Bulletin Board

Change in the Amount in Controversy for Federal District Court Appeals and Administrative Law Judge (ALJ)

The Medicare claim appeals process was amended by Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Section 1869 (c) of the Social Security Act (the Act) as amended by BIPA requires changes to the amount in controversy required for an Administrative Law Judge (ALJ) hearing or judicial court review.

For Administrative Law Judge (ALJ) requests made on or after January 1, 2008, the amount in controversy increased to $120.

For requests made to the U.S. District Court, the amount remaining in controversy for requests made on or after January 1, 2008 increased to $1,180.

Appeals Related to Decertification of Inpatient Rehabilitation Facilities

We have recently seen an increase in appeal requests submitted to the Claims Appeals Department because of Inpatient Rehabilitation Facility (IRF) decertifications.

The Centers for Medicare and Medicaid Services (CMS) issues a notice to any facility that has been determined to not meet the criteria required to maintain certification as an Inpatient Rehabilitation Facility (IRF). In these cases, both a presumptive review based on the Patient Assessment Instrument (PAI) and medical review of patient records for a statistical sampling of claims has been conducted.

Although claim information has been reviewed, no action is taken on the individual claim itself and therefore there are no appeal rights related to the individual claims.

CMS will issue a notice to any IRF provider who has been decertified. If a provider disagrees with the decision, they may submit an appeal request through the Provider Reimbursement Review Board (PRRB). These requests should not be submitted to WPS on the redetermination notice located on the Appeals Website.

Requests should be sent to:

Chairman
Provider Reimbursement Review Board
2520 Lord Baltimore Drive, Suite L
Baltimore, MD 21244-2670

Misrouted 2nd level (Reconsideration) and 3rd level (Administrative Law Judge Hearing) appeals.

WPS Medicare only processes the lst level of the appeal which is called a Redetermination.

A 1st level of appeal (Redetermination), can be done if a claim has been denied for medical necessity and the appeal request need to be received within 120 days from the denial date.

A template is provided for your convenience on the Website (www.wpsmedicare.com). You can also send a redetermination request letter on provider letterhead, dated, and signed which has to include the following information: beneficiary's full name, complete Medicare number, specific dates of ]] service, and type of service being appealed.

A redetermination decision letter will be sent to all parties involved if the decision is partially favorable or unfavorable. NOTE: The next level of appeal rights and where the request needs to be sent is included in the redetermination decision letter.

If the redetermination decision is fully favorable, a claim adjustment will be processed. (No decision letter will be sent.)

Actions you should take:

Do not send the 2nd and 3rd level of appeal request to WPS.

If you are requesting a 2nd level of appeal (Reconsideration), a Qualified Independent Contractor (QIC) handles these. NOTE: The second level of appeal rights and where the second level appeal request needs to be sent are stated in the redetermination decision letter.

If you are requesting a 3rd level of appeal (Administrative Law Judge Hearing) these are handled by the ALJ. NOTE: The third level of appeal rights and where the third level appeal request needs to be sent are stated in the reconsideration decision letter.

If you have any questions about the appeal process or status of an appeal, please contact us at (866) 518-3298.

How do I Appeal a CERT Denial?

If you have received notification that a claim has been denied by the CERT due to non-submission of records, or insufficient documentation, and you have obtained the requested records, you should send those records to the CDC. They will determine if their review can be completed with the additional records, which may result in a revision of the error rate and a reversal of the claim denial, when appropriate.

Records can be faxed to the CERT Documentation Contractor at (804) 864-9941.

Please be sure to include the CERTs original request letter since it contains the bar code or if the request letter is not available, write the CERT Claim ID number on each page of the records.

All other denials should be appealed through WPS-Medicare's Claims Appeals Department through the normal appeals process.

Appeal Request Template

An Appeal Request template has been developed to provide a more efficient, streamlined avenue for you to submit appeal requests. This template includes all of the relevant information necessary for submitting a complete appeal request.

You can copy this template to your facility letterhead, or print the template from the Appeals page on our Website. You can begin to use this template immediately.

Use of this template will help to insure all required information is present and that the requests are handled more efficiently. You are not required to utilize this template; however, we would strongly urge you to consider incorporating it into your appeal process.

Claim Appeal Determination Letters

The Centers for Medicare & Medicaid (CMS) previously eliminated the need for a separate appeal determination letter when an appeal decision was fully favorable to the appellant, as it was determined this was a duplication of the Medicare Summary Notice (MSN) and Remittance Advice (RA). We had continued to issue an appeal decision letter for Part A Reconsiderations which resulted in full reversals. This was also a duplicate effort of the MSN and RA. Therefore, effective July 16, 2004, the Appeals area discontinued issuance of decision letters for Part A Reconsiderations in which the decision was fully favorable. If you have submitted a request for a Part A Reconsideration, and have not received a decision letter, you will need to check your Remittance Advice to determine if the claim has been adjusted for payment. You will continue to receive the verification of payment letter, when liability is changed from beneficiary to provider liable. This letter must be completed and returned to us before the claim is adjusted for payment. The receipt of a verification of payment request will also be an indication that the denial has been reversed.

Additional Appeals information.

Medicare Claims Processing Manual Chapter 29 - Appeals of Claims Decisions

What are not Appeal Requests?

Claims still in process that have not been medically denied or finalized. Claims in Status S (Suspense) and Status T (Return to Provider) can not be appealed.
Claims that requires correction(s) or adjustment(s). The Appeals area does not handle correction of coding errors. Before submitting an appeal, it is important that the provider research all possible reasons for denied or non-covered charges. Identifying the reason(s) for the denied or non-covered charges will prevent time spent filing unnecessary appeal requests.

Laboratory National Coverage Determination (NCD) Denials:

The Claims Appeals Department receives a significant number of appeal requests due to Laboratory National Coverage Determinations (NCDs). The Centers for Medicare & Medicaid Services (CMS) established criteria for coverage of clinical diagnostic laboratory services payable under Medicare Part B and developed 23 laboratory NCDs in November 2001. Each NCD has limitations, indications, coding guidelines, program requirements and reasons for denial. Further information regarding the establishment of national coverage and administrative policies for clinical diagnostic laboratory services can be found in the Federal Register, Vol. 66, No. 226, dated November 23, 2001. Reasons for affirming initial denials include: 1) tests performed for screening purposes, 2) tests not reasonable and necessary for the diagnosis or treatment of an illness or injury, and 3) failure to provide documentation to support medical necessity. Appropriate coding of laboratory claims will increase the potential for correct reimbursement and thus reduce the number of unnecessary appeal requests. Providers must submit all necessary documentation to support that the service was provided, as billed, and that the test was reasonable and necessary.

Additional information and updates to laboratory coverage. This link includes the NCD Coding Manual, Federal Register Final Rule, Program Memoranda and NCDs.

Page Last Updated: Wednesday, 17-Feb-2010 15:27:58 CST