Important Tips about Documentation When Submitting Appeals on C-SNAP

WPS Medicare often receives extensive documentation, in an effort to ensure that WPS receives all faxed documentation WPS asks that you submit appeal requests that are 20 pages or more by mail. Please keep in mind that occasionally, the information submitted is not required to adjudicate the case.

  • 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: Tuesday, 13-Dec-2011 17:21:55 CST