Home Health & Hospice Week
Claims Review Changes May Help Your Appeal
Change won’t apply to appeals prior to Aug. 1.
If your claim gets denied in medical review, Medicare contractors are now barred from attacking it on new grounds during your appeal.
Old way: Qualified Independent Contractors “have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item,” the Centers for Medicare & Medicaid Services explains in a recent MLN Matters article. “As a result, in some cases where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason.”
New way: As of Aug. 1, “for redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied,” CMS says in the article. The change won’t be applied retroactively, the agency adds.
See the article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1521.pdf.
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