How to Submit Successful Appeals, or Reopenings - Appeals Newsletter Part 1

Reopening Process - Simple clerical error corrections

Do not submit a new claim to fix the error.

Utilize the Noridian Medicare Portal when a reopening is appropriate for faster results. A correction can be done instantly, whereas a paper appeal can take 60 days.

  • Routine Denials - Do you need to change your diagnosis, or point to the correct diagnosis?
  • Bundling Denials - Do you need to add a modifier?

Redetermination Process

Determine if you need to appeal to get paid.

Submit a valid and complete appeal

  • Make sure you use the Redetermination form, not the Reopening form
  • Complete the “Action Request and Comments (paper), or Details and Explanation” on the portal form, with what, or why you are appealing
  • Clear reason for the appeal not provided
    • Documentation to support your appeal
  • Wrong form being submitted
  • Does primary diagnosis follow the NCD/LCD for medical necessity
    • Verify your diagnosis pointer in Box 24E, or the electronic equivalent, refers to the correct primary diagnosis code in Box 21

How can the provider help?

  • Make sure you are aware of what, and how many, your billing service is appealing
    • Excess appeals mean excess costs to you
  • Make sure you are not submitting appeals for multiple procedure reductions or reductions for mid-level providers (Nurse Practitioner or Physician Assistant). 
  • Understand reductions for non-participating versus participating Medicare providers
  • Confirm your place of service on the claim is correct
  • Verify your diagnosis pointer in Box 24E, or the electronic equivalent, refers to the correct primary diagnosis code in Box 21
    • Review NCD/LCD for medically necessary diagnosis codes

Forms

CMS MCD Search

42 CFR 410.75 Chapter-IV Subchapter-B Part-424 Subpart-D Ssection-424.55

 

Last Updated Jan 04 , 2023