Medicare Claims Appeals Process Handbook

Anyone who submits Medicare claims and receives Medicare reimbursements needs to be fully prepared to follow the appeals process when claims are rejected and/or refunds are requested.

Medicare Claims Appeals Process Handbook helps you understand - and explain - the process every step of the way. You'll know exactly what you can and can't do, the essential timeframes for pursuing appeals, where to send information, and how to proceed - at every level of the appeals process!

The Medicare Claims Appeals Process Handbook will help you:Increase your likelihood of success in the claims appeal by lowering the possibility of procedural error and avoiding costly errors

• Navigate all four levels of the administrative appeal process
• Proceed to federal court if necessary
• Stay current with changing rules, regulations, and procedures
• Put best practices in place - immediately!

Only Medicare Claims Appeals Process Handbook includes letters, forms, charts, and more - all designed to provide you with practical support throughout the process.

Medicare Claims Appeals Process Handbook has been updated to include:

• Expanded material on electronic claims submission
• A sample denial of an “unusual circumstance” waiver request
• Information on medical necessity denials
• A new National Coverage Analysis (NCA) tracking sheet and proposed decision memo for MRIs
• Updated Medicare redetermination request forms
• Request for review of Administration Law Judge (ALJ) Medicare decision/dismissal
• Comparison of standard and expedited appeals processes
• Updated CMS appointment of representative form
• New material on the role of the Medicare administrative contractor
• A sample Medicare Summary Notice
• Important information on overpayment and suspension of payments
• Recent case law regarding exhaustion of administrative remedies
• Updated material on good cause for reopening

• 1. OVERVIEW OF CLAIMS PROCESSING SYSTEM
  • Providers and Suppliers Defined
  • Contractor Responsibilities
  • Utilization Review Committee Decisions
  • Submitting a Claim
  • Medical Review
  • Reasons for Claim Denials
  • Waiver of Liability
• 2. THE ROLE OF NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS
  • National Coverage Determinations Defined
  • Procedures for Establishing New National Coverage Determinations
  • Reconsideration of a National Coverage Determination
  • Review and Appeals of National Coverage Determinations
  • Local Coverage Determinations Defined
  • Process for Developing New Local Coverage Determinations
  • Local Coverage Determination Reconsideration Process
  • Review and Appeals of Local Coverage Determinations
• 3. OVERVIEW OF THE NEW CLAIMS APPEALS PROCESS
  • Summary of the Prior Appeals Process
  • Legislative Changes to the Medicare Appeals Process
  • Levels of Administrative Appeals
  • Expedited Appeals Process
• 4. PROVIDER AND SUPPLIER APPEAL RIGHTS AND RULES FOR REPRESENTATION
  • Provider and Supplier Appeal Rights
  • Assignment of Appeal Rights
  • Rules for Representation
• 5. INITIAL DETERMINATIONS
  • The Role of the Medicare Administrative Contractor
  • Initial Determinations
• 6. POST-PAYMENT AUDITS
  • Post-Payment Review
  • Overpayment
  • Consent Settlement
  • Recovery of Overpayment
  • Interest Charges on Overpayments
  • Waiver of Recovery of Overpayment
• 7. REDETERMINATIONS
  • Rules for Filing Requests for Redetermination
  • Parties to a Redetermination
  • Procedures for Contractors
  • Withdrawals and Dismissals of Requests for Redetermination
  • Effect of Redetermination
• 8. QUALIFIED INDEPENDENT CONTRACTOR RECONSIDERATIONS
  • Rules for Submitting a Request for Reconsideration
  • Rules for Presenting Evidence
  • Rules for Medical Necessity Determinations
  • Criteria for Review
  • Rules for Reviewers
  • Rules for Issuing a Decision
  • Escalating a Case from the Qualified IndependentContractor to an Administrative Law Judge
  • Withdrawal or Dismissal of a Request for Reconsideration
  • Effect of Reconsideration
• 9. ADMINISTRATIVE LAW JUDGE APPEALS
  • Office of Medicare Hearings and Appeals
  • Administrative Law Judge Jurisdiction
  • Requirements to Establish the Right to an Administrative Law Judge Hearing
  • Requirements for Filing a Request for Hearing
  • Parties to an Administrative Law Judge Hearing
  • Dismissals and Remands
  • Disqualification of an Administrative Law Judge
  • Amount in Controversy Requirement
  • Time and Place for an Administrative Law Judge Hearing
  • Issues at an Administrative Law Judge Hearing
  • Prehearing and Posthearing Conferences
  • Criteria for Administrative Law Judge Review
  • Escalation
  • Hearing on the Record
  • Evidence Requirements
  • Hearing Procedures
  • The Administrative Law Judge Decision
• 10. MEDICARE APPEALS COUNCIL REVIEW
  • Departmental AppealsBoard
  • Cases Reviewed by the Departmental Appeals Board
  • Medicare Appeals Council Review
  • Rules for Granting or Dismissing a Request for Medicare Appeals Council Review
  • Issues Regarding Evidence
  • Escalation from the Medicare Appeals Council to Federal District Court
  • Medicare Appeals Council Review Based on Centers for Medicare & Medicaid Services Referral
  • The Medicare Appeals Council Decision
  • Court Review
  • Cases Remanded by a Federal District Court
• 11. JUDICIAL REVIEW
  • Filing a Civil Action in Federal Court
  • Federal Court Jurisdiction
  • Judicial Review of National Coverage Determinations
  • Judicial Review of Violations of the Administrative Procedures Act
  • Expedited Appeals Process
• 12. QUALITY IMPROVEMENT ORGANIZATION REVIEWS
  • Quality Improvement Organization Eligibility Requirements
  • Coordination with Contractors
  • Hospital Responsibilities Related to Quality Improvement Organization Review
  • Quality Improvement Organization Medical Reviews
  • Limitation on Liability
  • Quality Improvement Organization Initial Denial Determinations, Diagnosis Related Group Assignment Changes, and Technical Denials
  • Medicare Quality Improvement Organization Review of Diagnosis Related Group Changes
  • Claim Reconsideration Procedures
  • Administrative Law Judge Hearings
  • Departmental Appeals Board Appeals
  • Judicial Review
  • Expedited Determinations and Reconsiderations
  • Reopening of a Reconsidered Determination, an Administrative Law Judge Hearing Decision, or Medicare Appeals Council Decision
• 13. REOPENINGS
  • Reopening vs. Appeals
  • Time Frames for Reopening
  • Rules for Reopening for Fraud or Similar Fault
  • Guidelines for a Reopening Request
  • Time Frame to Complete a Reopening
  • Notice of a Revised Determination or Decision
• 14. THE RECOVERY AUDIT CONTRACTOR PROGRAM
  • The RAC Demonstration Program
  • The RAC Permanent Program
  • Appeals of RAC Determinations