT 84130-0569 Fax: (714) 364-6266 Vision Issues
UnitedHealthcare Appeals/Grievance Coordinator  P.O Box 30978 Salt Lake City, UT 84130


To reach us by telephone please call the number listed on the back of your UnitedHealthcare ID card. Claim for a service already provided but not paid for: You may not obtain Informal Reconsideration of your denied request for the payment of a  service. Instead, you may start the review process by seeking a Formal Appeal. Our acknowledgement: We have 5 business days after we receive your request for Informal Reconsideration("the receipt date") to send you and your treating physician or provider a notice that we received your request.

Our decision: We have 30 days after the receipt date to decide whether we should change our decision and authorize your requested service. Within that same 30 days, we must send you and your treating physician or provider our written decision. The written decision must explain the reasons for our decision and tell you the documents on which we based our decision.

If we deny your request: You have 60 days to appeal to Level 2.

If we grant your request: We will authorize the service and the appeal is over.

If we refer your case to Level 3: We may decide to skip Level 1 and Level 2 and send your case straight to an independent reviewer at Level 3.

Level 2 Formal Appeal

Your request: You may request a Formal Appeal if: (1) we deny your request at Level 1, or (2) you have an unpaid claim and we did not provide a Level 1 review. After you receive our Level 1 denial, you or your treating physician or provider must send us a written request within 60 days to tell us you are appealing to Level 2. If we did not provide a Level 1 review of your denied claim, you have 2 years from our first denial notice to request Formal Appeal. To help us make a decision on your appeal, you or your treating physician or provider should also send us any more information (that you haven't already sent us) to show why we should authorize the requested service or pay the claim. Send your appeal request and information to:

Physical Health Issues

UnitedHealthcare
Central Escalation Unit

P.O. Box 30573

Salt Lake City, UT 84130-0573

Fax: 801-567-5498



To reach us by telephone please call the number listed on the back of your UnitedHealthcare ID card. Our acknowledgement: We have 5 business days after we receive your request for Formal Appeal ("the receipt date") to send you and your treating physician or provider a notice that we received your request. Our decision: For a denied service that you have not yet If we grant your request: We will authorize the service or pay the claim and the appeal is over.

If we refer your case to Level 3: We may decide to skip Level 2 and send your case straight to an independent reviewer at Level 3.



Level 3: External, Independent Review

Your request: You may appeal to Level 3 only after you have appealed through Levels 1 and 2. You have four months after you receive our Level 2 decision to send us your written request for External Independent Review.

Send your request and any more supporting information to:

Physical Health Issues

UnitedHealthcare

Central Escalation Unit

4316 Rice Lake Road

Duluth, MN 55811

Fax: 801-938-2100 or 801-938-2109

Mental Health Issues

United Behavioral Health

Appeals Coordinator

1900 East Golf Road, Suite 300

Schaumburg, IL 60173


Fax: 1-800-322-9104


To reach us by telephone please call the number listed on the back of your UnitedHealthcare ID card.

Neither you nor your treating physician or provider is responsible for the cost of any external independent review. The process: There are two types of Level 3 appeals, depending on the issues in your case:


(1) Medical necessity

These are cases where we have decided not to authorize a service because we think the services you (or your treating physician or provider) are asking for, are not medically necessary to treat your problem. For medical necessity cases, the independent reviewer is a provider retained by an outside independent review organization (IRO), procured by the Arizona Insurance Department, and not connected with our company. For medical necessity cases, the provider must be a provider who typically manages the condition under review.

(2) Contract coverage

These are cases where we have denied coverage because we believe the requested service is not covered under your insurance policy. For contract coverage cases, the Arizona Insurance Department is the independent reviewer.


Medical Necessity Cases

Within 5 business days of receiving your request, we must:

1. Mail a written acknowledgement of the request to the Director of Insurance, you, and your treating physician or provider.


2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar document; all medical records and supporting documentation used to render our decision; a summary of the applicable issues including a statement of our decision; the criteria used and clinical reasons for our decision; and the relevant portions of our utilization review guidelines. We must also include the name and credentials of the health care provider who reviewed and upheld the denial at the earlier appeal levels.

Within 5 days of receiving our information, the Insurance Director must send all the submitted information to an external independent review organization (the "IRO").

Within 21 days of receiving the information the IRO must make a decision and send the decision to the Insurance Director.eceived, we have 30 days after the receipt date to decide whether we should change our decision and authorize your requested service. For denied claims, we have 60 days to decide whether we should change our decision and pay your claim. We will send you and your treating physician or provider our decision in writing. The written decision must explain the reasons for our decision and tell you the documents on which we based our decision.

If we deny your request or claim: You have four months to appeal to Level 3.


Within 5 business days of receiving the IRO's decision, the Insurance Director must mail a notice of the decision to us, you, and your treating physician or provider.

The decision (medical necessity): If the IRO decides that we should provide the service or pay the claim, we must authorize the service or pay the claim. If the IRO agrees with our decision to deny the service or payment, the appeal is over. Your only further option is to pursue your claim in Superior Court.


Contract Coverage Cases

Within 5 business days of receiving your request, we must:

1. Mail a written acknowledgement of your request to the Insurance Director, you, and your treating physician or provider.

2. Send the Director of Insurance: the request for review; your policy, evidence of coverage or similar document; all medical records and supporting documentation used to render our decision; a summary of the applicable issues including a statement of our decision; the criteria used and any clinical reasons for our decision; and the relevant portions of our utilization review guidelines. Within 15 business days of receiving this information, the Insurance Director must determine if the  ervice or claim is covered, issue a decision, and send a notice to us, you, and your treating physician or provider. If the Director decides that we should provide the service or pay the claim, we must do so. Referral to the IRO for contract coverage cases: The Insurance Director is sometimes unable to determine issues of coverage. If this occurs, the Insurance Director will forward your case to an IRO. The IRO will have 21 days to make a decision and send it to the Insurance Director. The Insurance Director will have 5 business days after receiving the IRO's decision to send the decision to us, you, and your treating physician or provider. The decision (contract coverage): If you disagree with the Insurance Director's final decision on a coverage issue, you may request a hearing with the Office of Administrative Hearings ("OAH"). If we disagree with the Director's determination of coverage issues, we may also request a hearing at OAH. Hearings must be requested within 30 days of receiving the coverage issue determination. OAH has rules that govern the conduct of their
hearing proceedings.

Obtaining Medical Records 

Arizona law (A.R.S. §12-2293) permits you to ask for a copy of your medical records. Your request must be in writing and must specify who you want to receive the records. The health care physician or provider who has your records will provide you or the person you specified with a copy of your records. Designated Decision-Maker: If you have a designated health care decision-maker, that person must send a written request for access to or copies of your medical records. The medical records must be provided to your health care decision-maker or a person designated in writing by your health care decision-maker unless you limit access to your medical records only to yourself or your health care decision-maker. Confidentiality: Medical records disclosed under A.R.S. §12-2293 remain confidential. If you participate in the appeal process, the relevant portions of your medical records may be disclosed only to people authorized to participate in the review process for the medical condition under review. These people may not disclose your medical information to any other people.

Documentation for an Appeal

 If you decide to file an appeal, you must give us any material justification or documentation for the appeal at thetime the appeal is filed. If you gather new information during the course of your appeal, you should give it to us as soon as you get it. You must also give us the address and phone number where you can be contacted. If the appeal is already at Level 3, you should also send the information to the Department.

The Role of the Director of Insurance

Arizona law (A.R.S. §20-2533(F)) requires "any member who files a complaint with the Department relating to an adverse decision to pursue the review process prescribed" by law. This means, that for appealable decisions, you must pursue the health care appeals process before the Insurance Director can investigate a complaint you may have against our company based on the decision at issue in the appeal.

The appeal process requires the Director to:

1. Oversee the appeals process.

2. Maintain copies of each utilization review plan submitted by insurers.

3. Receive, process, and act on requests from an insurer for External, Independent Review.

4. Enforce the decisions of insurers.

5. Review decisions of insurers.

6. Report to the Legislature.

7. Send, when necessary, a record of the proceedings of an appeal to Superior Court or to the Office of Administrative Hearings (OAH).

8. Issue a final administrative decision on coverage issues, including the notice of the right to request a hearing at OAH.

Receipt of Documents

Any written notice, acknowledgment, request, decision or other written document required to be mailed is deemed received by the person to whom the document is properly addressed on the fifth business day after being mailed. "Properly addressed" means your last known address.



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.