Radiology Coding Alert

Identify each of the 5 levels of the appeals process.

You know how to properly submit a claim to Medicare, but what happens when the payer denies it? While others within your practice may handle administrative duties such as these, it’s important for the entire staff to have a fundamental knowledge of what the appeals process entails.

Fortunately, the Medicare Administrative Contractor (MAC) National Government Services (NGS) Medicare recently held a webinar to help address some of the most important steps you should consider when appealing a denied claim.

Take a look at these crucial points to round out your skills within the entirety of the billing department.

See How Reopenings Differ From Appeals

A reopening is not an appeal, but a request to reopen a claim, according to Shelly Dailey, MSN, BSN, RN, CPHM, Medicare home health and hospice clinical consultant at NGS.

Reopenings are not processed through the appeals department and only occur at the discretion of the contractor, Dailey explains. If a contractor refuses to reopen a claim for a minor error, that decision is notappealable.

Timeline:  A reopening can be performed within one year of the claim’s finalized date, Dailey says.

There are several reasons for a reopening, according to Dailey. These include the following:

• Mathematical errors.
• Transposed procedure diagnostic codes.
• Inaccurate data entry.
• Computer errors.
• Incorrect data items such as the provider number or »the date of service.

On the other hand, appeals are different from reopenings. You cannot file an appeal for a reopening.

Appeals:  Before you can make an appeal request, you first have to have a processed claim, according to Dailey. When Medicare has either fully or partially denied the claim, then you may submit an initial appeal for a redetermination, which is also known as a Level 1 appeal.

The purpose of the appeals process is to “ensure correct adjudication of claims,” Daily explains. CMS governs all appeals activities. Additionally, all providers and beneficiaries have the right to appeal any claim determination their MAC makes.

Observe Levels of Appeals Process

There are five levels of the appeals process. They are as follows:

• Level 1: Redetermination, which goes through your MAC. Caution: For a redetermination Level 1 appeal to be considered complete, the provider must include all of the following information: the beneficiary’s name; the Medicare number; the requested service; the date of service; and the name and signature of the requesting individual. If all of these elements are not included with your initial Level 1 appeal, your MAC will dismiss the case as incomplete, according to Dailey.
• Level 2: Reconsideration, which goes through the qualified independent contractor (QIC). Requests for Level 2 appeals can only be made in writing.
• Level 3: Administrative Law Judge Hearing (ALJ). Requests for Level 3 appeals can be made in writing only. Also, your claim must be worth at least $160 to file a Level 3 appeal.
• Level 4: Medicare Appeals Council Department Appeals Board (DAB). Claims for a Level 4 appeal must also be worth at least $160.
• Level 5: U.S. Federal District Court. Claims for a Level 5 appeal must be worth at least $1,630.

Don’t miss: Documentation is the key to the success of any level of appeal, Dailey says. Providers must include all pertinent information to avoid the dismissal of the case.

Pay Attention to Time Limits

There are strict time limits for filing at each level of appeal, Dailey explains. They are as follows:

• For the Redetermination, you have 120 days from the date of receipt of your denial to file another appeal. The MAC then has 60 days to review your redetermination.
• For the QIC Reconsideration, you have 180 days from the receipt of your redetermination notice to file another appeal. QIC has 60 days to complete the review.
• For the ALJ Hearing, you have 60 days from the receipt of your reconsideration notice to file another appeal. The ALJ has three months to complete the review.
• For the DAB Review, you have 60 days from the receipt of the ALJ decision to file another appeal. The DAB has 90 days to review the claim.
• For the Judicial Review, you have 60 days from the receipt of the DAB decision to file another appeal. The Judicial Review has 60 days to complete their review.