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Part B Insider (Multispecialty) Coding Alert

APPEALS:

There's More To Know About New Appeals Process

Published on Thu Mar 24, 2005

The carrier won't have to notify you when it receives your appeal request

Starting in January, when a Medicare carrier rejects your first-level appeal, the carrier will also issue a helpful new notice.

These notices will include specific reasons for the denial and an account of missing information or documentation required for the reconsideration at the Qualified Independent Contractor (QIC) level, Jennifer Frantz with the Centers for Medicare and Medicaid Services revealed at the April 15 Open Door Forum on the new appeals process.

Other new forum information:
 

  • Administrative Law Judges (ALJs) will now review each case de novo. That means that unlike before, providers don't have to submit new evidence to receive an ALJ hearing - and, in fact, can't do so under early and full presentation requirements.
     
  • Medicare Appeals Council reviews are now required before appeals move into district court instead of being discretionary as before, CMS indicated.
     
  • Carriers and intermediaries no longer are required to send you a notice acknowledging that they received your appeal request. CMS recommended calling the contractor after a few weeks to make sure they received the redetermination request. CMS is looking into the possibility of indicating in the Common Working File that a request has been received, one official noted. QICs will send acknowledgements, and eventually a Web site will allow you to track your cases, CMS said.
     
  • The Medicare appeals process will work on a two-track system for a while, and some appeals will run according to the old system. To decide whether the old or new rules apply (including full and early presentation of evidence), look at whether your claim went to a QIC for review. If not, the old rules apply.
     
  • Everyone will use the same forms for appeals next year, because there will no longer be distinctions between the Medicare Part A and Part B appeals processes.
     
  • A physician in the same specialty as yours won't necessarily examine your claims in medical review as providers had hoped, notes Tammy Tipton, president of Appeal Solutions in Blanchard, OK. Rather, CMS said that a general practitioner or other physician might review the claims.
     
  • CMS is taking comments on the interim final appeals rule until May 9. The agency will publish a final rule within three years, after it has gained experience withthe new process.

    The interim final rule is at www.cms.hhs.gov/providerupdate/regs/CMS4064IFC.pdf. A fact sheet on the new process is at www.cms.hhs.gov/appeals/factsheet.pdf. The revised Medlearn Matters article on the changes is at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3530.pdf.

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