Making Sense Out of the Medicare Claims Process: An excerpt from The Medicare Claims Appeals Process Handbook

The Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) undoubtedly represent the most significant legislative changes to Medicare since the programs inception in 1965, especially with respect to the claims appeals process under the original Medicare program. With these changes come, at least for some, significant advantages over the prior appeals process. For example, a process that could exceed 1,000 days under the prior system may now take less than 300 days.

These historic pieces of legislation have also added to the complexity of the structure of the Medicare claims appeals process. With the enactment of BIPA and the MMA, Congress initiated a complicated restructuring of all levels of the appeals process, and one which will inevitably create obstacles for health care professionals and advocates who seek to challenge improper denials of Medicare coverage and necessary health care items and services. Even so, successful challenges to denials of Medicare coverage are possible for those with a thorough understanding of the rules governing the Medicare appeals process. It is for this purpose that the Medicare Claims Appeals Process Handbook is written.

The Medicare Claims Appeals Process Handbook describes each level of the appeals process in detail, covering practical information such as the essential timeframes for pursuing appeals, where to send information, and how to proceed at each level of the appeal process. Throughout the chapters, exhibits and appendixes such as sample letters, forms, charts, and checklists, provide the reader with practical support throughout the process.

Excerpt from Chapter 7: Redeterminations

A request for redetermination must explain why the requesting party disagrees with the contractors initial determination. In addition, the requesting party should include any evidence that the party believes the contractor should consider in making the redetermination. A party may submit evidence after filing the request for redetermination, however, each submission will extend the contractors decision making time frame 14 calendar days.

A party does not have to include its evidence in the request for redetermination, but it should inform the contractor in writing that it plans to do so and the approximate timeframe. The letter at Exhibit 7.4 is a request for redetermination that includes a notification of future evidence submission. Providers and suppliers should consider this alternative when they have not completed gathering evidence but must submit the redetermination request to stop recoupment or avoid missing the submission deadline without good cause. If the provider or supplier does not notify the contractor of future evidence submission, the contractor could issue a decision before the party submits the evidence.

The Medicare Claims Appeals Process Handbook also includes complete coverage of: