Webinar
12/6/05
Topic: Appeals
Questions & Answers
Question 1:
When a hearing/reconsideration is required, what information must NHIC
provide to the provider? For example, if a claim has been downcoded by the
carrier, will the coding methodology and worksheet be provided in advance for
review by the provider?
Answer 1:
The worksheet will not be given to the provider. The information will be communicated in the
reason for denial.
Question 2: In 2006, will telephone reopenings
handle the same issues as present redeterminations?
Answer 2: No, a reopening is not the same
thing as redetermination.
Question 3: What training do reviewers of
records receive prior to conducting documentation reviews?
Answer 3:
Those who review records are registered nurses.
Question 4:
Which form is going to replace the CMS 1965?
Answer 4: The CMS 20033 form will replace the
1965.
Question 5: What is the difference between a
correction to a claim and a redetermination?
Answer 5:
A correction to a claim is a billing error, for example when an
incorrect date of service or an incorrect procedure code is found on the claim. Redeterminations are requested when
everything on the claim is correct and you believe the claim should be paid as
it is. In other words, you are
dissatisfied with the initial determination and you would like the carrier to
take a second look at the same claim with no changes made.
Question 6:
What guidelines are used by the RNs who review charts in
Answer 6:
Yes, the RNs use both 95 and 97 guidelines.
Question 7: How is the minimum dollar amount in
controversy determined?
Answer 7:
The amount in controversy is the dollar amount you expect to receive
from Medicare.
Question 8:
What internal/external validation system does NHIC employ to ensure its
review staff’s accuracy?
Answer 8:
All Medicare claims processing systems are audited by CMS, CERT, and now
the Recovery Audit Contractors (In California).
Question 9:
Is there a guide I can download regarding the appeals process?
Answer 9:
There is information in the Introduction to Medicare billing guide, on www.medicarenhic.com. We are also going to eventually put the
appeals process slide show on our e-learning page on our website.
Question 10:
Does Medicare look at additional ICD-9-CM codes on the initial
claim? I heard they only look at the
first.
Answer 11:
You need to reference only one code in item 24E on the CMS-1500 form or
electronic equivalent. Medicare does
receive and can access all ICD-9-CM codes in item 21 to verify medical
necessity.
Question 12:
We bill 99354 and we tried to send the initial claim with the report and
we continue to get the CMS letter asking for the report. What can we do about this problem?
Answer 12:
Respond to the development letter (also known as ADS letter) to avoid
denials. You can wait until you receive
a letter before you send in documentation.
Be sure to include a copy of the ADS letter with your documentation. Some codes generate an ADS letter
automatically.
Question 13: How long does it take for a
hearing to be scheduled from the time the request is filed?
Answer 13:
Most hearings are completed within 120 days of request.
Question 14: What is the website for the NCCI
edits?
Answer 14:
www.cms.hhs.gov/physicians/cciedits
Question 15:
We sent an appeal in July and according to the representative on the
phone, it was not handled correctly.
What do we do?
Answer 15:
Contact telephone redeterminations and bring it to their attention.
Question 16:
Our doctor’s specialty is listed as internist with Medicare, and they
are seeing patients on the same day as another doctor with two specialties, one
being internists. How can we get paid?
Answer 16:
Even if the providers are not in the same group practice, Medicare will
not pay for two visits on the same day from doctors of the same specialty.
Question 17:
What is the telephone redetermination phone number for
Answer 17:
866-539-5597
Question 18:
Effective January 1, 2006, will we not be able to use telephone
redetermination?
Answer 18:
Telephone redetermination will not be available for claims that
adjudicate in 2006. It will remain open
for approximately 120 days to accommodate claims that adjudicate in 2005.
Question 19:
How do I access audio capability on my PC for future meetings?
Answer 19:
The audio portion is done over the phone.
Question 20:
I noticed two different zip codes on the slide for
Answer 20: ** We apologize for the typo on
the appeals address zip code for
12/22/05