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Practice Management Alert

Reader Questions:

Limit Resubmissions for New Medicare Appeals Process

Published on Sat Apr 16, 2005

Question: I've heard a lot of talk about what the new Medicare appeals process will entail. What are the basics that our billing office needs to know?


Arkansas subscriber


Answer: The new Medicare appeals process takes effect next January and will eliminate differences between Part A and Part B procedures so that everyone will use the same forms. Here are two major changes:

Change 1: The new process won't allow providers to resubmit claims the carrier has denied unless a "minor technical error" caused the denial. And if the carrier decides the error wasn't minor, it can reject your resubmission and you'll have to appeal the denial by the original appeal deadline.

What this means: If you plan to reopen claims, you'll need to do so as quickly as possible so you have time to appeal if the carrier denies the reopening.

Change 2: The new process forbids providers from submitting new information after the second stage of the appeal: the Qualified Independent Contractor (QIC) level. The only exception will be if you have "good cause," such as if you need to respond to new evidence that CMS might submit.

What this means for you: You'll need to expedite your appeals process and attach complete documentation - including all pictures and substantiating evidence - when you file your first appeal. Train your billing staff now to focus on researching appeal documentation up front.

Other important highlights:  
 

  • New denial notice. When Medicare denies your first-level appeal, it will issue a new notice that outlines specific reasons for the denial and lists documentation required for claim reconsideration at the QIC level.
     
  • No appeal receipt notice. CMS will no longer require carriers to notify you when they receive your appeal request. The agency recommends that providers call the carrier after a few weeks to ensure it received the appeal.

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