How to Submit an Appeal: “The Redetermination Level” PRESENTED BY PART B PROVIDER OUTREACH & EDUCATION MAY 21, 2013 1 Disclaimer This resource is not a legal document. This presentation was p prepared p as a tool to assist our p providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. p of this material for p profit is p prohibited. Reproduction 2 Acronyms Acronym Term ADR Additional Documentation Request ALJ Administrative Law Judge CCI Correct Coding Initiative CERT Comprehensive Error Rate Testing DAB Departmental Appeals Board ICN Internal Control Number MRN Medicare Redetermination Notice NPI National Provider Identifier PHI Protected Health Information PTAN Provider Transaction Access Number 3 Agenda • Levels L l off A Appeals l & Wh Where tto Fil File • Redeterminations • Requirements for Submission via Letter • How to send Appeal Request • Completion of CMS 20027 Form • Completion of Cahaba Redetermination SMART Form • CERT and Self-Service Tools 4 Five Levels of Appeals: Where to File Level of Appeal Where to File Redetermination MAC (Cahaba GBA) Reconsideration Qualified Independent Contractor (Q2A) Administrative Law Judge (ALJ) Hearing Office of Medicare Hearing and Appeals (OMHA) Departmental Appeals Board Medicare Appeals Council (MAC) Review Board as instructed on ALJ decision Federal Court United States District Court 5 Level 11 Redetermination • Parties dissatisfied with their initial determination can file an appeal 120 days from the initial claim denial • Submit a redetermination request via the following: – CMS-20027 Form – the Cahaba GBA Medicare Part B Redetermination SMART Form or – a written redetermination request on companyy letterhead with the required information • Requests are completed within 60 days of receipt – The date request is received into our mailroom • Submit all supporting documentation – Provide anyy additional information needed with the redetermination request 6 Redetermination RequestRequest Letterhead If neither form is used for a written redetermination request, q the request must be submitted with all the following: • • • • • • Beneficiary name name. Beneficiary’s Health Insurance Claim Number (HICN). Dates of service at issue. The specific services or items for which the redetermination is being requested. Name and signature of the party or representative of the party. Provider information such as Provider Transaction Access Number (PTAN), National Provider Identifier (NPI) and Tax Identification Number (TIN). 7 Appeals on Full or Partial Denials A full or partial denial may occur on the claim:  Your remittance advice (RA) will let you know which procedure(s) are p paid and which were denied,, if applicable. pp  When submitting your appeal for denied service(s), you should let us know if you are appealing the entire claim or only specific lines on the claim by indicating the procedure code(s) you are appealing.  Only one appeal should be requested per Internal Control Number (ICN), regardless of multiple codes on the claim being appealed. 8 Redetermination Outcomes Redetermination can have 5 possible outcomes: • Full Reversal (favorable) • Partial Reversal (partially favorable) • Full Affirmation (unfavorable) • Dismissal • Affirmation-Claim Paid 9 Medicare Redetermination Notice • The redetermination letter issued is the Medicare Redetermination Notice (MRN) • The MRN will contain all the information necessary to request the next level of appeal • The Appeals Department will send the QIC reconsideration request q form with the redetermination letter *Received for an Affirmation or Partial Reversal* 10 Top 5 Reasons for Redeterminations 1) Medical Necessity 2) Duplicate Charge 3)) CCI and Frequency q y 4) Screening/Preventive Services 5) Modifiers 11 Where to Locate Appeal Forms? 12 CMS 20027 Form Form- (Top Portion) Place the Internal Control Number (ICN) Here 13 CMS 20027 Form Form- (Bottom Portion) Bee Medicare 14 Cahaba Medicare B Redetermination SMART F Form- (Top (T Portion) P ti ) 15 Cahaba Medicare B Redetermination SMART F Form- (Bottom (B tt Portion) P ti ) 16 Appeals Mailing Address All paper redetermination request must be submitted to: Alabama Georgia Tennessee Cahaba GBA Part B Redeterminations P.O. Box 1921 Birmingham, g , AL 35201-1921 Cahaba GBA Part B Redeterminations PO Box 12967 Birmingham, g , AL 35202 Cahaba GBA Part B Redeterminations P O Box 12724 Birmingham, g , AL 35202-6724 17 Appeals Fax Number All Medicare B Redetermination (SMART form only) request must be faxed to: State Fax a Number u be Alabama Georgia 855-215-9290 Tennessee 18 Redetermination Request Issues • • • • • • • • • • Handwritten SMART Forms Faxing Redetermination request made on CMS 20027 Redetermination Request with invalid ICN Multiple SMART Forms faxed as one batch Coversheets on top of SMART Forms Pl i 2 digits Placing di it in i each h box b off the th SMART F Form Writing Multiple ICNs in box and attaching spreadsheet Not enough digits for Item 6 of SMART Form Wrong Date Format (i.e. MM/DD/YY) Wrong Forms (i.e. CMS 20033-Reconsideration) 19 Comprehensive Error Rate Testing p g (CERT) ( ) CERT Program: • Medicare Trust Fund Measures improper payments in the Medicare fee-for-service program and is designed to comply with the Improper Payments Elimination and Recovery Act of 2010 (IPERA) CERT Documentation Contractor: Measure • Correct Claim Process/Payment Assess A Evaluate •Contractor and Provider Protect Responsible for requesting and receiving the medical record documentation from providers C CERT Review C Contractor: Review selected claims and associated medical record documentation http://www.cms.gov/cert/ 20 Online Eligibility and Claim Status Portal Eligibility Verification: Claims Status: • • • • • • • • • • • • • • • Part A & B Entitlement ESRD Preventive Service Medicare Secondary Advantage Plan Home Health Hospice Claim Number Date of Service Total Submitted Charges Allowed Charge Amounts Status of Claim Amount Paid Deductible Amounts Adjustment Date 21 Connectivity Vendor • Effective July 1 1, 2013 2013, Cahaba GBA will no longer support dial-up connections • All electronic transactions should be routed through a Cahaba GBA approved Network Service Vendor (NSV) • Current user ID and password can be used • Direct questions to the Cahaba GBA EDI Helpdesk http://www.cahabagba.com/part-b/claims-2/electronic-data-interchange-edi/connectivity/ EDI Helpdesk 1-866-582-3253 22 Appeals Decision Tree SHOULD YOU YOU SUBMIT SUBMIT AN AN APPEAL or NOT NOT to Cahaba GBA? SHOULD APPEAL or to Cahaba GBA?  Designed to help you determine if you should file a redetermination request q  Series of Questions  Yes or No  Eliminates submission of request in error  Accuracy  Interactive Decision Tree  Saves Time and Postage  Click your way to the correct answer 23 Appeals Calculator 1 24 Appeals Calculator 2 25 Go Green Campaign • Sign-up for Electronic Funds Transfer (EFT) • Enroll to receive Electronic Remittance Advice (ERA) • Complete and/or update enrollment application via Provider Enrollment Chain and Ownership System (PECOS) • Submit Additional Documentation after it is requested through Electronic Submission of Medical Documentation (esMD) 26 Fore See Survey This survey will ask you to rate the following (not all-inclusive): – Quality of Information – Freshness of content – Clarity of Organization – Convenience of the services – Your ability to find the information you want – Consistency of speed – Overall satisfaction 27 References • Appeals pp Brochure http://www.cahabagba.com/documents/2013/02/2013-appeals-brochure.pdf • Appeals A l Q Quick i kR Reference f G Guide id http://www.cahabagba.com/documents/2013/02/2013-appeals-quick-reference-chart.pdf • The CMS C S Medicare Appeals Process Brochure https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MedicareAppealsprocess.pdf • The Claims Processing Manual 100-4 Chapter 29 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf 28 Question & Answer Session THE END 29 Thank you for Joining Us! Participants can obtain the evaluation via one of the following options: 1 1. Upon the conclusion of the event event, the evaluation will be launched; or, You may copy and paste the electronic evaluation link http://listmgr.cahabagba.com/subscribe/survey?f=1476 to your browser and complete the survey. 2 2. We appreciate your feedback and comments. 30