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Reimbursement:

UNDERSTAND THE APPEALS ROPES OR RISK YOUR REIMBURSEMENT

Published on Tue Jan 06, 2009

Dollars matter the higher in the appeals process you go.

Medicare has shaken up its appeals system in the last few years, so make sure you know how to pursue appeals for incorrectly denied claims.

Here are the current four levels of appeals as outlined by the HHS Office of Inspector General:

• Level One: Contractor redetermination. At the first level, an appellant may request a redetermination with a Medicare carrier or intermediary within 120 days of receipt of the notice of the initial determination. The redetermination must be made by an individual who was not involved in the initial determination. This individual reviews evidence, including previously submitted evidence and any additional evidence that the parties submit or the individual obtains, to uphold or reject the initial determination. At levels one and two, the appellant may contest a denied claim of any dollar amount. Generally, the contractor must make a redetermination decision within 60 days of receipt of the request for redetermination.

• Level Two: Qualified Independent Contractor (QIC) redetermination. To appeal a Level One decision, the appellant may request a reconsideration with a QIC within 180 days of receipt of the Level One decision. The QIC reviews historical evidence and prior findings, as well as any new evidence submitted by the appellant. QICs are bound by national coverage determinations (NCD), Centers for Medicare & Medicaid Services rulings, and applicable laws and regulations.

QICs are not bound by local coverage determinations (LCDs), local medical review policies (LMRPs), or CMS program guidance, such as program memoranda and manual instructions. QICs, however, do give substantial deference to those policies, if applicable. Generally, a QIC has 60 days to make a decision from the date when the appellant filed an appeal.

• Level Three: Administrative law judge hearing. To contest a Level Two reconsideration, the appellant may request a hearing before an ALJ.This request must be filed within 60 days from the receipt of notice of the Level Two reconsideration decision. At this level, the minimum amount in controversy is $120.

ALJs are bound by NCDs, but an ALJ may review the facts of a particular case to determine whether an NCD applies to a specific claim and, if so, whether the NCD was applied correctly. ALJs are not bound by LCDs, LMRPs, or CMS program guidance. ALJs, however, do give substantial deference to those policies, if applicable. Generally, the ALJ must decide Part A and Part B claims appeals within 90 days of the dates appeal requests were filed.

• Level Four: Medicare Appeals Council review. To appeal a Level Three decision, the appellant may request a review with the MAC within 60 days of receipt of the ALJ hearing decision. This is the last level of administrative review. The MAC may deny a request, undertake a review, or remand the case to an ALJ for further action. The MAC is bound by NCDs, but it may review the facts of a particular case to determine whether an NCD applies to a specific claim and, if so, whether the NCD was applied correctly.

The MAC is not bound by LCDs, LMRPs, or CMS program guidance, but the MAC does give substantial deference to those policies, if applicable. Generally, the MAC must make a decision on Medicare Part Aand Part B claims appeals within 90 days of the filing date. If the appellant disagrees with the MAC decision and the amount in controversy is at least $1,220, the appellant may file a civil action in federal district court within 60 days of receiving the MAC decision.

 

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