Wiki First level appeal for Medicare

[heartyoga]

We have a patient with Jr after his name. (e.g. John Smith Jr).

Our billing system would not recognize eligiblity if it is entered as John Smith Jr. but it would read it if it's typed as John SmithJr.

However, our claims for 2018 keep on being denied by Palmetto GBA (TN MAC) as invalid, and if we rebilled it, it denies as duplicate (even if we have zero payments due to denials).

We have tried every permutation available for the name trying to get it to go through the computer systems.

Is it appropriate the go online for the first level appeal?


Thanks!

 

[thomas7331]

In my experience, since an appeal is a request for a review of a payment determination, a claim has to be actually reviewed and paid or denied by the payer before you can file an appeal. Medicare will not review appeals of claims that have been rejected as invalid submissions. It is odd though that a claim would deny as a duplicate against a previous invalid claims submission - a duplicate denial suggests that the payer actually has received and processed a valid claim at some point and made their payment or decision to deny.

I'd recommend trying to escalate this with your payer and/or your billing system and/or electronic clearinghouse vendors first to find out where the breakdown or misunderstanding is occurring. If you file an appeal, you will likely be waiting a month or two only to get a rejection letter back which will just delay the problem.