Redetermination Requests and Submission of Documentation - Update Medicare/Noridian 03/2014

Redetermination Requests and Submission of Documentation - Update

Providers requesting a redetermination must send the request in writing stating what they are appealing and reason why they are appealing. Providers can choose to send the written request on company letterhead or by completing CMS form 20027. Noridian recommends the use of the Interactive Redetermination Form that is downloadable from the Noridian website under the Forms section.

Redetermination Requests
*At a minimum, the request letter must contain the following information:

• Beneficiary name;
• Medicare health insurance claim (HIC) number;
• The specific service(s) and/or item(s) for which the redetermination is being requested;
• The specific date(s) of the service; and
• The name and signature of the party or the representative of the party.

*These elements are included on the Noridian Interactive Form.
Send only one (1) request form or letter per beneficiary denial. When submitting a Redetermination, please attach the required documentation to support the appealable item(s). Redetermination requests should include *ALL medical documentation pertaining to the claim or line item. Reasonable and necessary denials must include a copy of the Advance Beneficiary Notice (ABN) signed by the beneficiary if available. Also attach a corrected UB04 form.
*Noridian suggests referencing the Medical Documentation Requirements found under Resources in the Appeals Section under Browse by Topic.

Resources
The following resources can be found on the Noridian website – Appeals section:

• Medical Documentation Requirements – Alphabetized by Item/Service
• Signature Requirements – Explanation of valid signature and alternatives
• Inquiries and Solutions – Answers the common Redetermination and  Reconsideration questions including Recovery Auditor (RA) appeal questions
• Appeals Not Necessary for Certain Reason Codes - A line item or claim rejection occurs, providers may adjust the claim through the normal claim submission process, if the change does not affect liability.
• Remark Codes – Explains Remittance Advice Remark Codes (RARCs) that are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC)

 

Last Updated Mar 05, 2014 from Noridian https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/redetermination-requests-and-submission-of-documentation-update

 

Medicare Redeterminations: Top Five Requested Codes and Tips

Redeterminations: Top Five Requested Codes and Tips

Noridian conducted data analysis on the top procedure codes from redetermination requests submitted since October 2013. Below are the top five CPT/HCPCS codes, resources and tips to assist your office when submitting such requests.
CPT 88305 - Pathology Examination of Tissue Using a Microscope

• These appeals were denied because the requesting party failed to provide the following:
  • Indicate requirement of a valid order/intent to order.
  • Documentation must be signed and dated by the performing provider.
    • CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 
  • Pathology Reports - Include surgery/procedure notes when biopsies taken.
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 

CPT 99214 - Established Patient Office or Other Outpatient

• These appeals were denied because the requesting party failed to provide the following:
  • Evaluation and Management (E/M) outpatient/office notes must be dated and signed by the performing provider. Medical necessity is required for this level of service. Services must meet requirements of this code, including two of the three components:
    • Detailed history
    • Detailed exam
    • Medical decision making of moderate complexity located in CPT book
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7 
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 

CPT 99232 - Subsequent Hospital Inpatient Care, Typically 25 Minutes

• These appeals were denied because the requesting party failed to provide the following:
  • 99232 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in same the day for unrelated issues. Medical necessity is required for this level of service. Documentation must support additional services.
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 
  • Documentation submitted with the redetermination request must be signed and dated by the performing provider and must meet two of the three key components
    • Expanded problem focused history
    • Expanded problem focused exam or
    • Medical decision making of moderate complexity
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual,  Chapter 12, Section 30.6.9 

CPT 99233 - Subsequent Hospital Inpatient Care, Typically 35 Minutes

• These appeals were denied because the requesting party failed to provide the following:
  • Provides the same instructions as those for 99232 with the following exception:
  • 99233 should meet two of the three components:
    • Detailed interval history
    • Detailed exam
    • Medical decision making of high complexity
  • Medical necessity is required for this level of service.
  • For further clarification:
    • CMS 1995 Documentation Guidelines for Evaluation and Management Services 
    • CMS 1997 Documentation Guidelines for Evaluation and Management Services 
  • 99233 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in the same day for unrelated issues. Documentation must support additional services.
  • For further clarification:
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30 
    • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.9 

HCPCS A0425 - Ground Mileage, per Statute Mile

• These appeals were denied because the requesting party failed to provide the following:
  • Include the following documentation in the request:
    • Trip report which must be signed and dated by a crew member.
    • Discharge notes
    • Progress notes that support the necessity of the ambulance trip
    • Certification for medical necessity of the ambulance transport 
    • CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 
    • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15 

Published: 01/30/14

Last Updated Jan 30, 2014

From Noridian: https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/redeterminations-top-five-requested-codes-and-tips

Noridian Telephone Reopening: Requests Containing Ambulance, Critical Care and MolDX Services No Longer Accepted (Medicare)

Effective immediately, claims containing the below procedure codes now require documentation be submitted with their Reopening request and will no longer be corrected via a Telephone Reopening.

• Ambulance: A0021-A0999
• Critical Care: 99291 and 99292
• Molecular Diagnostic (MolDX): 81200-81383, 81400-81479, 88380-88381, G0452, 81479, 84999, 85999, 86849, 87999, 88199, 88299, 88399, 89398, 83890-83914, and 88384-88386

When documentation is required to process a Reopening, providers must submit the request as a Written Reopening with a completed "Reopening Form" or through Endeavor. If a request is more complex, beyond clerical errors or omissions, it is appropriate to submit a Redetermination via the "Redetermination Form."

For more Telephone Reopening information, go to https://med.noridianmedicare.com/web/jeb/topics/appeals/telephone-reopening.

Last Updated Oct 17, 2013 By Noridian

https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/telephone-reopening-requests-containing-ambulance-critical-care-and-moldx-services-no-longer-accepted

Complaints and Disputes Against Insurers

When an insurer or payer denies a claim unfairly or otherwise conducts business in an inappropriate manner, a physician practice can and should take action. Use the information on this page to better understand and navigate the complaint process.

Complaint proceduresPhysicians should first try to resolve the issue through the third-party payer’s internal complaint submission process. If you feel that your issue was not properly addressed in the internal process, consider seeking an impartial review by a state insurance regulatory agency, your state medical association or the AMA. Understand what to expect during the complaint process.

Filing a complaint against an insurer – mapTo assist you with the process of filing a complaint with the AMA, your state medical association or state insurance regulatory agency, the AMA has compiled the complaint process procedures for every state. Information is available through an easy-to-use interactive map.

Health plan complaint formUse the AMA Health Plan Complaint Form to let the AMA know about the hassles and unfair business practices you experience in your day-to-day interactions with health insurers.

File a HIPAA-related complaint
Physicians are encouraged to file a complaint with the AMA when an insurer is out of compliance with Health Insurance Portability and Accountability Act (HIPAA) transaction and code set standards. Also learn how to file a complaint with the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).

Courtesy of : AMA http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/complaints-disputes.page?