1. law, govt and politics

INTOTAL CLAIM RECONSIDERATIONS AND
PROVIDER PAYMENT APPEALS FAQS
1. What is the difference between a “Corrected Claim” and “Clean Claim?”
DMAS defines a “Clean Claim as a claim that “has no defect, impropriety, lack of any required
substantiating documentation”
A Clean Claim has all the required pertinent information that gets the claim adjudicated the first
time.
A Corrected Claim, however, is a resubmission of a claim with alterations made to the original
claim. Providers resubmitting claims for corrections must clearly mark the claim “Corrected
Claim.” Failure to mark the claim appropriately may result in the denial of the claim as a
duplicate. Corrected claims must be received within the applicable timely filing requirements of
the originally submitted claim. Corrected claims must include all the line items from the original
claim submitted. If line items are not included in the corrected claim, it is assumed that deletion
of the line item is part of the correction.
2. What is INTotal’s practice regarding the submission of “Corrected Claims?”
Unless additional documentation has specifically been requested to support the claim
adjudication of a previously processed claim, all Corrected Claims should conform to these
standards:
For professional (Doctor’s) and institutional (Hospital) paper claim forms, the only mechanism
accepted to indicate the claim is a correction or a void of a previous processed claim will be the
following:
For Professional Claims, the form to use is the CMS 1500 form. Providers should complete Box
Number 22 which is used for Medicaid Resubmission and/or Original Reference Number.
(When resubmitting a claim, the provider must enter the appropriate claim frequency code in the
left-hand side of the field. 7 – Replacement of prior claim, 8 – Void/cancel of prior claim)
For Institutional Claims the appropriate form is UB04 form. Providers should complete Box
Number 4 which is Type of Bill.
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Examples of Corrected Claims:
 Corrected Procedure Code
 Corrected Modifier
 Resubmitted with CLIA number
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(When resubmitting a claim, enter the appropriate claim frequency code in the 3 Position of the
Type of Bill. 7 – Replacement of prior claim, 8 – Void/cancel of prior claim)
3. What is Reconsideration?
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Claim resubmission from the provider about a disagreement with the manner in which a claim
was processed, but does not require a claim to be corrected.
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Examples of Reconsiderations:
 Previously denied for timely filing with attached justification
 Previously paid, however disputing reimbursement
 Previously denied for no authorization, and one now exists
4. What is a provider payment Appeal?
If a claim is denied, a provider has the right to an appeal - a full and fair review of the denial. A
provider payment appeal is any of the process and procedures that deal with the review of any
unfavorable adjudication of claims. These procedures include reconsideration by the Health plan
(Internal) and if necessary, an independent review entity, hearings before Administrative Law
Judges (ALJs), reviews by the State Fair Hearings, and judicial review (External).
5. What is the Provider Appeal Process?
The right to appeal is available to providers for disputes of post-adjudicated claims related to
medical necessity, billing/coding, and no preauthorization for services. Provider appeals may be
submitted without written consent from the member, but must be submitted in writing from the
provider.
6. What are the different levels of Appeal?
If a claim is denied or deemed underpaid, a provider has two (2) primary levels of Appeal.
Providers are entitled to First and Second Level post-service appeals for claim denials related to
billing/coding, cosmetic, experimental/investigational, medical necessity, and no
preauthorization.
First level appeals are reviewed by the health plan claim analysts who were not involved in the
initial decision. All first level appeals should be decided within 30 days of the plan’s receipt of
your appeal. Once a decision is made, the provider will be sent a written decision that gives
information about further appeal options.
Second level appeals are heard by a committee that was not involved with the first level appeal.
All second level decisions should be made within 30 days of receiving your appeal. The provider
will be sent a written decision that gives information about further appeal options.
At any level of the appeal process documentation or evidentiary information may be submitted
or requested for review. Please refer to Provider Manual for further clarification.
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7. How long does a Provider have to submit a Level I Post-Service appeal?
Providers will have 90 calendar days from the claim adjudication (EOP) date to submit a Level I
Post-Service Provider Appeal for any claims that has an adverse adjudication outcome.
8. How long does a Provider have to submit a Level II Post-Service appeal?
For billing disputes, when Level II Post-Service Provider Appeal rights are available within 30
calendar days from the date of the Level I Post-Service Provider Appeal denial letter to submit a
written Level II Post-Service Provider Appeal.
For medical necessity denials, when Level II post-service provider appeal rights are available
within 30 calendar days from the date of the Level I Post-Service Provider Appeal denial letter to
submit a written Level II Post-Service Provider Appeal.
9. How do I submit a Level I Provider appeal?
The Provider Appeal form replaced the Provider Resolution Form. This form will continue to be
updated from time to time and it is recommended providers print the form from the website
each time to ensure they are using the most up-to-date version. Access the form on the INTotal
provider website. A completed form can then be mailed to:
INTotal Health
Attn: IRU
PO Box 5448
Richmond, VA 23220-5448
Assistance with the appeals process can also be obtained by calling INTotal Provider Services at
1-855-323-5588
**The INTOTAL provider appeals form is also found in the Provider Manual and the INTotal
Website: www.intotalhealth.org.
10. If a Provider states they want to file an Appeal over the phone, what do you do?
The representative should take all actions to rectify the issue over the phone and determine if it
is a “one and done.” If the issue cannot be resolved at that point, the representative will need to
educate the Provider that they will need to submit the Appeal with the appropriate form and
assist them through the process to expedite the Appeal.
11. How can I check the status of a Provider appeal that has been submitted?
Providers can call 1-855-323-5588 and an INTOTAL representative can assist you.
Provider Relations Representatives can contact the IRU via the IRU email
([email protected]). Someone from the IRU will respond within 24/48 hours. PR Reps can
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also validate status by checking member’s folder in Macess and looking at the
properties/workflow tab of the document. Or validate the Provider Appeals Database managed
by the Internal Resolution Unit (IRU).
12. What other options are available if the Appeal request remained denied/upheld?
Providers must exhaust both Levels of the Appeal with the Health Plan. If provider still is not
satisfied with outcome, they may file the Appeal with Department of Medical Assistance (DMAS).
13. What is the most expedient way to ensure that a provider’s request for Reconsideration and/or
Payment Appeal is addressed?
Providers are encouraged to utilize the Reconsideration & Payment Appeal Forms to ensure that
their request for reviews, reconsiderations and appeals are handled in a timely and efficient
manner. They should thoroughly fill out the form and provide a concise description of the issue
to ensure an effective resolution of the problem.
14. If a provider is on hold (PVOH), or has reason to believe that due reimbursement was retracted in
error should a Provider Rep create a ChangeGear Ticket?
A Provider Relations representative will create a change gear ticket and assign it to the IRU team.
The cost containment department will review it.
15. If a provider is dissatisfied with the outcome from a ChangeGear request, how should a Provider
Rep proceed?
Provider reps may send an email to the IRU ([email protected]). If further discussion is
needed outside of emails the issue can be discussed in the regularly scheduled PR/IRU meeting.
16. Where can one find more information about INTotal provider appeals in general?
Appeal information can be found in the INTOTAL provider manual and website:
www.intotalhealth.org
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