Long-Term Care

Master the Medicare appeals process

LTC Educator's Corner, September 7, 2009

At one point or another, many SNFs will disagree with their fiscal intermediary’s (FI), Medicare administrative contractor’s (MAC), or carrier’s decision to deny a claim. When this occurs, a facility should not hesitate to file an appeal.

Appealing a denial must be a team effort, involving all facility staff members who participated in billing or providing the service in question. Although the individual staff members involved may vary depending on the service or reason for denial, a facility’s MDS coordinator, administrator, billers, therapists, and members of the clinical and medical records staff all typically play a role in the appeals process.

Nursing home billers are critical to preventing and identifying denials and gathering information for an appeal. Since the appeals process can be confusing and time-consuming, SNF billers must have a clear understanding of the system and the important role they play.

Understand the process
FIs, MACs, and carriers deny claims for several reasons, such as insufficient documentation or the diagnosis code not supporting the medical necessity of the service. In some situations, the person reviewing the claim could have overlooked important information and mistakenly denied it. Regardless of the reason for denial, providers have the right to appeal.

The following are the five levels of the Medicare appeals process:

1. Redetermination. The first level of appeal, known as redetermination, must be filed with the FI, MAC, or carrier responsible for the initial determination. Facilities must submit a written request for redetermination within 120 days of receiving the notice of initial determination. Although not required, a request for redetermination can be filed using Form CMS-20027, which can be found on the CMS Web site at www.cms.hhs.gov/CMSForms/CMSForms. The FI, MAC, or carrier has 60 days from receipt of the redetermination request to issue its decision.

2. Reconsideration. If it is unsatisfied with the result of the redetermination, a facility can move on to the second level of appeal, known as reconsideration, in which a qualified independent contractor (QIC) reviews the claim.

A facility must file a written reconsideration request with the appropriate QIC within 180 days of receiving the redetermination. The Medicare Redetermination Notice will identify the QIC to which a facility should submit the request. Although not required, a reconsideration request can be filed using Form CMS-20033, which will be mailed with the Medicare Redetermination Notice. The QIC has 60 days from receipt of the reconsideration request to issue its decision.

3. Administrative law judge (ALJ) hearing. The ALJ hearing is the third level of appeal. A written request for an ALJ hearing must be filed within 60 days of receiving the QIC decision. Although not required, an ALJ request can be filed using Form CMS-20034.

To request an ALJ hearing, the amount that remains in controversy must meet the minimum amount requirement, which is adjusted annually ($120 this year). The ALJ has 90 days to issue a decision. However, if it is unable to do so, the facility can request that the appeal be escalated to the next level of review.

4. Medicare Appeals Council. If it is unsatisfied with the result of the ALJ hearing, a facility can request a review by the Medicare Appeals Council, which is part of the Departmental Appeals Board. The request for a review by the appeals council must be filed within 60 days of receiving the ALJ decision.

The ALJ will provide instructions on how and where to submit a request for an appeals council review. The appeals council has 90 days to issue a decision, and if it fails to do so, the facility may request the council to escalate the appeal to the judicial review level.

5. Judicial review. The final stage of the appeal process is judicial review in a U.S. District Court. To request a judicial review, the amount that remains in controversy must meet the minimum amount requirement, which is adjusted annually ($1,220 this year). A facility must file a request for a judicial review within 60 days of receiving the Medicare Appeals Council’s decision.

The biller’s role
SNF billers can help their facility avoid denials through accurate coding and ensuring that the documentation supports the services on the claim. However, avoiding denials altogether would be nearly impossible, and SNF billers should be prepared to identify and respond to denied claims.

FIs, MACs, and carriers communicate claim determinations to providers using a notice called remittance advice. Remittance advice notices are issued daily and are usually sent to a SNF’s business office.

Once a biller identifies a denial, he or she should communicate with other staff members involved in billing or delivering the denied service to determine whether the documentation supports a case against the contractor’s decision. If so, these staff members should begin to compile the documentation and information needed to request a redetermination.

Prove your point
If a facility chooses not to use Form CMS-20027 to request a redetermination, the written request must include the following information:

  • Beneficiary’s name
  • Medicare health insurance claim number
  • Specific services and/or items being appealed
  • Specific dates of service
  • Name and signature of the beneficiary or representative of the beneficiary
In addition to the basic information included in the request, facilities should send documentation related to the denial reason and any other information that supports the need for the skilled service during the period in question. Examples of the additional documentation that may support a claim are:
  • Physician orders
  • Progress notes
  • Therapy evaluations
  • MDS assessments
  • Documentation to support the codes on each MDS
  • Medication and treatment records
  • Discharge summary
HCPro, Inc. offers many educational tools to help master the Medicare appeals process including HCPro’s Medicare Boot Camp – Long-Term Care Version which covers the Medicare rules and regulations applicable to skilled nursing facilities. The objective of this four-day course is to provide course participants with a detailed understanding of the Medicare "rules" with a particular emphasis on the operational application of those rules. The Medicare appeals process is one agenda item covered during the four-day course. Be able to identify correct level of appeals process. At the end of the course, you’ll be able to:
·        Identify the correct level of appeals process
·        Identify the difference between reopening versus an appeal
·        Identify the requirements for Medicare claims appeals
·        Identify the CMS forms used during the appeals process

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