1.1 - Filing a Request for a Redetermination
1.2 - Appointment of a Representative
1.3 - Clerical Error Reopenings
1.4 Direct Data Entry vs. Clerical Error Reopening
1.5 Documentation to include with your Appeal Request
1.6 Withdraw of an Appeal Request
1.7 Reconsideration (Second Level Appeal) by a Qualified Independent Contractor (QIC)
1.8 - Administrative Law Judge
1.9 - Amount in Controversy Requirements
1.10 Redetermination and Reconsideration Processing
Reference: CMS Publication 100-4 (Medicare Claims Processing Manual), Chapter 29 Section 310
The first level of appeal is a redetermination. A redetermination is an independent reexamination of an initial claim redetermination. A redetermination can be requested if you are dissatisfied with the initial processing of your claim. A redetermination must be filed within 120 days of the date of receipt of the initial claim determination notice. All requests for redeterminations must be filed in writing. Regulations dictate that requests for redeterminations may not be filed over the telephone.
Medicare providers who submit claims to Medicare Administrative Contractors (MACs) have the same right to appeal claims as beneficiaries. This means the provider does not need to submit an Appointment of Representative form with an appeal request.
Novitas Solutions has developed the Medicare Part A Redetermination Request Form for your use. A Medicare Redetermination Request form should be completed for each claim in question. Request forms should be mailed to Novitas Solutions to submit requests for claim redeterminations (first level appeals).
Mailing addresses can be found here: [Jurisdiction L] | [Jurisdiction H]
All written requests for a redetermination must contain the following items:
The beneficiary name;
The beneficiary Medicare number;
The specific service(s) and/or item(s) for which the redetermination is being requested;
The specific date(s) of service; and
The printed name and signature of the requestor.
Your appeal request will be dismissed if any of the above information is not included with the request (Medicare Claims Processing Manual, Chapter 29, Section 310.1B2).
Additionally, if there are multiple denied lines on the claim, but you are only questioning/disputing one line, please be explicit in what you are requesting that we review.
As stated in CMS Publication 100-4, Chapter 29, Section 270.1, an individual appointed by a beneficiary or provider/supplier to act as the representative of the beneficiary/provider/supplier in connection with a claim(s) is known as an appointed representative. The beneficiary/provider/supplier has authorized their representative to make or give any request or notice; to present or to elicit evidence; to obtain information; and to receive any notice in connection with the claim or claims. This appointment must be accepted by the appointed individual to be valid.
Billing clerks or billing services employed by a physician or supplier to prepare and/or bill claims, process payment, and pursue appeals act as an agent of the physician and do not need to be appointed as a representative.
Appointment of Representative requirements is met if a completed CMS Form 1696 is submitted to the Medicare contractor. The form must be signed and dated by both the beneficiary/provider and the representative. See CMS Form 1696 *.
Reference: CMS Publication 100-4, Chapters 29 & 34 and MLN article MM 4147 – Reopenings and Revisions of Claim Determinations and Decisions
Section 937 of the Medicare Modernization Act required CMS to establish a process, separate from appeals, whereby providers, physicians and suppliers could correct minor errors or omissions. CMS believes that it is neither cost efficient nor necessary for contractors to correct clerical errors through the appeal process.
CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:
Mathematical or computational mistakes;
Transposed procedure or diagnostic codes;
Inaccurate data entry;
Computer errors;
Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate; or
Incorrect data items, such as provider number, use of a modifier or date of service.
Note that clerical errors or minor errors are limited to errors in form and content, and that omissions do not include failure to bill for certain items or services. A reopening shall not be granted to add items or services that were not previously billed. Third party payer errors do not constitute clerical errors.
Examples of issues that may not be handled as a clerical error reopening are as follows:
Inpatient services (e.g, hospital, SNF inpatient, inpatient rehab facility or IRF)
Limitation of liability issues;
Initial claim determinations issued as a result of the following:
Prepay MR review, e.g., reason code denials to include but not limited to 50017, 50174, 59174, 50MIS;
Comprehensive Error Rate Testing (CERT) denials (TOB is XXH);
Program Safeguard Contractor (PSC) denials;
MSP issues (Note: third party payer errors do not constitute clerical errors);
The addition of lines or items that were not previously billed;
The additional diagnosis/data does not permit payment of the claim; or
The denial(s) is solely the result of an OCE rejection edit that can be corrected by the provider via Direct Data Entry (DDE).
REMINDER: The clerical error reopening process does not replace the submission of an adjustment or corrected claim via Direct Data Entry (DDE) in FISS. The DDE adjustment should be submitted whenever possible since it is the most efficient way to correct simple errors. The Clerical Error Reopening Request Form should only be used for those situations where you are unable to do the DDE adjustment.
Novitas Solutions has developed a form for requesting a clerical error reopening. Use of the clerical error reopening form will expedite your reopening requests.
Medical records are not required; however, a corrected UB-04 claim form is required to be submitted with your request. Circle or highlight the change(s) that you are requesting. Your medical record documentation must support the changes you are making in your clerical error reopening request and be available for review upon request.
If the changes you are requesting do not allow payment of the claim, your request for a clerical error reopening will not be accepted. A clerical error reopening is a discretionary action on the part of a Medicare contractor. The decision not to reopen a claim cannot be appealed. You may request a redetermination on the original claim if appeal rights were given, but you must do so within the required time frame of 120 days from the date of receipt of the initial determination notice.
IMPORTANT: Regardless of a rejected request for reopening, the 120 days from the date of receipt of the initial determination notice does not change.
Redetermination requests must include all pertinent medical documentation pertaining to the services in question. The medical record documentation must include the patient’s name and must be complete and legible. If you are making changes to the claim, include a copy of a revised UB-04 claim form. In addition, if an Advance Beneficiary Notification (ABN) or other beneficiary notice was issued, include a copy of this document.
Remember that medical record documentation must be legible. Each page of the record should identify the patient and the date. A hand written or electronic signature and credentials should follow each record entry (stamp signatures are not acceptable). The record should be of good copy quality for review purposes.
Effective August 1, 2008, Novitas Solutions will not routinely request additional inpatient documentation from providers who failed to submit all the necessary medical records. The redetermination will be performed based on the medical record documentation that you submitted with your initial claim and appeal request. Providers, physicians and other suppliers are responsible for providing all the information the contractor requires to adjudicate the claim(s) at issue.
If the service being appealed was denied due to a Local Coverage Determination (LCD), you should review the LCD policy for the documentation requirements that are necessary to support the service. The LCDs are available on the Novitas Solutions internet site.
If the service being appealed was denied due to a National Coverage Determination (NCD), you should review the NCD policy for the documentation requirements that are necessary to support the service. The NCDs are available on CMS’ website *.
The following list may be used as a guideline (not all-inclusive list) when submitting documentation with your redetermination request.
OUTPATIENT RECORDS
Issue |
Documentation |
Cosmetic Surgery |
Surgical report, pathology report, history and physical , physician's progress notes |
Dental Services |
Dental surgical report, pathology report, history and physical , physician's progress notes, physician orders and laboratory reports |
Diagnostic Tests: Radiology |
Physician orders, history and physical, test results, e.g., x-ray reports |
Drugs (J codes) |
Physician orders, history and physical, medication record, nurses notes |
Laboratory Services |
Physician orders, laboratory report(s), pathology report |
Physical, Occupational, and Speech therapy |
Physician orders, therapy evaluation and progress notes; physician certification/recertification |
INPATIENT RECORDS
SKILLED NURSING FACILITY INPATIENT RECORDS
Issue |
Documentation |
Inpatient Hospital |
Complete Hospital Records including emergency room reports, admission history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory and pathology reports, X-ray reports, operating room and anesthesia report, discharge summary, Advance Notice of Non-Coverage (signed by the beneficiary), denial notification issued by the provider, billing form |
Inpatient Rehab Facility |
Complete Hospital Records including history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory reports, X-ray reports, therapy evaluation and progress notes, physician certification/recertification, Advance Notice of Non-Coverage(signed by the beneficiary), billing form |
SNF Inpatient |
Hospital discharge summary, physician certification, progress notes, and orders, nurses notes, medication records, therapy records, if applicable, copy of the MDS, signed Advance notice of non-coverage and denial notification issued by the provider, if applicable |
An appeal request for a claim that was denied by Medical Review (MR) for lack of documentation or for insufficient documentation must be submitted with all the medical record documentation that was requested in the additional documentation request (ADR). The ADRs that you receive requesting additional supporting documentation are very specific regarding the type of information that is required. Thoroughly review the ADR to be sure that all items requested in the ADR have been submitted with your appeal.
A request for a redetermination may be dismissed under the following circumstances.
At the Request of the Party
A request for redetermination may be withdrawn at any time prior to the mailing of the redetermination upon the request of the party or parties filing the request for redetermination. You must submit the request in writing. A letter documenting your request to withdraw the appeal will be issued and will provide you with the criteria that must be met if you wish to review the service at another time.
Failure to File Timely
When a request for a redetermination is not filed within the required time limit (120 days from the date of the initial determination) and good cause for failure to file timely was not found by the FI or MAC, the request will be dismissed. It is the responsibility of the individual filing the request to provide information to support the late filing request.
Conditions and examples that may establish good cause for late filing by a provider may be found in
CMS’ Claims Processing Manual, Chapter 29, Section 240.4 *.
Party Failed to Make a Valid Request
When it is determined that the provider failed to submit a valid request for redetermination as identified in Section 1.1, the request will be dismissed. You may file your request again with the required information if it has been 120 days or less since the date of receipt of the initial determination.
Appeal Rights for Dismissals
You may request that we vacate our dismissal within 6 months of the date of the mailing of the dismissal notice if you think you have good and sufficient reason to dispute the dismissal. You also have the right to appeal a dismissal to the Qualified Independent Contractor (QIC) if you believe it was incorrect. The reconsideration request to the QIC must be filed within 60 days of the date of the dismissal. The dismissal letter will provide you with detailed information regarding your options and the time frames for each option.
A second level appeal is called a Reconsideration. Requests for a Reconsideration must be filed with a Qualified Independent Contractor (QIC). The name and address of the QIC will be specified in each Redetermination notice. Requests should be submitted in writing with a copy of the Redetermination Notice to the following address:
Maximus Federal Services
Medicare Part A East
3750 Monroe Avenue
Pittsford, NY 14534-1302
A Reconsideration request form should be used and will be provided with each Redetermination notice issued. A Reconsideration Request Form can be downloaded *. In lieu of the form, the Reconsideration request must include the following items:
The beneficiary’s name;
Medicare health insurance claim number
The specific service(s) and items (s) for which the reconsideration is requested and the specific date(s) of service;
The name and signature of the party or representative of the party; and
The name of the contractor that made the Redetermination
A request for reconsideration must be filed within 180 days of the date of receipt of the notice of the Redetermination. The date of filing for request filed in writing is defined as the date received by the QIC in their corporate mailroom.
If you are dissatisfied with the Reconsideration decision issued by the QIC, you may request a hearing by an Administrative Law Judge (ALJ) by writing along with the first page of the decision. Requests must be made within 60 days of receipt of the QIC decision.
The ALJ does not have the authority to overturn national coverage limitations made by the Centers for Medicare and Medicaid Services (CMS). However, if the appeal involves an assigned claim and a medical necessity denial, the ALJ will determine whether the limitation of liability provision of the law was properly applied.
You may request an ALJ hearing by writing to the address listed below or you may contact any Social Security Administration Office.
OMHA Southern Field Office
Miami Florida
100 SE 2nd Street, Ste. 1660
Miami, FL 33131-2100
This section is informational only since the amount in controversy requirements only apply to the ALJ and Federal Court Levels. The amount in controversy is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements.
Administrative Law Judge (ALJ)
The amount remaining in controversy for ALJ hearing requests made before December 31, 2014 is $140.00. This amount will rise to $150 for ALJ hearing requests filed on or after January 1, 2015. This amount will remain at $150 for ALJ hearing requests filed on or after January 1, 2016.
Departmental Appeals Board (DAB)
None.
Federal District Court Review
The amount in controversy for Federal District Court review requests filed on or before December 31, 2014 is $1,430. This amount will increase to $1,460 for appeals to Federal District Court filed on or after January 1, 2015. This amount will increase to $ 1,500 for appeals to Federal District Court filed on or after January 1, 2016.
Generally, a redetermination decision will be issued within 60 days of receipt of the redetermination request. For fully favorable decisions, the parties will receive notice of effectuation via a Medicare Summary Notice (MSN) or Remittance Advice (RA).
For partially favorable decisions and unfavorable decisions, the parties will receive a written redetermination decision with the rationale for the decision as well as notice of effectuation via a MSN or RA. If you do not agree with the decision, you will be provided instructions on how to pursue the next level of appeal, reconsideration by the QIC. The decision will also include a Reconsideration Request Form that is to be submitted to the QIC if you wish to appeal the redetermination decision.
A. Letter of Written Assurance
Prior to paying a provider for fully favorable or partially favorable cases where the beneficiary was previously liable, the MAC must ascertain whether the provider has been reimbursed for the previously denied services from another source. The MAC will withhold the Medicare reimbursement until the party has assured, in writing, that any prior payment has been refunded.
Returning a Letter of Assurance promptly will result in quicker payment to you. Only after the Letter of Assurance has been received will a claim adjustment be initiated to make payment. If no Letter of Assurance is received, no payment will be made.
B. Cert Appeals vs. Claim Adjustments
Some Part A providers are cancelling claims and resubmitting adjusted claims when CERT alerts them via a Tech Stop or Non-Response Contact that documentation is missing or that a coding error has occurred. Because these claims have been medically reviewed by the CERT contractor, providers are instructed to cease the practice of cancelling and adjusting claims that are selected in the CERT review process.
At the time of the Tech Stop or Non-Response Contact, the claim has been medically reviewed, but has not yet been denied. Novitas Solutions will initiate the adjustments for any necessary denials. When the CERT adjustment has been made in the FISS system, it will appear as an XXH type of bill. If you need to make a correction or addition to the claim, providers may appeal the denials on the XXH type of bill. The proper appeals process should be followed.
Providers should continue the practice of submitting an adjustment claim for an incorrectly billed line item, when the provider identifies the error outside of the medical review or CERT process.
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