Optometry Coding & Billing Alert

Published on Fri Mar 03, 2006 PDF

Some carriers require redeterminations even for minor errors

The new and improved appeals process is causing headaches for some providers. For the cure, you may need to contact a provider education specialist.

As of Jan. 1, the first level of the appeals process became known as a -redetermination.- For minor errors, your carrier can -reopen- your claims instead of giving you a full -redetermination.-

Downside: 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, says Erica Schwalm, a biller with Healthcare Resource System  Inc. in Wilbraham, Mass.

Instead of allowing -reopenings- of claims with minor errors, NHIC wants providers to resubmit every single denial through the more cumbersome -redetermination- process, Schwalm says. 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 says. It 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.

Snag: 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 says.

Track Down Contacts at Carrier's Office

For these sorts of questions, call your carrier's provider education specialists or the medical director's office, says consultant Quinten Buechner with ProActive Consulting in Cumberland, Wis. You shouldn't call customer service with these sorts of questions. If you-re submitting a number of claims with the same problem, you should get a name of someone at your carrier to send those claims to, and follow up with that individual, he says.

There's not a one-size-fits-all solution for supporting documentation, Buechner says. The vague requirements for supporting documentation are due to the fact that carriers may need to resolve different disputes in different ways. For example, to deal with -incident-to- billing issues, you may submit office schedules to prove a doctor was present during a service. For other disputes, you may need office notes, journal articles or patient charts.

Red flag: It's up to your individual carrier whether to accept late appeal requests. If you miss the 120-day deadline to file for a redetermination, the carrier can choose to accept your request anyway.

Your carrier should have its own guidelines on exemptions to the 120-day requirement, so you should ask your carrier for its policies.