Part B Insider (Multispecialty) Coding Alert

Published on Thu Mar 24, 2005 PDF

But you can only resubmit denials for 'clerical errors'

Good news: You may be able to submit new information later in the appeals process than you'd thought.

The new appeals process that takes effect next January for physicians forbids you from submitting any new information after the second stage of the appeal: the Qualified Independent Contractor (QIC) level. But at an April 15 Open Door Forum on the appeal changes, the Centers for Medicare and Medicaid Services said you could submit new evidence later in the process.
 
Anticipate These Restrictions

Under the new process, you could only submit new information if you have "good cause," including if you need to respond to new evidence that CMS might submit if it joins the process at the Administrative Law Judge (ALJ) level. You could also introduce new evidence to respond to information that arose at the QIC level.
 
This provision is intended to stop venue-shopping and situations where people have documentation, but choose not to submit it until the higher level, said Tony Culotta, director of CMS enrollment and appeals division. And another CMS official said the agency plans to join appeals at the ALJ level only for large dollar amounts or important policy issues.

Limits on resubmission: Provi- ders expressed concern about a gray area in the new appeals process. CMS won't allow you to resubmit claims that the carrier has denied - unless the denial resulted from a minor technical error. But if the carrier decides that the error wasn't minor, it can reject the resubmission.

If the carrier rejects the resubmitted claim, then you still have to appeal the denial by the original deadline, CMS officials said.  And there's no time limit for carriers to make up their minds whether to accept a resubmission, which means you could be stuck with a tight deadline to appeal.

CMS officials promised to educate carriers on what constituted "technical errors" and set a timeframe for making decisions about accepting reopened claims.

If practices plan to "use the reopening process on a lot of claims, they need to do that as quickly as possible, so if the carrier denies the reopening," they still have time to appeal, says Tammy Tipton, president of Appeal Solutions in Blanchard, OK.