Medicare Compliance & Reimbursement

Some carriers require redeterminations even for minor errors.

The new and improved appeals process is causing headaches for some providers.

As of Jan. 1, the first level of the appeals process became known as a "redetermination." For minor errors, carriers can "reopen" providers' claims instead of giving them a full "redetermination."

But many of the details of the new process remain unclear, and the carriers haven't been too helpful. At least one carrier, National Health Insurance Corp., says it'll no longer process anything over the phone, even denials due to minor errors, according to Erica Schwalm, a biller with Healthcare Resource System Inc. in Wilbraham, MA.

Instead of allowing "reopenings" of claims with minor errors, NHIC wants providers to resubmit every single denial through the more cumbersome "redetermination" process, says Schwalm. This applies even to claims denied with reason code MA-130, meaning some beneficiary information was missing, invalid or incomplete.

Also, Schwalm hasn't been able to obtain detailed instructions about the documentation that she must include with a redetermination request. "The instructions for attachments are vague," she complains. The instruction just says, "submit with supporting documentation." If she wants to change a diagnosis code, it's not clear whether she needs to send in all office notes, for example.

Because the carrier has up to 60 days to process redetermination requests, it may be a while before providers learn whether they've submitted the proper documentation, Schwalm worries.

For these sorts of questions, providers should call their carriers' provider education specialists, or the medical director's office, notes consultant Quinten Buechner with ProActive Consulting in Cumberland, WI. Providers shouldn't call customer service with these sorts of questions. If a provider is submitting many claims with the same problem, the provider should get a name of someone at their carrier to send those claims to, and follow up with that individual, he advises.

The vague requirements for supporting documentation are due to the fact that different issues may require many different resolution strategies, notes Buechner. For example, to deal with "incident-to" billing issues, a provider may submit office schedules to prove a doctor was present during a service. For other disputes, a provider may need office notes, journal articles or patient charts.

Note: Individual carriers can decide whether to accept late appeal requests. If providers miss the 120-day deadline to file for a redetermination, the carrier can choose to accept the provider's request anyway. Carriers can come up with their own guidelines on exemptions to the 120-day requirement.