Oncology & Hematology Coding Alert

Dig into the 5 levels of the appeals process.

You submit a claim to your Medicare Administrative Contractor (MAC) for a Part B patient, but Medicare denies the claim. You want to appeal the decision, but you have no idea how to move forward.

The National Government Services (NGS) MAC recently held a webinar to help clarify the five levels in the Medicare Part A and Part B appeals process. Read on to make sure you understand how the process works and appeal the decisions where a disagreement exists.

See How ‘Reopenings’ Differ from Appeals

A reopening, also referred to as apre-redeterminationis not an appeal. Rather it is a request to reopen a claim, according to Shelly Dailey, MSN, BSN, RN, CPHM, Medicare home health and hospice clinical consultant with NGS.

Reopenings are not processed through the appeals department and occur at the discretion of the contractor, Dailey explains. If a contractor refuses to reopen a claim for a minor error, that decision is not appealable.

Timeline:  A reopening can be performed within one year of the claim’s finalized date, Dailey says.

There are several reasons for a reopening, according to Dailey. These include the following:

• Mathematical errors
• Transposed procedure diagnostic codes
• Inaccurate data entry
• Computer errors
• Incorrect data items such as the provider number or the date of service.

Appeals: Before an appeal request can be made, you must first have a processed claim, according to Dailey. When Medicare has either fully or partially denied the claim, you may submit a request for redetermination, known as a Level 1 appeal.

The purpose of the appeals process is to “ensure correct adjudication of claims,” Daily explains. Centers for Medicare and Medicaid Services (CMS) governs all appeals activities. Additionally, all providers and beneficiaries have the right to appeal any claim determination their MAC makes.

Observe Levels of Appeals Process

There are five levels of the appeals process. They are as follows:

• Level 1: Redetermination, which goes through your MAC.

           o Caution: For a redetermination Level 1 appeal to be considered complete, the provider must include all of the following information:
              ♦ beneficiary’s name;
              ♦ Medicare number;
              ♦ requested service;
              ♦ date of service;
              ♦ name and signature of the requesting individual; and
              ♦ an explanation of why the appellant disagrees with the contractor’s decision.

                    o If all of these elements are not included with your initial Level 1 appeal, your MAC will dismiss the case as incomplete, according to Dailey.

• Level 2: Reconsideration, which goes through the qualified independent contractor (QIC).​

           o Requests for Level 2 appeals can be made in writing. The CMS website also has form CMS-20033 that can be filled out for considerations.
           o CMS website also has form CMS-20033 that can be filled out for reconsiderations.

• Level 3: Administrative Law Judge (ALJ) Hearing.

           o Requests for Level 3 appeals can be made in writing. Level 3 appeals can also be made using form OMHA-100.
           o The claim must be worth at least $160 to file a Level 3 appeal.
           o Level 3 appeals can also be made using form “OMHA-100”

• Level 4: Medicare Appeals Council Department Appeals Board (DAB).
• Level 5: US Federal District Court. Claims for a Level 5 appeal must be worth at least $1,630.

Don’t miss: Documentation is the key to the success of any level of appeal, Dailey says. Providers must include all pertinent information to avoid dismissal of the case.

Pay Attention to Time Limits

There are strict time limits for filing at each level of appeal, Dailey explains. They are as follows:

• For the Redetermination, you have 120 days from »»the date of receipt of your denial to file another appeal. The MAC then has 60 days to review your redetermination.
• For the QIC Reconsideration, you have 180 days »from »the receipt of your redetermination notice to file another appeal. QIC has 60 days to complete the review.
• For the ALJ Hearing, you have 60 days from the »»receipt of your reconsideration notice to file another appeal. The ALJ has 90 days to complete the review.
• For the DAB Review, you have 60 days from the »»receipt of the ALJ decision to file another appeal. The DAB has 90 days to review the claim.
• For the Judicial Review, you have 60 days from »the receipt of the DAB decision to file another appeal. The Judicial Review has 60 days to complete their review.