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Medicare Billing Protocol - Appeal of Claim

Medicare Billing Protocol - Appeal of Claim

Medicare Billing Protocol - Appeal of Claim

INTRODUCTION

This topic describes how the Medicare Part A & B Claim Appeals Process applies to providers, physicians and suppliers in the Medicare Fee-For-Service Program (also known as Original Medicare). Once an initial claim determination is made, any party related to that initial determination, such as beneficiaries, providers, and suppliers or their respective appointed representatives has the right to appeal the Medicare coverage and payment decision.[1]

There are five levels in the Medicare Part A and Part B appeals process. The levels are [1]:
  • Level 1-Redetermination by a Medicare Administrative Contractor (MAC)
  • Level 2- Reconsideration by a Qualified Independent Contractor (QIC)
  • Level 3- Administrative Law Judge (ALJ) Hearing or Review by Office of Medicare Hearings and Appeals (OMHA)
  • Level 4- Review by the Medicare Appeals Council (Council)
  • Level 5- Judicial Review in U.S. District Court 

The protocol below, based on Medicare resource[1][2], can be easily adapted and implemented in wound and hyperbaric therapy clinics. For a sample workflow and protocol for Medicare Billing, see topic "Medicare Billing Protocol and Workflow". Additional, customized insights can be obtained from our advisory panel through WoundReference Curbside Consults

PROTOCOL

Process: Level 1 Medicare Appeal Redetermination by a Medicare Administrative Contractor (MAC)

Important tasks When Key points (how to execute task) Reason (why execute this task?)
Prepare Upon receipt of remittance advice
  • Review the Remittance Advice (RA)
  • Identify the denied charges and reason

A redetermination is the first level of appeal after the initial determination on a claim. It is a look at the claim by MAC staff not involved in the initial determination. 


File a request for redetermination Within 120 days from receipt of RA that lists the initial determination
  • File your request in writing by following instructions provided in the RA
  • You may use the Medicare Redetermination Request (Form CMS-20027) or any written document, so long as it contains the required elements listed in the RA
  • Your request must be sent to the address listed on the RA or filed in person (or follow the instructions from your MAC for filing electronically)
  • You and your representative must include your name and signature
  • Attach any supporting documentation to your redetermination request
  • Keep a copy of everything you send to Medicare as part of your appeal

The Qualified Independent Contractor (QIC) conducts the reconsideration, which is an independent review of the administrative record, including the redetermination. The reconsideration may include review of medical necessity issues by a panel of physicians or other health care professionals

Receive notice of the decision of claim payment approval or denial Within 60 days of the receipt of the request for redetermination The Medicare appeal process is a specific set of actions to be followed thoroughly
Appeal level 1 is successful or move to Appeal level 2

Upon receiving the notice of the redetermination decision

  • You will receive a revised RA
  • If you disagree with the MAC redetermination decision, you may request a reconsideration by a QIC. 
  • A reconsideration is a review of the redetermination decision.

The Medicare appeal process is a specific set of actions to be followed thoroughly


Process: Level 2- Reconsideration by a Qualified Independent Contractor (QIC)

Important tasks When Key points (how to execute task) Reason (why execute this task?)
Prepare Upon receipt of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA)
  • Review the RA or MRN
  • Identify the denied charges and reason

Prompt attention to claims payment or denial leads to improved revenue cycle

File a request for reconsideration Within 180 days from the date of receipt of MRN or RA 
  • File the request in writing by following instructions provided on the MRN or RA. 
  • You may use the Medicare Reconsideration Request (Form CMS-20033), or any written document, so long as it contains the required elements listed in the MRN. 
  • Clearly explain why you disagree with the redetermination decision 
  • You and your representative must include your name and signature 
  • Submit the following:
    • A copy of the RA or MRN
    • Any evidence noted in the redetermination as missing
    • Any other useful documentation
  • Documentation submitted after you file the reconsideration request may extend the QIC's decision timeframe
  • The QIC conducts the reconsideration, which is an independent review fo the administrative record, including the redetermination.
  • The reconsideration may include a review of medical necessity issues by a panel of physicians or other healthcare professionals.
  • Any other evidence Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you demonstrate good cause for submitting the evidence late relevant to the appeal 

Receive notice of the decision of claim payment approval or denial Within 60 days of the receipt of the request for reconsideration
  • If the QIC cannot complete its decision in the applicable timeframe, it will inform you of your rights and the procedures to escalate the case to the Office of Medicare Hearings and Appeals (OMHA)
  • Before escalating your appeal to OMHA, if you do not receive a decision on the reconsideration within 60 days, consider allowing an additional 5 to 10 days for mail delays
The Medicare appeal process is a specific set of actions to be followed thoroughly
Appeal level 2 is successful or move to Appeal level 3
Upon receiving the notice of the redetermination decision
  • You will receive a revised RA
  • If you disagree with the reconsideration decision or wish to escalate your appeal because the reconsideration period passed, you may request one of two options under OMHA review: (1) an Administrative Law Judge (ALJ) hearing or (2) an OMHA ALJ attorney adjudicator decision.
  • This level of appeal gives you the opportunity—via telephone, video teleconference (VTC), or occasionally in person—to explain your position to an ALJ.
  •  If you don’t wish to attend a hearing, you can ask OMHA (either an ALJ or attorney adjudicator) to make a decision based on evidence and the administrative record of the appeal (known as an on-the-record decision).
  • The Health and Human Services (HHS) OMHA, which is independent of CMS, is responsible for the Level 3 Medicare claims appeals

Process: Level 3 Medicare Appeal Reconsideration by an Administrative Law Judge (ALJ) Hearing or Review by Office of Medicare Hearings and Appeals (OMHA)

Important tasks When Key points (how to execute task) Reason (why execute this task?)
Prepare Upon receipt of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA)
  • Review the Remittance Advice (RA)
  • Identify the denied charges and reason
  • You may only request an ALJ hearing if a certain dollar amount remains in controversy following the QIC’s decision

Prompt attention to claims payment or denial leads to improved revenue cycle

File a request for reconsideration File your request for an ALJ hearing, or a waiver of hearing, within 60 days of receipt of a reconsideration decision letter or file a request with the QIC for OMHA review after the expiration of the reconsideration period
  • File your request in writing by following instructions provided in the reconsideration letter.
  • You may also request an ALJ hearing by completing the Request for ALJ Hearing or Review of Dismissal (Form OMHA-100) and the multiple claim attachment (Form OMHA-100A) as needed.
  • If you do not want a telephone hearing, you may ask for an in-person or VTC hearing, but you must demonstrate good cause.
  • The ALJ determines whether the case warrants an in-person hearing on a case-by-case basis.
  • If you would prefer to not have a hearing, you may ask for an on-the-record review by filling out the  Waiver of Right to an ALJ Hearing form (Form OMHA-104) and submitting it with the OMHA-100 form.
  • If an on-the-record review is granted, an OMHA attorney adjudicator will issue a decision based on the information within the administrative record along with any evidence submitted with the request. 
  • You must send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. 
  • If you are requesting the case be escalated to the Council, you must send a copy of the request to all other parties and to the ALJ.
  • The ALJ sets hearing preparation procedures. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and the parties to the hearing.
The Medicare appeal process is a specific set of actions to be followed thoroughly
Receive notice of the decision of claim payment approval or denial

Due to the record number of appeals requests, there continues to be a delay in OMHA ALJ hearing assignments.

OMHA processes ALJ hearing requests in the order received and as quickly as possible, given pending requests and adjudicatory resources.


  • The ALJ or attorney adjudicator makes the decision. 
  • If the OMHA cannot complete a decision in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to the Council
  • The ALJ or attorney adjudicator forwards the decision and case file to the Administrative QIC (AdQIC), which serves as the central manager for all OMHA Original Medicare claim case files. In certain situations, the AdQIC may refer the case to the Council on CMS’ behalf. 
  • If no referral is made to the Council, and the ALJ or attorney adjudicator decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC it must pay the claim, according to the OMHA decision, within 30–60 days.
  • If OMHA does not issue a decision within the applicable timeframe, you may ask OMHA to escalate the case to the Council.
  • New appeal requests are processed as quickly as possible. 
  • You will receive an Acknowledgement of Request letter after your case is entered into the OMHA case tracking system.
The Medicare appeal process is a specific set of actions to be followed thoroughly
Appeal level 3 is successful or move to Appeal level 4
Upon receiving the notice of the redetermination decision
  • You will receive a revised RA
  • If you disagree with the ALJ or attorney adjudicator decision, or you wish to escalate your appeal because the OMHA decision timeframe passed, you may request a Council review. 
  • The HHS Departmental Appeals Board (DAB) Medicare Operations Division conducts the Council review
  • The Medicare appeal process is a specific set of actions to be followed thoroughly

Process: Level 4 Medicare Appeal Review by the Medicare Appeals Council

Important tasks When Key points (how to execute task) Reason (why execute this task?)
Prepare Upon receipt of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA)
  • Review the Remittance Advice (RA)
  • Identify the denied charges and reason

Prompt attention to claims payment or denial leads to improved revenue cycle

File a request for Council review File request for Council review within 60 days of receipt of the ALJ's decision or after the OMHA decision timeframe expires
  • File your request in writing by following the instructions provided by OMHA. 
  • You may also request a Council review by completing the Request for Review of ALJ Medicare Decision/Dismissal (Form DAB-101) or the electronic version accessible through the DAB E-File webpage.
  • Explain which part of the OMHA decision you disagree with and your reasons for the disagreement 
  • Send a copy of the Council review request to all the parties included in OMHA’s decision
The Medicare appeal process is a specific set of actions to be followed thoroughly
Receive notice of the decision of claim payment approval or denial Within 90 days from receipt of a request for review of an ALJ decision.
  • The Council makes the decision. If the Council cannot complete its decision in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to U.S. District Court.
  • The Council forwards the decision and case file to the AdQIC, which serves as the central manager for all Council Original Medicare claim case files. 
  • If the Council decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC it must pay the claim according to the Council’s decision within 30–60 days.
  • Generally, the Council issues a decision within 90 days from receipt of a request for review of an ALJ decision. 
  • If the Council review stems from an escalated appeal, then the Council has 180 days from the date of receipt of the request for escalation to issue a decision. 
  • If the Council does not issue a decision within the applicable timeframe, you may ask the Council to escalate the case to the judicial review level.
  • If you are requesting escalation to U.S. District Court, a copy of the request must be sent to all other parties and to the Council.
The Medicare appeal process is a specific set of actions to be followed thoroughly
Appeal level 4 is successful or move to Appeal level 5

  • You will receive a revised RA
  • If you disagree with the Council decision, or you wish to escalate your appeal because the Council ruling timeframe passed, you may request judicial review.
  • The Medicare appeal process is a specific set of actions to be followed thoroughly

Process: Level 5 Medicare Appeal Judicial Review in the U.S. District Court

Important tasks When Key points (how to execute task) Reason (why execute this task?)
Prepare Upon receipt of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA)
  • Review the Remittance Advice (RA)
  • Identify the denied charges and reason
  • You may only request a judicial review if a certain dollar amount remains in controversy following the Council decision

Prompt attention to claims payment or denial leads to improved revenue cycle

File a request for Judicial review File a request for Judicial review within 60 days of receipt of the Council's decision or after the Council ruling timeframe expires
  • The Council’s decision (or notice of right to escalation) contains information on how to file a claim in U.S. District Court.
The Medicare appeal process is a specific set of actions to be followed thoroughly

Receive notice of the decision of claim payment approval or denial  No statutory time limit
  • The U.S. District Court makes the decision.
The Medicare appeal process is a specific set of actions to be followed thoroughly
Appeal Level 5 is successful or no other options for appeal

  • You will receive a revised RA
  • No additional options for appeal
  • The Medicare appeal process is a specific set of actions to be followed thoroughly

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. CMS.GOV. CMS.GOV Centers for Medicare and Medicaid Services Original Medicare (Fee for Service) Appeals . 2018;.
  2. The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S.Department of Health & Human Services (HHS). et al. Medicare Part A & B Appeals Process . 2017;volume ICN 006562 ():1-18.
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