Article Detail - JE Part A

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.

• Is it paid correctly? Review your remittance advice before appealing
  • CMS Internet Only Manual (IOM) Pub 100-04 Chapter 12 Medicare Claims Processing Manual
  • CMS Internet Only Manual Pub 100-04 Chap 5 page 34 - 2022 Multiple Procedure Payment Reduction for Selected Therapy Services
  • CMS Therapy Services
• Are there any MSP issues involved? Utilize the MSP website to send to the correct team
• Are you replying to an Additional Documentation Request (ADR)
  • Where does the letter state to send documentation?

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
• Check to see if your issue is something that can be done through reopenings
• 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