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Medicare appeal - Most commonly asked questions ?

Q: Can I resubmit or adjust a claim when an appeal is processing?

A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.

Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.

Q. Can minor errors or omissions be corrected outside of the appeals process?

A. Yes. There are two ways to correct a claim. A clerical error reopening can be initiated via the telephone or in writing; or, in many cases, the denied service(s) can simply be corrected and resubmitted. Resubmitting claims to correct minor clerical errors or omissions is the most efficient method for addressing certain denied services.*

*Resubmit the denied service(s) ONLY - resubmitting an entire claim will create a duplicate denial.

If these issues are received via written and telephone requests, it may take up to 60 days to process and finalize an adjustment, versus 14-30 days for a resubmitted claim. Ensure that you review the type of clerical error or omission you are attempting to correct and select the most efficient option available.
Note: Single-line clerical reopenings can be requested through the Part B Interactive Voice Response system (IVR). Click here for more details. If you’re registered for SPOT, you may submit Part B clerical reopening requests online. Click here for more details.
Determine if the error can be corrected and resubmitted prior to writing in or calling to request a clerical error reopening.

• Minor clerical errors or omissions that can be corrected and resubmitted:
• Change of diagnosis codes
• Add, change, or delete modifiers (e.g., 25, 50, 59, 78, 79, RT, LT)
• Incorrect place of service
• Written or telephone clerical error reopenings are appropriate only for services that were processed and received an approved amount, and could include the following types of situations:
• Number of services (NB) billed
• Submitted charge amount
• Date of service (DOS)
• Add, change or delete certain modifiers
• Procedure code; excluding codes requiring documentation on the initial submission or codes being upcoded


Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?

A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.

Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.

The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Q. What actions do providers take to request an appeal of a Medicare overpayment for an MSP claim and stop the accounts receivable offset?

A. If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.


Q: Is there a resource for providers or beneficiaries that outline what services or items can be appealed?

A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.




Q. What actions do providers take to request an appeal of a Medicare overpayment for an MSP claim and stop the accounts receivable offset?

A. If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.


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: Will First Coast’s medical review (MR) department request additional documentation from providers during the CERT process?

A. The CERT contractor will request medical records that support services rendered on randomly-selected claims. The CERT contractor reviews the medical records and determines whether the claims were billed and paid in accordance with Medicare guidelines. If CERT errors are assessed due to “insufficient documentation” or “no response to documentation request”, First Coast may attempt to procure additional documentation from the provider. First Coast will review documentation for completeness and will fax them to CERT contractor, which may result in an error being removed.


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 they received to the affiliated contractor, or First Coast Service Options Inc.


Q. What is the address for overpayment appeals?
A. The address for a Florida overpayment appeals is as follows:
First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248


Clerical reopening requests in Medicare

How to correct your claim


Minor errors or omissions may be corrected outside of the appeals process.
Part B clerical reopening requests may be submitted online through SPOT or via telephone through the interactive voice response (IVR) system.


Option 1: Submit reopenings online using SPOT

The SPOT offers registered users the time-saving advantage of correcting clerical errors in their eligible Part B claims quickly, easily, and securely -- online.
To begin, search for the claim you wish to correct by its ICN or by its date(s) of service in Claim Status. The SPOT will automatically determine if any line items are eligible and prepopulate the online request form accordingly.


FAQs

• What types of changes may I include in a claim reopening request? May I change more than one field on each line item? Can I add or remove line items?
• How do I access a claim I wish to reopen? How will I know if any of the line items associated with a claim are eligible?
• Are there any restrictions on modifiers or procedure codes when using SPOT to reopen a claim?
• When I try to edit a field (e.g., modifier, DOS), the SPOT won’t allow me to add a value, delete a value, or edit a value. How can I resolve this problem? Are there any other issues that may prevent the SPOT from accepting a new/replacement value for an edited field?

Login to SPOT external link

Option 2: Submit reopenings on the telephone with the IVR

If you don’t have online access, you may submit your Part B clerical reopening request through First Coast’s IVR system. Although the IVR offers the same primary request types as the SPOT, the IVR offers the additional option of making history corrections to your claim.
To access your claim through the IVR, you must enter the billing provider’s information (i.e., NPI, PTAN, and TIN), the beneficiary’s information (i.e., name, date of birth, Medicare number), and the ICN of the claim you wish to correct.
If you would like to take advantage of First Coast’s telephone submission method for clerical reopening requests, please refer to Telephone reopening requests via the IVR.


Claim reopening: Request types FAQ

Q: What types of changes may I include in a claim reopening request? May I change more than one field on each line item? Can I add or remove line items?

A: Part A providers may use SPOT to submit a request for clerical corrections to eligible line items in your Part A claim. Providers must submit any accompanying documentation along with the CMS-1450 (UB-04) form pdf file.
Part B providers may conduct a clerical claim reopening through the SPOT with the ability to make corrections to the following fields:
• Date of Service (DOS)
• Diagnosis Code (primary)
• Procedure Code
• Modifier
• Units Billed
• Only one claim reopening request type may be selected for each eligible line item, and the type of request is determined by the primary field to be corrected.
• Some types of requests may allow the editing of more than one field (i.e., primary and secondary fields). However, the primary field is based upon the request type selected, and the primary field is always a required field.
• Some modifiers and procedure codes are ineligible for clerical claim reopening through SPOT.

Claim Reopening: Request types and tips
Claim reopening request type

DOS From, DOS To, Billed Amount

Anesthesia providers must use units and not minutes when adjusting units billed. The conversion factor is 1 unit = 15 minutes. For example, 75 minutes would be entered as 5 units (75/15=5 units).
Limitations to claim reopenings on the SPOT
• Multiple request types (e.g., Edit Procedure Code and Add Modifier) may not be utilized for the same eligible line item
• Line items may not be added or removed
• History corrections (e.g., updates to beneficiary information or status) may not be submitted
• Rendering provider’s NPI may not be changed
• Claim reopening requests submitted through the SPOT must be filed within one year of the receipt of the initial determination
• Multiple modifiers, procedure codes, or diagnosis codes may not be added through the SPOT
• Claim reopening requests without any changes may not be submitted through the SPOT

Claim reopening: Accessing the claim FAQ


Q: How do I access a claim I wish to reopen? How will I know if any of the line items associated with a claim are eligible?


A: Before you may initiate the Claim Reopening Request process, you must first access the claim and any of its eligible line items that you wish to correct. To view an illustration of how to correct a claim on SPOT, First Coast offers this helpful tutorial.

Users may access claims they wish to reopen through two different paths on the SPOT:

• Claim Status: Search for the claim based on its Dates of Service or Internal Control Number (ICN)
• Claim Reopening: Search for the claim based on its ICN
The SPOT will determine whether a claim or any of its associated line items are eligible for the reopening automatically.
For step by step instructions, please refer to The SPOT: User Guide pdf file
Accessing the claim: ‘Claim Status’ path
Once the claim has been accessed, the SPOT will determine the eligibility of the claim and any of its associated line items automatically.
If you located the claim through Claim Status, view the line item detail: If a line item is eligible, the SPOT will display the hyperlink: View line items eligible for claim reopening above that line item:

Restricted modifiers and procedure codes FAQ

Q. What are the restricted modifiers and procedure codes that cannot be corrected through the reopening process using SPOT?

A. Modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) may not be corrected through the Secure Provider Online Tool (SPOT). In fact, due to their nature, there are several modifiers and procedure codes in which claims may not be corrected through SPOT.
Here is a list of modifiers and procedure codes that cannot be corrected using SPOT:
Modifiers that cannot be corrected using SPOT include:
21, 22, 24, 51, 52, 53, 56, 62, 66, 99, CC, GA, GY, GZ, SG, WU
CPT®/HCPCS that may not be corrected using SPOT include:
J0200, J0390, J0395, J0520, J0735, J1094, J1700, J1710, J1885, J1960, J1990, J2323, J2440, J2670, J2760, J3490, J3590, J7130, J7184, J7199, J7310, J7326, J7628, J7629, J7648, J7658, J7659, J7683, J7684, J8499, J9165, J9201, J9217, J9219, J9270, J9357, J9999, Q0144, Q2027, Q2034, Q2035, Q2036 Q2037, Q2038, Q2039, Q2045, Q2046, 90654, 90655, 90656, 90657, 90658, 90659, 90660, 90667, 90668, 90715, 90724, 90779, 96549
If your claim includes any of the modifiers or procedure codes listed above, you may submit a request for redetermination using SPOT’s Secure Messaging.

Compatibility view and other causes of reopening errors - FAQ

Q: When I try to edit a field (e.g., modifier, DOS), the SPOT won’t allow me to add a value, delete a value, or edit a value. How can I resolve this problem? Are there any other issues that may prevent the SPOT from accepting a new/replacement value for an edited field?

A: First, if the SPOT will not allow you to edit, remove, or enter a value in an editable field, check the compatibility settings in your internet browser.
If ‘Compatibility View’ is on, you must turn it off. The SPOT will not function correctly when ‘Compatibility View’ has been selected.
How to change ‘Compatibility view’ settings
To check whether your browser has been set to Compatibility View, please follow these steps:
1. If you are using Internet Explorer, click the Tools menu
2. If ‘Compatibility View’ has been selected, you will see a checkmark next to ‘Compatibility View.’

Other potential causes of edit errors


When a user selects a request type that requires the editing of one or more fields (i.e., Edit DOS From, Edit DOS To, Edit DOS Both, Edit Modifier, Edit Diagnosis Code, or Edit Procedure Code), the SPOT will validate the new/replacement value as soon as the cursor leaves the edited field based upon specific criteria.
The SPOT will validate the new/replacement value as soon as the cursor leaves the edited field based upon the following criteria:
• Formatting -- each field has a specific set of formatting guidelines. To view the formatting guideline for a specific field, place your cursor over the Information tooltip next to the corresponding column.
Information tooltip example
• Authenticity -- the value entered must be an authentic diagnosis code, modifier, or procedure code (as applicable). For example, a value of 000.1 is not a real diagnosis code and would not be accepted as a replacement code by the SPOT.
• Acceptability -- the value entered must be one that is permissible to use in a claim reopening through the SPOT. For example, the WU modifier may not be used as a replacement code for a claim reopening.
• Logic -- the relationship between the DOS From and DOS To values must be a logical relationship. For example, the DOS From value cannot be later than the DOS To value.
Since the SPOT validates an edited field after the cursor has moved out of the field, the SPOT will reject the new/replacement value and revert to the field’s original value if any of the following conditions occur:
• User tried to copy and paste a new/replacement value in the edit field
• User moved the cursor out of the editable field before typing in a new/replacement value
• User entered an invalid value
• User did not enter a new/replacement value in all required fields (applicable to Edit DOS Both request type)
• User entered a new/replacement value that may not be utilized in a claim reopening request
• User entered a new/replacement value that does not meet conditional requirements (e.g., entering a DOS From value that is later than the DOS To value)
• User entered a new/replacement value that does not meet formatting requirements (e.g., entering DOS From value as m/d/yy instead of mm/dd/yyyy)
Request type example: Edit Modifier
Once you have accessed the claim you wish to correct, follow these steps:
1. Select the line item you wish to correct
For this example, select Line Item 01
2. Select the Request Type based upon the field you wish to edit for that line item.
For this example, select Edit Both DOS for Line item 01

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