Navigating the Medicare Appeals Process
When claims are denied, you have to be prepared to appeal. But before you take that step, determine if your claim qualifies to be reopened. These are some of the valid reasons for reopening a claim: Mathematical or computation errors, inaccurate data entry, such as units of service, place of service, modifiers, misapplication of fee schedule, computer errors, denial of claims as duplicates when the supplier believes Medicare incorrectly identified the claim as a duplicate, and incorrect data items, such as provider number, use of modifier or date of service.
If your claim doesn’t fit the criteria to be reopened, then you have to set the appeals process in motion. There are five levels of appeals, which must be followed in sequential order. If you skip any of the levels below, your claim will be subject to dismissal.
- Level 1 – Redetermination. (Submit request to Part B contractor.) You have 120 days from the receipt of the notice of the initial determination (EOMB) in which to file.
- Level 2 – Reconsideration. (Submit request to your QIC – Qualified Independent Contractor.) You have 180 days from the date of receipt of redetermination in which to file.
- Level 3 – Administrative Law Judge (ALJ) Hearing. You have 60 days from the date of receipt of reconsideration in which to file. The amount remaining in controversy (AIC) much reach a certain threshold to qualify. For calendar year 2015, that amount was $150.
- Level 4 – Medicare Appeals Council Review. You have 60 days from the date of receipt of the ALJ’s decision in which to file. There is no minimum AIC requirement for an Appeals Council review.
- Level 5 – Judicial Review in U.S. District Court. You have 60 days from the date of receipt of the Appeals Council’s decision (or declination of review) in which to file. For 2015, the AIC threshold required is $1,460.
Make every attempt to resolve your appeals in levels 1 and 2, so your claims don’t have to escalate to level 3 or beyond. The current ALJ backlog could mean you have to wait more than a year for your case to be heard.
Lastly, here are some tips you can take to ensure that your business is staying proactive in managing incoming claim denials.
1. Set aside time on a regular basis to work on denials.
2. Start with the EOMBs. Make sure that your staff examines them closely to determine the reasons for each denial.
3. Pay close attention to the Medicare time limit for filing appeals. If you miss these deadlines, your company will lose money that could easily equate to thousands of dollars.
4. Follow Medicare’s appeals guideline. Your appeal will be dismissed if it doesn’t conform to Medicare requirements.