Since we were all in kindergarten, we have been taught to work out our differences when we disagree. Ultimately, it provides an opportunity for the other side to understand our perspective, and we may even gain some type of ground in the relationship.
The same is true for Centers for Medicare and Medicaid (CMS) appeals. When documentation regarding an ambulance run is complete, a record is submitted with what appear to be clearly documented facts for reasonable care and transport of a patient, including the perceived medical necessity, transport mileage and level of service provided. Days or weeks later, however, an Assignment of Benefits (AOB) with a coded message that the transport was not covered, and therefore payment for the claim is not be issued to the EMS agency, may still be returned.
Fortunately, in this denial is an opportunity: that of an appeal. In stances where treatments were reasonably justified, it may be beneficial to make the appeal—and quickly. Filing an appeal as soon as a denial is received could possibly jump-start the lengthy process and improve chances of a timely billing cycle. Jump-starting the process is also beneficial due to the complications that could be encountered along the way. Just like any other process in government, as it was in kindergarten, there are specific instructions and deadlines that must be paid attention to for success in the appeal.
In this context, an appeal is the process used by a party (a beneficiary, provider, or supplier with standing in the initial decision) when the party disagrees with an initial determination or revised determination for healthcare items or services. Any of these parties, their agent or an appointed representative can file the appeal. If the party is using an appointed representative, there is a document (Form CMS-1696 or its equivalent) that must be completed in writing and submitted.
Before filing an appeal, know that certain Medicare rules allow you to correct minor omissions and errors without starting the appeal process. More information may be located on the CMS website.
If a denial is due to more than just minor errors or omissions, it’s important to know that filing Medicare appeals is a process with five levels for Original Medicare:
Each of these levels has its own unique requirements; thus, we will only focus briefly on the first three.
Redetermination is the first level of an appeal after the initial determination on a claim. The request for redetermination must be made within 120 days from the receipt of the Remittance Advice (RA) that lists the initial determination for that specific claim. Each RA will have specific instructions on how to appeal; alternatively, you can follow the instructions provided by your MAC or file form CMS-20027. Each appeal must have a name and signature, and there is no minimum Amount in Controversy (AIC) requirement. Instructions dictate that supplemental documents can be submitted to help support the claim. It is highly recommended to include those documents specific to the denial at this stage.
In many cases, this level of appeal is performed by either the submitting entity or a partnership agency such as R1. R1 submits claims on a client’s behalf to help mitigate the extent of effort required by clients.
Once submitted, the redetermination will be performed by other individuals within the MAC. Appealing entities should receive a decision within 60 days in the form of a Medicare Redetermination Notice (MRN) or a revised RA if the claim is paid in full.
Reconsideration, the second level on an appeal, provides the opportunity for a review by a QIC. The request for this reconsideration must be filed within 180 days of the MRN or RA and can be filed by following the instructions on the MRN, RA or CMS-20033 form. The most important thing to remember about the second level is that this stage in the appeal provides the last opportunity for clients to submit additional supporting documentation for subsequent levels of appeals unless good cause can be shown for not including them at this stage.
Additionally, there is also no AIC requirement at this level. Frequently, R1 will also submit these appeals with support from the client. No matter who submits the appeal, reconsideration will be performed by individuals within the QIC, including healthcare professionals, nurses or physicians. A decision is usually sent within 60 days plus mailing time. If the QIC cannot meet this deadline, a notification will likely be sent regarding the delay.
The opportunity for review by an ALJ under the oversight of the United States Department of Health & Human Services Office of Medicare Hearings and Appeals arises in the third level. This appeal request must be filed within 60 days of receipt of the reconsideration decision or after the expiration for that decision. You should follow the instructions on the decision paperwork or form CMS-20034 A/B.
There are other unique requirements associated with this third level that will require your research. For example, there is an AIC minimum requirement that is updated annually. There are also requirements for notices to other parties. All of this important information is available on the CMS and HHS websites.
Note, too that the ALJ system is backed up, and the delay to be heard can equal many months, perhaps years. In fact, CMS recommends waiting 22 weeks before resubmitting if no response is heard from the ALJ.
Now that you understand how the appeals process works and you have been able to determine that you should move forward with the process for your agency, make sure to keep these great tips from CMS in mind:
Another key lesson learned from kindergarten was that of patience. In a fast-paced world that expects instant gratification or resolution, such patience may be hard to come by. However, the wheels of justice move slowly. The claim denial appeal process is methodical and it can take months, even years, to resolve a claim. Yet, if we follow instructions and are patient, we can have successful outcomes in the appeals process.