Guide to EHR s Governmental Appeals Management. Updated: October

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Guide to EHR’s Governmental

Appeals Management

Updated: October 2012

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-Introduction to EHR’s Appeals Management Services

EHR is committed to helping your hospital respond to the increase in appeals volume associated with the Recovery Auditor (RA) program, and other Medicare and Medicaid Fee-for-Service denials. EHR Physician Advisors have extensive experience with all stages of the governmental payor appeals process and have achieved unmatched success in

identifying and obtaining the reversal of thousands of inappropriate Recovery Auditor (RA), Medicare Administrative Contractor (MAC), Medicaid Integrity Contractor (MIC), and Quality Improvement Organization (QIO) medical necessity denials at all levels of appeal. EHR's methodology combines expert physician clinical expertise, focused on medical necessity, with legal and regulatory arguments so all appeal avenues are explored.

Governmental payor medical necessity denial appeals require specialized skills and extensive experience in order to achieve optimal results. To that end, EHR utilizes teams of specially trained legal and clinical professionals with experience and an intimate knowledge of Medicare and Medicaid appeals processes. EHR appeals RA, MAC, MIC, and QIO denials based upon the evidence-based EHR LogicTM approach to medical necessity, payment rules, regulatory and

guidance underpinnings, and points of law. These four pillars of the EHR appeal are the hallmark of the EHR approach and the reason for EHR’s singular success.

EHR has vast experience managing the entire appeals process through multiple levels of appeal including preparing memoranda, if appropriate or required, and representing hospitals at Administrative Law Judge (ALJ) hearings. EHR has successfully appealed thousands of Medicare and Medicaid-related government Intermediary denials.

A critical component in the appeals process is timely and complete submission of all appropriate data and documentation associated with the denial. The purpose of this guide is to consolidate the process, forms, and

instructions you will need to submit appropriate appeal information to EHR. This guide provides information about the data you will need to submit for each denial, the methods you can select to send that information to EHR, points of contact at EHR, and additional information about what to expect throughout the appeals process.

If you have questions regarding EHR’s appeals management services, please do not hesitate to contact your EHR Director of Strategic Accounts.

We look forward to a continued successful denials and appeals management partnership with you!

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-Key Success Factors in the Appeals Process

1. When to Send an Appeal

To ensure appropriate appeals preparation time, all denials information should be submitted to EHR as soon as all of the required information is available but with a minimum of 15 calendar days prior to either an appeal due date or a recoup due date if stopping recoupment is desired.

2. Things You Can Do to Improve the Likelihood of Success

• Send all requested data. It may seem like a lot of information, but the materials we include on our checklist are the same data we need to make the best appeal on your behalf.

• Complete the EHR Denial Cover Form. The information in this form allows EHR to quickly assess the denial and prepare your appeal. In the case of an electronic submission through EHR Integrated, the Denial Cover Form is not necessary. If you wish for EHR to participate in the Discussion period, then the EHR denial cover is required.

• Send any responses you receive within three (3) business days of receipt. In order to keep the appeal process moving as quickly as possible, send appeal responses or any other correspondence from your payors immediately. If you receive this information, please assume that EHR did not receive it and we

cannot preserve your rights to the next level of appeal without it. 3. A Few Items of Significance

• AOR (Appointment of Representation) – EHR cannot submit an appeal on behalf of your hospital/ provider without a completed AOR form. This form can be stamped/electronically signed and has to be dated. The date should reflect the date that you are submitting the case to EHR for appeal.

• EHR Denial Cover Form (or completed EHR IntegratedTM submission outside of Discussion) – The Denial

Cover Form contains a checklist of required documents and also summarizes key information that allows EHR to expedite assignment of the appeal. Although a combination of documents you provide may contain the information, it is often difficult to locate and will help you make a complete submission each time.

• Dates on Forms – EHR cannot use a Denial Cover Form or AOR Form that has been dated longer than 30 days prior to the date of your case submission. Please make every effort to sign the date on the form and submit to EHR on that same day.

• Complete Correspondence – Each document sent by your payor is significant to our review of the denial and submission of your appeal. Do not assume that the payor provided the same letters, requests, or information to EHR.

• Timing – In order to preserve the full extent of your rights on appeal, it is essential to conduct each appeal action within the prescribed timelines. The best way to assure we meet deadlines is to send complete case information as soon as possible.

• Personnel Changes – Please notify EHR of any personnel changes as soon as possible so we can update our notifications and reports recipient distribution lists.

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-Process for Submitting a Medicare Fee-for-Service Denial to EHR

1. Prepare the copies of the following materials for each denial for submission to EHR:

EHR Denial Cover Form (access form in EHR’s Compliance Library at www.ehrdocs.com/library)  Signed AOR Form can be stamped/electronically signed (access form in EHR’s Compliance Library at

www.ehrdocs.com/library)  Entire medical record

Copies of all written correspondence sent to or received from payor regarding the case  Applicable Denial Information:

o Denial Letter – at a minimum is needed for QIO, Medicaid, Commercial Payor, and Managed

Medicare/Medicaid Denials

o Remittance Advice or FISS Screens MAP 1714 and MAP 1741 – required for RA (if no Demand is issued),

Pre-Pay FI/MAC Denials and all PIP Providers

o Demand Letter and Review Results Letter – required for RA, Post-Pay FI/MAC, or ZPIC/PSC Denials. If no

Demand provided, please provide Post-RA Remittance Advice.

Be advised that should you (the provider) opt to send only the post-audit Remit Advice for your overpayment claim (and not the Demand Letter), we cannot guarantee the Medicare Appeals Contractor (MAC) will accept the appeal as valid. The MAC may dismiss the appeal as incomplete due to lack of Demand Letter, which ultimately may negatively impact your overall appeal timeliness.

Note on Recoupment:

EHR will not appeal within the appropriate timeframes to automatically stop recoupment or request that the CMS contractor stop recoupment unless specifically requested to do so by the hospital on the EHR Denial Cover Form. There is a significant financial impact surrounding the decision to stop recoupment, and the decision must be made by the hospital.

Note on Redacting of Documents to Preserve Patient Confidentiality (including RA/Audit Pull Lists):

EHR prefers to not receive RA/Audit Pull Lists from hospital clients as the information on those lists is contained elsewhere in your submission to EHR. However, if the hospital supplies a Pull List or any other documentation that contains information for more than just the patient for whom you are appealing, as a part of the denial information, EHR requires that the hospital black out or delete patient names, HIC numbers, dates of birth and any other

identifiable information for all patients in that documentation other than that of the specific patient that is the subject of the appeal as each individual appeal record can only contain information for that particular patient. This will help the hospital and EHR ensure compliance with the requirements that Protected Health Information only be disclosed to authorized parties. The redacting also applies to those hospitals submitting cases through EHR

Integrated.

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-Process for Submitting a Medicare Fee-for-Service Denial to EHR Cont’d

2. Submit all of the above materials to EHR via one of the following methods:

EHR Exchange

Submit your appeal request, including required data and documentation, via the EHR Exchange. Through EHR’s online portal, client hospitals can submit cases securely for all retrospective appeals. The online portal also provides real-time status of all of your open cases. If you’d like to use the portal for referring appeals cases, please contact your Director of Strategic Accounts.

EHR Integrated

Submit your appeal request, including required data and documentation via a certified EHR Integrated partner’s solution. View a list of certified solutions on EHR’s website at www.ehrdocs.com.

EHR Enhanced File Transfer

Enhanced File Transfer (EFT) allows the hospital to submit appeal files via two secure methods: Secure File Transfer Protocol (SFTP) and Web-based Electronic Transfer using Hyper Text Transfer Protocol Secure (HTTPS). EFT ensures the highest levels of compliance with data security allowing for fast secure, simple and reliable transfer of files. Both methods meet HIPAA and HITECH security requirements. If interested in this option, please contact your Director of Strategic Accounts with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, email, and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure email to ensure the strictest security and compliance with HIPAA regulations.

Release Of Information (ROI) Vendor Portal

Submit required documentation to EHR for appeal via the hospital’s ROI vendor. EHR has established relationships with some ROI vendors. If interested in this option, please contact your Director of Strategic Accounts to determine if EHR is currently working with your ROI vendor.

Mail/Carrier (UPS, FedEx, etc.)

Mail all required documentation to EHR using any postal service. EHR will accept hard copy documents or CD/DVD with all required documentation for an appeal. If you are sending multiple patients please include a packing list. Hospitals are encouraged to use a carrier that allows for tracking of delivery. Please send to:

Executive Health Resources® 1351 N. Belcrest, Suite 100

Springfield, MO 65802

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-If planning to provide documentation on CD/DVD, please follow these guidelines: 1. The name of the facility must be written on the front of the CD.

2. All documents should be in PDF format.

3. The medical record must be in one, combined PDF document and all other documents saved as individual PDFs.

4. DO NOT secure or password-protect the individual PDF documents and/or files on the disc.

5. DO password protect access to the entire CD/DVD and email instructions for how to unlock the CD to

DCG@ehrdocs.com.

6. If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD.

7. Multiple medical records can be placed in one CD/DVD.

3. Following receipt of the denial, EHR will begin its appeals management process. Throughout the active appeals process, if an appeal response is mistakenly sent to the hospital instead of EHR, the response should be immediately sent to the attention of EHR Government Appeals and Regulatory Affairs via fax or email:

For Medicare denials Fax to (610) 557-4729 - OR -

Email to AppealSupport@ehrdocs.com

Please add “Medicare Appeals Documents” in the subject line of your email

Note on Destruction of Patient Records:

EHR does not destroy electronic records unless they are duplicative or incorrectly sent. All case-related data is kept indefinitely, with sustained indefinite access control. No unnecessary data are captured; therefore no extraneous data need be destroyed. Hard copy medical records are stored in a secure location until the first level of appeal is submitted or 3 months, whichever is first. The documents are then shredded.

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-Overview of EHR’s Medicare Appeals Management Process

Once a case is referred to EHR for appeal management, EHR will:

1. Review all of the documentation submitted for each denial. If the case is missing key elements required for appeal submission, the client will be notified via email. At the end of each week, EHR will also send a report of submitted cases from the prior week.

2. Create an appeal letter which addresses medical necessity and/or coding as appropriate, CMS requirements regarding inpatient hospital admissions, coding guidance, any applicable regulation and guidance, applicable evidence-based data and expert guidance, and any other pertinent information.

3. Send the appeal letter to the appropriate payor, state or Federal agency or contractor by traceable means. All letters are sent to meet the designated deadlines.

4. Upon receipt, review and forward the appeals results letter to the hospital.

o If the hospital receives an appeal results letter, it should be sent to EHR as soon as possible so that EHR can update our records.

5. Proceed to next level of appeal, if appeal was not successful at prior level.

Note on the Redetermination Level of Appeal Outcome:

If the decision is favorable at the Redetermination level of appeal, EHR will not receive notification from the MAC. The hospital will receive the favorable result through a paid remittance advice. The hospital should immediately forward a copy of the paid remittance to EHR.

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-6. Prepare memoranda, if appropriate or required, and represent the hospital client at any level of appeal that requires an external or judicial hearing.

7. Prepare and send the hospital client:

 Notifications when action was taken by EHR and/or is required by the hospital client  Electronic copies of all completed letters of appeal and appeal response letters  Final Determination Notice and Case Received reports on weekly basis

Note on Timing and Appeals Status:

In EHR’s experience, the timeframe for an appeal that goes full-term can exceed 24 months. The status of the appeal may not change for months while each appeal agency reviews the appeal.

Note on Administrative Law Judge Appeal and Departmental Appeals Board Levels:

EHR will notify the hospital before moving on to the Administrative Law Judge (ALJ) level of appeal and provide 14 calendar days for the hospital to consult with EHR and/or opt out of this appeal level. Conversely, EHR will notify the hospital of the Administrative Law Judge decision and provide 14 calendar days for the hospital to consult with EHR and opt in to the Department of Appeals Board (DAB) level of appeal.

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-EHR Key Contacts

Email:

AppealSupport@ehrdocs.com

If you are sending cases (hard copy documents or CD) by Mail/Carrier (UPS, FedEx, etc.),

please send to the following address:

Executive Health Resources®

1351 N. Belcrest, Suite 100

Springfield, MO 65802

About EHR’s Appeals Management Client Services

The Appeals Management Client Services department is the first point of contact for any client questions or concerns regarding retrospective appeals. The team provides a designated resource for clients and EHR associates with questions regarding specific appeals or the EHR appeals process. Client Management Specialists are specially trained to answer process questions, check on the status of a retrospective appeal, and quickly refer complex questions to the Appeal Management Liaisons. Appeal Management Liaisons work directly with clients to proactively identify and address any questions regarding the retrospective appeal process andprovide ongoing education in respect to the appeals process.

EHR Appeals Management Client Services

15 Campus Boulevard

Newtown Square, PA 19073

Toll-free: (866) 873-5029

Fax: (610) 557-4729

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-Process for Submitting a Medicaid Fee-for-Service Denial to EHR

1. Prepare the copies of the following materials for each denial for submission to EHR:

 EHR Denial Cover Form (access form in EHR’s Compliance Library at www.ehrdocs.com/library)  Signed AOR Form can be stamped/electronically signed (access form in EHR’s Compliance Library at

www.ehrdocs.com/library

 Entire medical record

Copies of all written correspondence sent to or received from payor regarding the case  Applicable Denial Information:

o Denial Letter – required for QIO, Medicaid, Commercial Payor, and Managed Medicare/Medicaid denials

Note on Redacting of Documents to Preserve Patient Confidentiality (including RA/Audit Pull Lists):

EHR prefers to not receive RA/Audit Pull Lists from hospital clients as the information on those lists is contained elsewhere in your submission to EHR. However, if the hospital supplies a Pull List or any other documentation that contains information for more than just the patient for whom you are appealing, as a part of the denial information, EHR requires that the hospital black out or delete patient names, HIC numbers, dates of birth and any other

identifiable information for all patients in that documentation other than that of the specific patient that is the subject of the appeal as each individual appeal record can only contain information for that particular patient. This will help the hospital and EHR ensure compliance with the requirements that Protected Health Information only be disclosed to authorized parties. The redacting also applies to those hospitals submitting cases through EHR

Integrated.

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-Process for Submitting a Medicaid Fee-for-Service Denial to EHR Cont’d

2. Submit all of the above materials to EHR via one of the following methods:

EHR Exchange

Submit your appeal request, including required data and documentation through the EHR Exchange. Through EHR’s online portal, client hospitals can submit cases securely for all retrospective appeals. The online portal also provides real-time status of all of your open cases. If you’d like to use the portal for referring appeals cases, please contact your Director of Strategic Accounts.

EHR Integrated

Submit your appeal request, including required data and documentation via a certified EHR Integrated partner’s solution. View a list of certified solutions on EHR’s website at www.ehrdocs.com.

EHR Enhanced File Transfer

Enhanced File Transfer (EFT) allows the hospital to submit appeal files via two secure methods: Secure File Transfer Protocol (SFTP) and Web-based Electronic Transfer using Hyper Text Transfer Protocol Secure (HTTPS). EFT ensures the highest levels of compliance with data security allowing for fast secure, simple and reliable transfer of files. Both methods meet HIPAA and HITECH security requirements. If interested in this option, please contact your Director of Strategic Accounts with the following information: contact information of the IT person handling this on behalf of the hospital/hospital system (including name, email, and telephone number). The connection details, usernames, and passwords will be sent directly to the IT contacts provided via a secure email to ensure the strictest security and compliance with HIPAA regulations.

Release Of Information (ROI) Vendor Portal

Submit required documentation to EHR for appeal via the hospital’s ROI vendor. EHR has established relationships with some ROI vendors. If interested in this option, please contact your Director of Strategic Accounts to determine if EHR is currently working with your ROI vendor.

Mail/Carrier (UPS, FedEx, etc.)

Mail all required documentation to EHR using any postal service. EHR will accept hard copy documents or CD/DVD with all required documentation for an appeal. If you are sending multiple patients please include a packing list. Hospitals are encouraged to use a carrier that allows for tracking of delivery. Please send to:

Executive Health Resources® 1351 N. Belcrest, Suite 100

Springfield, MO 65802

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-If planning to provide documentation on CD/DVD, please follow these guidelines: 1. The name of the facility must be written on the front of the CD.

2. All documents should be in PDF format.

3. The medical record must be in one PDF document and all other documents in separate PDFs. 4. DO NOT secure or password-protect the individual PDF documents and/or files on the disc.

5. DO password protect access to the entire CD/DVD and email instructions for how to unlock the CD to

DCG@ehrdocs.com.

6. If sending multiple denials, please include a packing list which includes a listing of all cases included on the CD.

7. Multiple medical records can be placed in one CD/DVD.

3. Following receipt of the denial, EHR will begin its appeals management process. Throughout the active appeals process, if an appeal response is mistakenly sent to the hospital instead of EHR, the response should be immediately sent to the attention of EHR Government Appeals and Regulatory Affairs via fax or email:

For Medicaid denials Fax to (610) 557-4733 - OR -

Email to AppealSupport@ehrdocs.com

Please add “Medicaid Appeals Documents” in the subject line of your email

Note on Medicaid Appeals:

States have demonstrated significant variability in managing appeals. This includes different documentation requirements, appeal timelines, appeal levels available, and responsiveness. The EHR team will work directly with the hospital to obtain any addition information necessary to successfully file each Medicaid appeal.

Note on Destruction of Patient Records:

EHR does not destroy electronic records unless they are duplicative or incorrectly sent. All case-related data is kept indefinitely, with sustained indefinite access control. No unnecessary data are captured; therefore no extraneous data need be destroyed. Hard copy medical records and other appeal related documents are stored in a secure location until the first level of appeal is submitted or 6 months, whichever is first. The documents are then shredded.

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-Overview of EHR’s Medicaid Appeals Management Process

Once a case is referred to EHR for appeal management, EHR will:

1. Review all of the documentation submitted for each denial. If the case is missing key elements required for appeal submission, the client will be notified via email. At the end of each week, EHR will also send a report of submitted cases from the prior week.

2. Create an appeal letter which addresses medical necessity and/or coding as appropriate, CMS requirements regarding inpatient hospital admissions, coding guidance, any applicable regulation and guidance, applicable evidence-based data and expert guidance, and any other pertinent information.

3. Send the appeal letter to the appropriate payor, state or Federal agency or contractor by traceable means. All letters are sent to meet the designated deadlines.

4. Email the appeal result or payor response letter to the hospital when received by EHR. If the hospital receives an appeal results letter, it should be sent to EHR as soon as possible so that EHR can update our records.

5. Proceed to next level of appeal, if appeal was not successful at prior level.

6. Prepare memoranda, if appropriate or required, and represent the hospital client at any level of appeal that requires an external or judicial hearing.

7. Prepare and send the hospital client:

 Notifications when action was taken by EHR and/or is required by the hospital client  Electronic copies of all completed letters of appeal and appeal response letters  Appeals status reports weekly and monthly

Note on Timing and Appeals Status:

The timeframe for an appeal that goes full-term can be lengthy. The status of the appeal may not change for months while each appeal agency reviews the appeal.

Note on Administrative Law Judge and Other Hearing Level Appeal:

EHR will notify the hospital before moving on to the Administrative Law Judge (ALJ) and other Hearing levels of appeal and provide 14 calendar days for the hospital to consult EHR or opt in to this appeal level.

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-EHR Key Contacts

EHR Appeals Management Client Services

15 Campus Boulevard

Newtown Square, PA 19073

Toll-free: (866) 873-5029

Fax: (610) 557-4733

Email: AppealSupport@ehrdocs.com

If you are sending cases (hard copy documents or CD) by Mail/Carrier (UPS, FedEx, etc.),

please send to the following address:

Executive Health Resources®

1351 N. Belcrest, Suite 100

Springfield, MO 65802

About EHR’s Appeals Management Client Services

The Appeals Management Client Services department is the first point of contact for any client questions or concerns regarding retrospective appeals. The team provides a designated resource for clients and EHR associates with questions regarding specific appeals or the EHR appeals process. Client Management Specialists are specially trained to answer process questions, check on the status of a retrospective appeal, and quickly refer complex questions to the Appeal Management Liaisons. Appeal Management Liaisons work directly with clients to proactively identify and address any questions regarding the retrospective appeal process andprovide ongoing education in respect to the appeals process.

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-Helpful Definitions

Levels of Appeal

Redetermination

The first level of the Medicare appeals process is handled by the Medicare Administrative Contractor (MAC), the entity responsible for processing the Medicare claim. In some jurisdictions, this entity is still called a Fiscal Intermediary (FI). The MAC has 60 days to render a decision from the date they receive the Redetermination request. If an appeal is upheld at this level, the hospital has the right to request a Reconsideration within 180 days of receipt of the decision, unless they want to prevent recoupment (the take-back of money).

Reconsideration

This is the second level of the Medicare appeals process handled by the Qualified Independent Contractor (QIC)(currently MAXIMUS Federal Services). The QIC has 60 days to render a decision from the date they receive the Reconsideration request. If an appeal is upheld at this level, the hospital has the right to request a hearing with an Administrative Law Judge (ALJ) within 60 days of receipt of the decision.

Administrative Law Judge (ALJ)

This is the third level of the Medicare appeals process and can involve a hearing. It is the first opportunity for the hospital to actually speak with a person that will render a decision as to whether the claim should be paid, unless the judge decides in the hospital’s favor without the need for a hearing. The ALJ usually takes more than 90 days to render a decision. There is no opportunity to prevent recoupment at the ALJ level.

Departmental Appeals Board (DAB)

This is the fourth level of the Medicare appeals process and involves a review of the documents from the prior appeal levels. There is generally no opportunity for a hearing. This level of appeal allows clients to appeal an administrative law judge’s decision – that the judge applied the wrong guidelines, regulations or laws, failed to apply the correct guidelines, regulations or laws, or improperly applied the correct guidelines, regulations or laws.

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-Helpful Definitions Cont’d

Appointment of Representation (AOR)

This form is required by the Centers for Medicare and Medicaid Services (CMS) to allow EHR to represent the hospital in the appeals process. It is partially completed by the hospital and then

submitted to EHR for completion. It is submitted with each appeal request.

Demand Letter

The letter the hospital receives from the MAC requesting

repayment based upon the findings of the Review Results Letter. This document triggers the formal appeals process. The hospital has to file an appeal within 120 days of receipt of the decision, unless they want to prevent recoupment (the take-back of money), which requires filing of the appeal within 30 days of the receipt of the decision.

Discussion Period

This period is triggered by the hospital’s receipt of the Review Results Letter. It is an opportunity for the hospital to ask the RA to review the case and perhaps have a discussion with the RA Medical Director, but is not part of the formal appeals process. If you would like EHR to engage in Discussion on your hospital’s behalf, you will need to state this on the EHR Denial Cover Form. If you decide not to engage in Discussion, you can still appeal once you receive a Demand Letter or post-audit remit advice. In this case, please send the appeal to EHR after you have received the Demand Letter.

EHR Denial Cover Form

This form is completed by the hospital and submitted along with the entire appeal file from the hospital. It sets forth what services the hospital is requesting that EHR perform and serves as a checklist of documents and information that should be submitted.

Fiscal Intermediary Shared System (FISS) This is a database of claims and beneficiary information used by the Medicare Administrative Contractors.

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-Medicare Administrative Contractor (MAC)

Formerly known as the Fiscal Intermediary, this is the entity under contract with CMS to process claims, reopen and revise paid claims based upon data analysis and medical review, and determine whether payment was proper. They are the first level of appeal, or Redetermination.

Office of Medicare Hearings and Appeals (OMHA)

This is a division under the Department of the Health and Human Services that is responsible for overseeing the Administrative Law Judges (ALJ) and the third level of appeal.

Qualified Independent Contractor (QIC) This is the entity under contract with CMS to process the second level of appeal, or Reconsideration.

Quality Improvement Organization (QIO)

This is the entity under contract with CMS to review claims for quality issues relating to care and medical necessity. They review claims based upon data analysis and medical review, and determine whether payment was/is proper.

Recoupment

The recovery by CMS of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the amount due. It does not include the hospital sending a check to CMS – that is considered a voluntary payment.

Recovery Auditor (RA)

This is the entity under contract with CMS to reopen and revise paid claims based upon data analysis and medical review, and determine whether payment was proper. If they find that initial payment was not proper, they either seek repayment (through the MAC) in the case of an overpayment determination, or they refund monies (also through the MAC) in those cases where they determine an

underpayment.

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-Remittance Advice

This is an electronic form that the hospitals obtain from CMS as a result of submitting a claim for payment. Pertinent information about the claim is found on this form, including all beneficiary information, claim payment status, denial information, and appeal rights.

Review Results Letter

The letter the hospital receives from the RA advising them of the findings of their review, but does not request repayment. This document triggers the Discussion Period (not part of the formal appeals process).

Teleconference Notification A notification of a peer-to-peer review or a hearing by teleconference to review payment on an admission.

Zone Program Integrity Contractor (ZPIC)

Also known as Program Safeguard Contractors

These entities are under contract with CMS to process referrals of fraud and abuse from the MAC or other contractor.

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-EHR Denial Cover Form/Page 1

EHR Appeals Denial Cover Form

Please complete all applicable fields below for each denial that is being referred to EHR.

Fields in the green shaded area along with the necessary documentation (see Document Submission Checklist on page 2) are required to initiate the EHR appeal

process.

Patient and Hospital Information

REQUIRED INFORMATION

Patient Name: _______________________________

Facility Number (EHR Assigned): _________________________ Admit and Discharge Dates: _______________________________ How was this billed? IP OBS OP

Was EHR Physician recommendation followed? Yes No Not Concurrently Reviewed

If concurrently reviewed, what was the EHR recommendation?

IP OBS OP Other __________________________

Type of Denial:

RA ___ Medicare ___A/B Re-Billing ___ Pre-Payment Rev. FI/MAC QIO ZPIC/PSC Medicaid

Managed Medicare Managed Medicaid Commercial

Recoupment:

Do you want to prevent recoupment on this case?: Yes No (Medicare and Medicaid Fee-for-Service Only)

Do you want EHR to engage the RA with the Discussion Period?: Yes No

Are you a Periodic Interim Payment (PIP) Provider?: Yes No (If yes, please make sure to include the RA showing denial)

For cases where the Denial is received verbally: Denial Issue Date: ____________

Date of Appeal Deadline: ____________

FOR COMMERCIAL DENIALS ONLY Payor/Contractor Name:

_______________________________________________ Appeals Address Line 1: _______________________________ Appeals Address Line 2: _______________________________ Appeals City, State, Zip: _______________________________

Hospital Name: _____________________________________ Health System Name: _______________________________ Hospital Address Line 1: _______________________________ Hospital Address Line 2: _______________________________ Hospital City, State, Zip: _______________________________

Select One Select All That Apply For Rehab Denials Adult NCD/LCD Pre-Admission Screening Ped Psych LTAC Post Admission Physician Evaluation IRF- Patient Assessment Instrument Individualized Comprehensive Plan of Care Insurance Policy Number/Member ID: ______________

Billing Account Number: _______________________________ Claim Number: _______________________________ Amount Billed: $ _______________________________

Amount Paid: $ _______________________________ Amount Denied $ ______________________________

Level of Care Details

REQUIRED FOR MEDICAID FEE FOR SERVICE AND COMMERCIAL DENIALS

List Dates Denied/Downgraded and Level of Care by Payor:

DRG/Case Rates Apply? Yes No Unknown DRG Code: _______________________________

Please indicate the type of Denial you would like EHR to perform on your behalf: Medical Necessity Coding/DRG Validation

Please provide any additional details that would be helpful to EHR:

Sample

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-EHR Denial Cover Form/Page 2

Document Submission Checklist

EHR Denial Cover Form

Entire Medical Record Signed AOR Form

Copies of all written correspondence sent to or received from the federal or state agency, commercial payor or contractor Denial Information—see bolded language for specific requirements

Denial Information should include:

Denial Letter-at a minimum is needed for QIO, Medicaid, Commercial, and Managed Medicare/Medicaid Denials

Remittance Advice or FISS Screens MAP 1714 and MAP 1741-required for RAC (if no Demand is issued), Pre-Pay FI/MAC Denials and PIP

Providers

Demand Letter recommended for RA, Post-Pay FI/MAC, or ZPIC/PSC Denials. If no Demand provided, please provide Post-RA

Remittance Advice

Review Results Letter required for Discussion

Be advised that should you (the provider) opt to send only the post-audit Remit Advice for your overpayment claim (and not the Demand Letter), we cannot guarantee the Medicare Appeals Contractor (MAC) will accept the appeal as valid. The MAC may dismiss the appeal as incomplete due to lack of Demand Letter, which ultimately may negatively impact your overall appeal timeliness.

Sample

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-EHR Denial Cover Form/Page 1

EHR Appeals Denial Cover Form Tutorial

Patient and Hospital Information

REQUIRED INFORMATION

Patient Name: _______________________________

Admit and Discharge Dates: _______________________________ How was this billed? IP OBS OP

Was EHR Physician recommendation followed? Yes No Not Concurrently Reviewed

If concurrently reviewed, what was the EHR recommendation?

IP OBS OP Other __________________________

Type of Denial:

RA ___ Medicare ___A/B Re-Billing ___ Pre-Payment Rev. FI/MAC QIO ZPIC/PSC Medicaid

Managed Medicare Managed Medicaid Commercial

Recoupment:

Do you want to prevent recoupment on this case?: Yes No (Medicare and Medicaid Fee-for-Service Only)

Do you want EHR to engage the RAC with the Discussion Period?: Yes No

Are you a Periodic Interim Payment (PIP) Provider?: Yes No (If yes, please make sure to include the RA showing denial)

For cases where the Denial is received verbally: Denial Issue Date: ____________

Date of Appeal Deadline: ____________

FOR COMMERCIAL DENIALS ONLY Payor/Contractor Name:

_______________________________________________ Appeals Address Line 1: _______________________________ Appeals Address Line 2: _______________________________ Appeals City, State, Zip: _______________________________

Facility Number (EHR Assigned): _________________________

Hospital Name: _____________________________________ Health System Name: _______________________________ Hospital Address Line 1: _______________________________ Hospital Address Line 2: _______________________________ Hospital City, State, Zip: _______________________________

Select One Select All That Apply For Rehab Denials Adult NCD/LCD Pre-Admission Screening Ped Psych LTAC Post Admission Physician Evaluation IRF- Patient Assessment Instrument Individualized Comprehensive Plan of Care Insurance Policy Number/Member ID: ______________

Billing Account Number: _______________________________ Claim Number: _______________________________ Amount Billed: $ _______________________________

Amount Paid: $ _______________________________ Amount Denied $ ______________________________

Level of Care Details

REQUIRED FOR MEDICAID FEE FOR SERVICE AND COMMERCIAL DENIALS

List Dates Denied/Downgraded and Level of Care by Payor:

DRG/Case Rates Apply? Yes No Unknown DRG Code: _______________________________

Please indicate the type of Denial you would like EHR to perform on your behalf: Medical Necessity Coding/DRG Validation

Please provide any additional details that would be helpful to EHR:

DISCUSSION

Please be advised the Discussion is not peer to peer but written form.

RECOUPMENT

EHR does not automatically prevent recoupment. This is a decision for the client

REQUIRED INFORMATION FOR APPEALS

The information highlighted in green is necessary to move forward in the appeals process. If it is not, you will receive an incomplete notification from EHR and the appeal does not move forward.

Level of Care Details

This information is required for Medicaid and

Commercial Denials

COMMERCIAL DENIALS

This information is required for commercial payors only including Managed Medicare and Medicaid

OPTIONAL INFORMATION

While information in this section is not required when submitting an appeal, it will allow EHR to provide its client hospitals more detailed reports and analytics on the effectiveness of your retrospective appeal program

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-EHR Denial Cover Form/Page 2

Document Submission Checklist

EHR Denial Cover Form

Entire Medical Record Signed AOR Form

Copies of all written correspondence sent to or received from the federal or state agency, commercial payor or contractor Denial Information—see bolded language for specific requirements

Denial Information should include:

• Denial Letter-at a minimum is needed for QIO, Medicaid, Commercial, and Managed Medicare/Medicaid Denials

• Remittance Advice or FISS Screens MAP 1714 and MAP 1741-required for RAC (if no Demand is issued), Pre-Pay FI/MAC Denials and PIP

Providers

• Demand Letter recommended for RA, Post-Pay FI/MAC, or ZPIC/PSC Denials. If no Demand provided, please provide Post-RA

Remittance Advice

• Review Results Letter required for Discussion

Be advised that should you (the provider) opt to send only the post-audit Remit Advice for your overpayment claim (and not the Demand Letter), we cannot guarantee the Medicare Appeals Contractor (MAC) will accept the appeal as valid. The MAC may dismiss the appeal as incomplete due to lack of Demand Letter, which ultimately may negatively impact your overall appeal timeliness.

DOCUMENT SUBMISSION CHECKLIST

Along with the EHR Denial Cover Form, please make sure all required documents are provided to EHR’s Appeals Support Team. Any missing documents will result in an incomplete notification and no action will take place until all information is received.

If you need assistance, please contact the EHR Appeals Support Team at 866-873-5029.

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-Medicare Appointment of Representation

Executive Health Resources, Inc. MedicareApptRep0412SAG

I do hereby swear that I am the above-mentioned provider or have the legal authority to

appoint a representative to act on behalf of the above-mentioned provider. Accordingly, I do

hereby appoint Godffery Tang, MD, of Executive Health Resources, Inc. to act as our

Representative regarding the appeal of a service for which Medicare has denied/reduced

payment or authorization. Dr. Tang has accepted this appointment as a Representative,

evidence of which can be found in the appeal request on the

Medicare Acceptance of Appointment of Representation page.

I understand that Dr. Tang may be delegating his appointment to one or more Designees

and I consent to that delegation.

Beneficiary Name

Claim Number/Appeal Number

Provider (Appellant) Name

Provider Address

Provider Signature

Date

HIC Number

Dates of Service

Provider Phone

Provider Number

Printed Name

23

-Name of Patient

Medicare Identification Number

DCN/CCN/Claim Key (QIO)

Admission Date Through Discharge Date

Name of Facility

Phone Number of Facility

Facility Address

PTAN (Provider Transaction Account Number)

Signature & Date

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Medicaid Appointment of Representation

Executive Health Resources, Inc. MedicaidApptRep0412SAG

I do hereby swear that I am the above-mentioned provider or have the legal authority to

appoint a representative to act on behalf of the above-mentioned provider. Accordingly, I do

hereby appoint Godffery Tang, MD, of Executive Health Resources, Inc. to act as our

Representative regarding the appeal of a service for which Medicaid has denied/reduced

payment or authorization. Dr. Tang has accepted this appointment as a Representative,

evidence of which can be found in the appeal request on the

Medicaid Acceptance of Appointment of Representation page.

I understand that Dr. Tang may be delegating his appointment to one or more Designees

and I consent to that delegation.

Beneficiary Name

Claim Number/Appeal Number

Provider (Appellant) Name

Provider Address

Provider Number

Provider Signature

Date

Medicaid Identification Number

Dates of Service

Provider Phone

Medicaid Contractor

Printed Name

24

-Name of Patient

Patient's Medicaid ID Number

DCN/CCN/Claim Key (QIO)

Admission Date Through Discharge Date

Name of Facility

Phone Number of Facility

Facility Address

Medicaid Contractor Denying Case

PTAN (Provider Transaction Account Number

Signature & Date

Figure

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