Medicare Compliance & Reimbursement

Home health agencies have something to cheer about.

Good news: You can get some PECOS edit denials fixed quickly and without going through the cumbersome (and expensive) appeals process.

“Claims are denied with reason code 37236 or 37237 when the NPI and/or physician’s last name or first name submitted on the home health claim does not match the physician’s information at the Provider Enrollment, Chain, and Ownership System (PECOS),” explains Home Health & Hospice Medicare Administrative Contractor CGS on its recently revised webpage on claims reopenings. “While claims denied for this reason will appear in status/location D B9997, the claim should be appealed using the reopening process, rather than the redetermination process,” the MAC instructs.

If you failed to match up the doc’s name in the PECOS record exactly, this newly revealed appeals procedure could save you a big headache.

Why? “A reopening is a process used to correct minor errors or omissions to a previously processed claim without using the formal appeals process,” CGS explains in a job aid on reopenings versus redeterminations. Redeterminations are the first level of Medicare’s formal appeal process, usually a more time-consuming and pricey process.

“This is a positive step,” cheers Mary Carr with the National Association for Home Care & Hospice. “It will allow agencies to have denied claims reviewed without going through the appeals process, and, hopefully, take less time and effort for both the provider and the contractors,” Carr tells Eli.

The change is “helpful and it’s not what I had expected,” says billing expert M. Aaron Little with BKD in Springfield, Mo. Using the reopening process “is great ... because otherwise if [a claim denied under the PECOS edits] had to go through the regular appeals process, there’s a chance the claim could end up getting denied again due to some other reason during the first-level appeal process,” Little says.

Watch for other HHH MACs to follow suit, observers suggest.

Tip: You have one year from the date of the initial determination to file for a reopening, CGS notes. “Reopenings are a discretionary action on the part of the contractor,” the MAC adds.

Note: CGS’s revised reopenings page is at www.cgsmedicare.com/hhh/appeals/reopenings.html—scroll down to “Ordering/Referring DenialReopenings.”