Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

Don't let the new time frames catch you napping

Starting Jan. 1, you'll have a new appeals process to cope with, according to a recent Medlearn Matters article (MM4019).

The basics: Your carrier will still perform the first level of appeals--which will now be known as a redetermination--and you'll have 120 days to request this level of appeal. You'll have 180 days to file a request for the next level of appeal, known as a reconsideration, which will be performed by the Qualified Independent Contractor.

After that, you have 60 days to request the third level of appeals, the Administrative Law Judge (ALJ). In January, the minimum amount at stake for an ALJ appeal will go up from $100 to $110. If the ALJ doesn't go your way, you have 60 days to appeal to the Department Appeals Board. And after that, you have 60 days to appeal in federal court, as long as you have at least $1,050 at stake.

Minor errors: If you've just made a minor error on a claim that caused it to be denied, then you may not need to appeal the denial, CMS says. You can ask your carrier to reopen the claim so you can correct the problem, instead of going through the appeal process.

Late filing: If you file a request for redetermination after the 120-day deadline, your carrier can still accept the request. Your carrier has until Jan. 1 to come up with a procedure for deciding whether you had a good reason to submit the request late, according to CMS.

A request for redetermination is received on the date that the carrier's corporate mailroom receives the document, according to Medlearn Matters article 3942.

Heads up: Some experts are concerned that you may miss the deadline for requesting a reconsideration because you have 180 days, not six months, according to Tammy Tipton, president of Appeal Solutions in Blanchard, OK. Remember: The 180 days includes weekends.

The most important change  to the appeals process is the fact that you must submit your complete case, including all documentation, to the carrier at the first level. After that, you can only add more information for "good cause" or to correct clerical errors, says Deborah Churchill, president of Churchill Consulting in Killingworth, CT.

Also under the new process, the carriers won't be able to collect any overpayments from you until they complete the appeals process--and only if they win.

Note: you can read the Medlearn Matters articles at www.cms.hhs.gov/medlearn/matters.