What Is an Appeal? and how to appeal the denial?

What Is an Appeal?

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan.

You can appeal if Medicare or your plan denies one of the following:

A request for a health care service, supply, or prescription that
You think you should be able to get
A request for payment for health care services or supplies or a
Prescription drug you already got that was denied
A request to change the amount you must pay for a prescription  drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

If you decide to file an appeal, ask your doctor or other health care provider or supplier for any information that may help your case.

How to File an Appeal

How you file an appeal depends on the type of Medicare coverage you have:

If you have a Medicare health plan, look at your plan materials, call your plan, or visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet, “Your Medicare Rights and Protections.”

If you have a Medicare Prescription Drug Plan, look at your plan materials, ■■call your plan, or look on pages 90–91 to learn how to file an appeal.

If you have Original Medicare, do the following to file an appeal:

Get the Medicare Summary Notice (MSN) that shows the item or  service you are appealing. Your MSN is the statement you get every 3 months that lists all the services billed to Medicare and tells you if Medicare paid for the services.

Circle the item(s) you disagree with on the MSN, and write an explanation on the MSN of why you disagree.Sign, write your telephone number, and provide your Medicare number on the MSN. Keep a copy for your records.

Send the MSN, or a copy, to the Medicare contractor’s address listed 4. on the MSN. You can also send any additional information you may have about your appeal.

You must file the appeal within 120 days of the date you get the MSN. If you want to file an appeal, make sure you read your MSN carefully, and follow the instructions. You can also use CMS Form 20027, and file it with the Medicare contractor at the address listed on the MSN. To view or print this form, visit
www.cms.hhs.gov/cmsforms/downloads/CMS20027.pdf.

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APPEALS AND GRIEVANCES - From wellcare Insurance

The Plan maintains a member complaint system that includes grievance and appeals processes for Medicare Advantage members.

An appeal is a request for review of an action taken by or on behalf of the Plan. A member, a member’s representative with the member’s written consent, or a provider acting on behalf of the member and may file an
appeal.

Example of actions include but are not limited to the following:
 Denial or limited authorization of a requested service, including the type or level of service;
 The reduction, suspension or termination of a previously authorized service;
 The denial, in whole or in part, of payment for a service;
 The denial or limited authorization of a requested medication;
 The failure to provide services in a timely manner, as defined by the state.
 

A grievance is any complaint or dispute other than one involving an organization determination expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services regardless of whether any remedial action can be taken. A member or a member’s representative, acting on behalf of the member and with the member’s written consent, may file a grievance. Possible subjects for grievances include but are not limited to the following:

 Quality of care of services provided;
 Rudeness of the provider; or

 Failure to respect the member’s rights.
 

The Plan ensures that decision-makers on grievances and appeals are not involved in previous levels of review or decision-making. These decision-makers are health care professionals with clinical expertise in treating the
member’s condition or disease or have sought advice from providers with expertise in the field of medicine related to the request when making decisions on any of the following:
 

 An appeal of a denial based on lack of medical necessity.
 A grievance regarding denial of expedited resolution of an appeal.
 A grievance or appeal involving clinical issues

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Insurance claim appeal - How to make it simple

How to simplify the claims auditing and appeals processes

1.Know the health plan’s claims appeals processes before you need to submit a claim appeal. Understanding these processes will allow you to acquire the health plan information (i.e., supporting documentation, health plan language) required to prepare a claim appeal.
 

2. Know where to locate the following health plan policies and, if possible, include them in the health plan contract:
 

*Claims adjudication procedures (i.e., definitions of complete or clean claims and medical necessity)
*  Rates and reimbursement methodology, including a comprehensive fee schedule
*  Claims appeals processes
 

3. Document, document, document. The supporting documentation of a claim submitted to a health plan must substantiate the performance of a service by the treating physician or health care professional. If a service is not documented, it didn’t happen in the eyes of the health plan—and the claim may not be paid.
 

4. Review and monitor all claims before submitting them to the health plan to ensure that you are filing complete and accurate claims. One way to avoid a claim denial is to correctly code the original claim. Implement a check and balance system between the physicians and the coding and billing professionals in your practice to determine whether claims are being coded appropriately.
 

5. Maintain a coding reference sheet in your practice with a list of commonly used International Classification of Disease-9th Edition-Clinical Modifications (ICD-9-CM) and CPT codes, as well as any other commonly reported codes on the standard claim form.
 

6. Evaluate the health plan’s explanation of benefits (EOB) for accuracy (i.e., potential processing errors, lack of recognition of a CPT modifier, incorrect physician fee schedule).
 

 7. Know your contracted fee schedule rate with each health plan for procedures and services commonly performed in your practice. Review each EOB you receive to ensure the negotiated reimbursement and discount rate with each health plan is calculated appropriately.
 

8. Maintain a health plan follow-up log that contains the reason the claim was partially paid, delayed or denied by the health plan, and also include the internal follow-up action by the practice staff to reduce future health plan underpayments and denials.
 

9. When submitting a formal claim appeal letter to a health plan, thoroughly explain your rationale for challenging the health plan’s claim denial. Additionally, include the appropriate documentation to support your request to reverse the denial.
 

10. Streamline your practice’s claims auditing and appeals processes by maintaining an appeals resource file with appeal template letters, rationales and supporting documentation of previously submitted claim appeal letters that resulted in overturning the denial.
 

11. Keep appealing. It may take more than one appeal to reverse a health plan’s incorrect denial. When a procedure or service has been appropriately performed, documented and reported, be persistent to ensure your practice obtains the proper compensation based on the negotiated health plan contracted rate.

12. If the appeal is not overturned by the health plan after you have exhausted the appeals process, file for an external review if available through the appropriate state or federal regulatory agency

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Why insurance denial appeal is important ?

How to appeal inappropriate health plan claim denials

In 2008, 66 percent of one physician practice’s total revenue came from claims originally underpaid or denied by health plans and other third-party payers. This revenue would have gone uncollected had the practice not implemented auditing and appeals strategies. Based on this example, it is estimated that physicians are losing billions of dollars in revenue each year by not appealing inappropriate claim denials.

There are many reasons why physician practices do not appeal denied claims; the most common is that they believe appealing claims will create an increased administrative burden on the practice. However, not appealing denied or partially paid claims can be quite costly to your practice and can often result in decreased revenue. Since introducing claims editing software into their claims processing systems, health plans have generated an increased number of inappropriate claim denials and reductions in payment.

An effective way for your practice to combat these erroneous payment reductions and denials is to be diligent in submitting appeals.

Why appeal?

When your practice increases its appeals for wrongfully underpaid or denied claims, the health plan may correct its claims editing software and processes. This, in turn, may result in improved claims processes and appropriate payment to your practice for the provision of health care services.

The following 12 steps simplify the claims auditing and appeals processes and can help to reduce your administrative burden. These processes make it easy for your practice to identify and appeal health plan claim denials when the health plan misapplies the American Medical Association (AMA) Current Procedural Terminology (CPT®)* codes, guidelines and conventions or the health plan’s contracted policies.

When a physician performs a procedure or service and then reports it according to CPT codes, guidelines and conventions, the health plan should recognize the physician work involved in providing this patient care. To ensure that your work is recognized, your practice should identify all inappropriate claim denials and communicate with the appropriate health plan representatives through each plan’s claims appeals processes.

What is lost when your practice does not appeal?

When your practice does not audit and appeal inappropriately paid or denied health plan claims, you may lose revenue.

You also may lose the opportunity to recover overhead expenses by not implementing a claims management process. This process is your practice’s internal designated workflow for accurately preparing, submitting and collecting on claims. When you challenge inappropriate claim payments, you demonstrate that your practice has made an effort to correct the plan’s inaccuracy. This could lead to a positive change in the health plan’s business practices.

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Claims Appeal Process - Peach state health plan

Claims Adjustment:

* Providers may resubmit a claim(s) to correct a simple billing error or to request an adjustment if you believe the payment made by the plan is incorrect. In order to be considered for payment claims in this category must be received within six (6) months from the month in which the service was rendered or within three (3) months of the month of payment on the EOP, which is later. Please include the word “resubmission” and the claim number on the claim form to help us identify that this is a resubmission of an existing claim. A Provider
Adjustment form must be completed for all resubmission requests along with the supporting documentation. Your claim will be reviewed and a decision rendered based on the information provided.

* Requests for Claim Adjustments that involve like or similar issues may be batched together using one Provider Adjustment Request Form (located on the PSHP.com web site) for dates of service after July 1, 2008. The form should clearly describe the issue with all supporting documentation attached and indicate the number of claims included.

Peach State Health Plan
P.O. Box 3030
Farmington, MO 63640-3800

Claims Appeals:

*  If you are not satisfied with result of your Claim Adjustment request, you may submit a written appeal within 30 days of the decision. You will receive acknowledgement of your written appeal within 10 days of receipt. Appeals received after the thirty (30) day time frame will not be considered for failure to appeal within the time frame.

*  Peach State will allow providers to batch multiple claim appeals for claims with dates of service after July 1, 2008 that are similar in nature submitted under the same Appeal Letter. The Letter of Appeal must indicate the nature of the complaint and the number of items attached.

*  A decision will be rendered within thirty (30) days of receipt of the appeal and you will receive notification of the decision via the EOP notice or written correspondence. Provider Appeals should be mailed to:
 

Peach State Health Plan
Attn: Provider Appeals
P.O. Box 3000
Farmington, MO 63640-3800

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Can Appeal limit can be extended to perform appeal ?

Appeal and Time limit filing

Good cause for extension of the time limit for filing appeals

The time limit for filing a request for redetermination may be extended in certain situations. Generally, providers, physicians, or other suppliers are expected to file appeal requests on a timely basis. A request from the provider, physician, or other supplier to extend the period for filing the request for redetermination would not be routinely granted.

Note: A finding by the contractor that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration.

Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following:

• Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties;

• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (the Centers for Medicare & Medicaid (CMS), the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline);

Note: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.

• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request;

• When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster);

• Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely;

• Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person;

• A death or serious illness in his or her immediate family; or

• A request was sent to a government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.

Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. Also, good cause does not exist where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

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