Does Your Appeal Request Require Documentation?

Please be sure that Medicare needs all the documentation that you including with your redetermination request. Many times, we receive 20 - 40 pages of documentation. Frequently, the information that is submitted is not required to process the redetermination. Following are some additional tips on submitting documentation:

  • For example if a claim is denied for medical necessity, please review your claim to determine if the denial is due to the diagnosis code billed or due to the frequency of the service. The documentation needed may only be a new diagnosis code. Check Medicare Policy for covered diagnosis codes and documentation submission requirements.
  • Please check that the documentation is for the date of service and the beneficiary that is on the claim which denied.
  • When sending documentation, clearly indicate the section of the documentation that supports your opinion that the claim should not have been denied. This should be stated on the redetermination request form, in the section "I do not agree with the determination of my claim. MY REASONS ARE:" or in the section "Additional Information Medicare Should Consider"
  • Appeals for services which have a "B", "I" or "N" status indicator on the Medicare Fee Schedule database are services which are always bundled or invalid for Medicare. The addition of a modifier with medical documentation will not enable Medicare to make a payment on appeal. To make payment, the fee schedule indicator for the code would need to be changed by CMS.
  • In addition, check CCI edits to ensure that modifiers can be applied to unbundle services. If the CCI indicator is "0" for a particular code pair, again, the addition of a modifier and notes on appeal will not cause Medicare to reverse the initial determination. In this situation, the CCI edit would need to be revised before Medicare could make payment.

Page Last Updated: Thursday, 15-Dec-2011 12:08:51 CST