Medicare Part A Appeals

1. Medicare Part A Appeals By: Dale R. Gibson

2. Understand the Appeals Process and your rights through the Appeals Process. Cover the following topics: • Claims Process • Appeals Process • 1. Redetermination • 2. Reconsideration • 3. Administrative Law Judge • 4. Departmental Appeals Board • 5. U.S. District Court Review

3. Appeals Process: • Explain the five levels of appeal • Determine who can request an appeal • Explain when it is appropriate to request an appeal • Identify appeals when the beneficiary is deceased

4. 1. Redetermination: • Define the requirements for redetermination • Request a redetermination • Recognize good causes for late filing

5. 2. Reconsideration: • Define a reconsideration • Identify the appropriate forms • Follow the life of a request for a reconsideration • Role of the Qualified Independent Contractor (QIC)

6. 3. Administrative Law Judge (ALJ) • Define (ALJ) • Explain the requirements of an ALJ • Determine the Amount in Controversy (AIC)

7. 4. Departmental Appeals Board (DAB) • Define the fourth level of the Appeals process • Explain the requirements of a DAB

8. 5. U.S. District Court Review • Define a U.S. District Court Review • Explain the requirements of a U.S. District Court Review, the final level of the appeal process

9. Claims Process Overview • Before we begin to describe the appeals process, let’s start with an overview of the claims process. This is important because not all claims have appeal rights.

10. Electronic Claim Lifecycle • The electronic claims process begins when the sender (physician, hospital, skilled nursing facility (SNF), billing service, or clearinghouse) enters claim information into a billing software system. Some billing systems contain features (edits) that verify information entered by the sender. The claims are contained in a “batch” that is transmitted to the gateway.  • The gateway sends an acknowledgement of receipt and applies the American National Standards Institute (ANSI) requirements to determine if the file is correctly formatted. Incorrectly formatted batches are rejected to the sender with an ANSI 997 report. The formatting errors must be corrected before the batch can be retransmitted.

11. Electronic Claim Lifecycle(cont.) • The pre-pass edits apply the Implementation Guide (IG) and additional FCSO business edits at the batch, provider, and claims levels. Batches that fail any of these edits are rejected to the sender, and the errors must be corrected before the batch can be retransmitted. Files that fail any of these edits at the provider or claim level will be rejected to the sender, and the files must be corrected before they can be retransmitted. • The Fiscal Intermediary Shared System (FISS), subjects the claim to further editing according to Medicare guidelines. The claim is then sent to the Common Working File (CWF), to verify beneficiary eligibility and deductible, and approve the claim for finalization. Once the claim is finalized, the provider receives the claim decision (payment, partial payment, denial) through the Medicare Remittance Notice (MRN) or Electronic Advice (ERA).

12. Processed Claims • A claim is considered to be processed when it goes through the FISS, which applies all Medicare policies, rules and regulations. Most claims are then forwarded to the CWF for final entitlement verification prior to finalization. Once claims are approved for finalization, the claim is either paid or denied. • Clean claims that are approved for payment will not finalize until the expiration of the payment floor, which is at the earliest 14 days for HIPAA (Health Insurance Portability and Accountability Act of 1996) – compliant electronic claims and at the earliest 29 days for non-HIPAA – compliant and paper claims.

13. Claim Outcomes • A claim can either be paid or denied. • Additionally, individual services within a paid claim can either be paid, denied, or reduced. • PAY - A service is approved for payment at the full fee schedule amount, or other applicable payment methodology. • DENY – A service may deny for a variety of reasons (e.g. provider and/or beneficiary entitlement, medical necessity). Refer to the message on your remittance notice for the reason the service was denied.

14. The Appeals Process Definition An appeal is a re-evaluation of the initial claim determination regarding payment and coverage issues. If you are dissatisfied with the determination made on your claim, you can file an appeal.

15. Five levels of the Appeals Process • 1. Redetermination • 2. Reconsideration • 3. Administrative Law Judge (ALJ) • 4. Departmental Appeals Board (DAB) • 5. U.S. District Court Review

16. Filing Time Limits and Threshold Amounts

17. Why Request and Appeal If you are dissatisfied with the denial of a claim or believe that it was not paid properly, you may request an appeal. Exceptions: • The following types of initial claim determinations do not have appeal rights: • A service for which an initial determination has not been made • Claims returned to provider • Claims denied due to entitlement issues • Claims denied due to late claim filing • Minor clerical errors and omissions

18. Who Can Request an Appeal Any person or entity considered a party to an appeal of a claim for items or services payable under Medicare Part A may request an appeal of the initial claim determination. Parties to an appeal include: • A Beneficiary • A Provider (Hospital, SNF, CORF, ORF) • A beneficiary’s representative Congressional office on behalf of the beneficiary

19. Appeals when the Beneficiary is deceased • When a provider or supplier appeals on behalf of a deceased beneficiary, and the provider or supplier is not a party to the appeal, the Fiscal Intermediary (FI) is responsible for determining whether another party is available to appeal the claim. • In order to determine whether another party is available to appeal the claim, the FI must perform the following verification: • The FI sends a letter to the provider to request written confirmation that he/she is not aware of any other party available to appeal • The provider is allowed 10 days to respond and provide written confirmation that he/she is not aware of any other parties available to appeal • If written confirmation is not received within 14 days, the appeal is dismissed

20. 1. Redetermination • A redetermination is the first level of the appeals process after the initial determination on a Medicare Part A claim. • A redetermination is an examination of a claim by FI personnel. They are not the same personnel who made the initial determination. • If you are dissatisfied with the denial of a claim or believe that it was not properly paid, you can request a redetermination to the FI that made the initial determination on the claim.

21. Redetermination Requirement • Requests for redeterminations related to an initial determination process on or after January 1, 2006 must be submitted in writing. • The request for a redetermination must be filed within 120 days from the date the claim finished processing. The starting date appears on your Medicare statement. • Extensions up to 60 days may be granted to allow for additional time needed to gather documentation in certain scenarios.

22. Good cause for late filing of a Redetermination • The time limit for filing a request for a redetermination may be extended in certain situation. • If the provider can show a good cause for the late filing of a request for a redetermination, the FI will honor the request. • An extension to this time limit is granted if good cause for late filing is shown. This generally includes cases in which filing was delayed due to factors outside of your control.

23. Examples of good cause for late filing are: • Incorrect or incomplete information about a claim from an official source • Unavoidable circumstances that are beyond the provider’s control (i.e., major floods, fires, tornadoes, other natural disasters)

24. Redetermination Elements A redetermination includes the following elements: • The reviewer is not the same person who made the initial claim determination • The reviewer takes a second look at the claim and supporting documentation • The redetermination is based on the appellant’s request and what is at issue • The file is reviewed carefully, with particular attention to the evidence that supported the original payment decision and the payment policies that were in effect when the initial determination was made • The FI will inform you of the Redetermination results within 60 days of receipt of the Redetermination request. The letter will give the information for the next level and the amount in controversy (if applicable)

25. How to Request a Redetermination All written requests for a redetermination must include the following pieces of information: • Beneficiary’s name and Medicare Health Insurance Claim (HIC) number • Service(s) being appealed, documentation must support medical necessity for service in question • Date(s) of service in question • Name and signature of the requester • Specific reason(s) you disagree with the original claim determination

26. How to Request a Redetermination (cont.) • All written requests must follow proper procedures and use the proper forms. • The letter of intent must be on top of each request, clearly stating this is a request for review • Do not staple multiple requests • Include supporting documentation

27. How to Request a Redetermination (cont.) Medical Records • In addition to all of the requirements listed, the request for redetermination should also include all applicable medical records and documentation that supports the service(s) at issue. • Failure of the provider to submit the requested information will result in a non-covered decision that will hold the provider liable for the charges.

28. 2. Reconsideration Definition If you are not satisfied with the redetermination decision, your next level of appeal is the reconsideration. • This is the second level in the appeals process. • The appeal is conducted by a QIC. • The introduction of QICs allow for an independent review of medical necessity issues by a panel of physicians or other healthcare professions.

29. Requirements The request for a reconsideration must be filed in writing to the QIC within 180 days of receipt of the redetermination. There is no dollar amount that must be in controversy.

30. How to Request: To request a reconsideration follow the information provided in the redetermination decision, complete the form attached to that letter or complete the form CMS-20033. The form must be submitted directly to the QIC. All requests must contain the following: • Beneficiary name • Medicare Health Insurance Claim (HIC) number • Specific service, item, and date for which the reconsideration is being requested • Name and signature of the party or representative and • Name of the fiscal intermediary that made the redetermination

31. Role of the Qualified Independent Contractor (QIC) • Once the QIC receives a request for reconsideration, it must process the request within 60 days of receipt. • The receipt date of the request is defined as the date received by the QIC in its corporate mailroom. • When the QIC receives a request for reconsideration, it requests the case file from the FI who made the redetermination decision.

32. Evidence Requirements • All evidence should be submitted with the request for reconsideration. All evidence must be presented before the reconsideration is issued. If all evidence is submitted, you will not be able to submit any new evidence to the ALJ, or further appeal unless you can demonstrate good cause for withholding the evidence from the QIC. • Be sure to include a copy of the Medicare Redetermination Notice (MRN) and any evidence that was identified as incomplete or missing in the redetermination decision. • If the decision remains unfavorable, and the appellant wishes to go to the Administrative Law Judge (ALJ) level, the request will go through the QIC. They will forward the information to the ALJ.

33. 3. Administrative Law Judge Definition • Review by and Administrative Law Judge (ALJ) is the third level in the appeal process. • If the party remains dissatisfied after the Level 2 Reconsideration and at least $120.00 (effective January 1, 2008) remains in controversy, a hearing before an Administrative Law Judge of the Bureau of Hearings and Appeals may be requested.

34. Requirements The dissatisfied party must request the ALJ hearing within 60 days of the reconsideration notice. The ALJ request and appropriate documentation should be sent to the entity specified in the QIC’s reconsideration notice. Appellants must send notice of the ALJ hearing request to all parties of the QIC reconsideration and verify this on the hearing request form or in the written request.

35. Requirements (cont.) • ALJ hearings are generally held by video-teleconference (VTC) or by telephone. If you do not want a VTC or telephone hearing, you may ask for an in-person hearing. • You must demonstrate good cause for requesting an in-person hearing • The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis • You may also ask the ALJ to make a decision without a hearing (on-the-record)

36. Requirements (cont) • The ALJ will generally issue a decision within 90 days of receipt of the hearing request. • The QIC will forward the ALJ hearing file to the appropriate Office of Medicare Hearings and Appeals (OMHA) field office. • In addition, FIs are no longer required to issue acknowledgement letters in response to a request for an ALJ hearing.

37. Amount in Controversy (AIC) • The Centers for Medicare & Medicaid Services (CMS) annually adjusts the amount in controversy (AIC) thresholds for the Administrative Law Judge and U.S. District Court Review levels by a dollar amount equal to the percentage increase in the medical component of the consumer price index for July 2003 to the July preceding the year involved. If the adjusted amount is not a multiple of $10.00, CMS must round the amount to the nearest multiple of $10.00.  • The AIC must be at least $120.00 for requests for an ALJ Hearing filed on or after January 1, 2008. • The AIC must be at least $1180.00 for requests for a U.S. District Court Review hearing filed on or after January 1, 2008.

38. Calculating the AIC • The amount in controversy is 80% of the difference between the billed charges, the approved amount, and any deductible remaining. • To meet the required amount in controversy, a provider may combine any series of claims that have been upheld at the Reconsideration (QIC) level to equal that amount.

39. 4. Departmental Appeals Board Definition • The fourth level in the appeals process is a review before the Appeals Council, which is within the Department Appeals Board (DAB). • If a party to the ALJ hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Appeals Council. • Requirements: • An Appeals Council Review: • Must be requested within 60 days of the ALJ hearing • Does not require a minimum claim amount in controversy • The written request for an Appeals Council Review should specify the issues and findings made by the ALJ with which the provider disagrees. • The Appeals Council will issue a decision within 90 days of receipt of a request for review. • The Appeals Council’s decision will contain information about the procedures for requesting judicial review.

40. 5. U.S. District Court Review Definition • Review by the U.S. District Court is the fifth and last level in the appeals process. • If the appellant is dissatisfied with the Departmental Appeals Board (DAB) Review, he or she may then commence civil action by requesting a U.S. District Court Review, the final level of the Medicare Appeals Process. • The Appeals Council’s decision will contain information about the procedures for requesting judicial review.

41. Requirements A U. S. District Court Review: • Must be within 60 days of the DAB • Requires at least $1180 in controversy (after January 1, 2008) • Request must be filed directly with the US District Court

42. Fiscal Intermediary Requirements • If a FI receives, either directly or by copy, a summons or complaint due to a party’s request for U.S. District Court review, and it does not appear that a copy was sent to the following address, the FI shall send the original to: Department of Health and Human Services General Counsel 200 Independence Avenue, S.W. Washington, D.C. 20201

43. Original Medicare (Parts A and B Fee-For-Service) Appeals Process Standard Process Expedited Process Part A and B (Some Part A) I FiscalIntermediary (FI), Carrier, or Medicare Administrative Contractor (MAC) Determination Notice of Discharge or Service Termination Initial Decision 120 days to file Noon the next calendar day FI, Carrier, or Medicare Administrative Contractor Redetermination 60 day time limit Quality Improvement Organization Redetermination 72 hour time limit First Level of Appeal

44. Qualified Independent Contractor Reconsideration 60 day time limit 180 days to file Noon the next calendar day Qualified Independent Contractor Reconsideration 72 hour time limit Second level of appeal 60 days to file Office of Medicare Hearings and Appeals AIC=> $120 90 day limit Third level of appeal

45. Medicare Appeals Council • 90 day time limit for processing 60 days to file Medicare Appeals Council may decline review Fourth Level of Appeal 60 days to file Federal District Court AIC=> $1,220 Final level of Appeal AIC = Amount in Controversy