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Tag Archives: Appeal

First level appeal for Medicare

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We have a patient with Jr after his name. (e.g. John Smith Jr).

Our billing system would not recognize eligiblity if it is entered as John Smith Jr. but it would read it if it’s typed as John SmithJr.

However, our claims for 2018 keep on being denied by Palmetto GBA (TN MAC) as invalid, and if we rebilled it, it denies as duplicate (even if we have zero payments due to denials).

We have tried every permutation available for the name trying to get it to go through the computer systems.

Is it appropriate the go online for the first level appeal?

Thanks!

Medical Billing and Coding Forum

‘Qualifying’ Appeal

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I am at a relatively new practice in Los Angeles, CA, and I am currently in charge of all billing and collections. For some insurances, we are getting letters saying that what we are sending does not ‘qualify’ as an appeal…….what? I’ve never heard this. Also, some insurances are just plain denying our ‘appeals’ (in quotes since they are not appeals, apparently) point blank, and we have no where to go. Has anyone worked with this before and how do I go about fixing it?

Medical Billing and Coding Forum

TFL for Each Level of Appeal

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The time limits for filing appeals vary according to the type of appeal:

Redetermination – The time limit for filing a request for redetermination is 120 days from the date of receipt of the Medicare Summary Notice (MSN) or Remittance Advice (RA). 

QIC Reconsideration – The time limit for filing a request for reconsideration is 180 days from the date of receipt of the notice of the redetermination. If a party requests QIC review of a MAC’s dismissal of a request for redetermination, the time limit for filing is 60 days from the date of receipt of the MAC’s dismissal notice.

ALJ Hearing – The time limit for filing a request for an ALJ hearing is 60 days from the date of receipt of the reconsideration notice.

Appeals Council Review – The time limit for filing a request for review by the Appeals Council is 60 days from the date of receipt of the ALJ’s decision.

Judicial Review – The time limit for filing for judicial review is 60 days from the date of the Appeals Council’s decision.

When the filing deadline for a redetermination ends on a Saturday, Sunday, legal holiday, or any other nonwork day, the MAC shall apply a rollover period that extends the filing deadline to the first working day after the Saturday, Sunday, legal holiday, or other nonwork day. For example, if the filing deadline for a redetermination falls on the Saturday before Columbus Day, the filing deadline is extended to the first working day after the Columbus Day holiday.

These time limits may be extended if ‘GOOD CAUSE‘ for late filing is shown.


Coding Ahead

Confidently Appeal a Special Investigation Unit Refund Request

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Communication is essential to a smooth appeals process. Your practice was the subject of a special investigation unit (SIU) audit, and now the payer is asking for a refund. You have two choices: pay or appeal. If you disagree with the findings, the smart choice is to meet with the payer, appeal the findings, and […]
AAPC Knowledge Center

Appeal for wrong place of service auth that PCP obtained

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I work for an ASC and the PCP obtained an authrozation for a different Surgery center( which we did not know about ). We did the surgery submitted charges with auth number the PCP provided, and we were denied due to no prior auth obtained for our surgery center. pcp tried to change it to our facility but ins company will not change and told PCP, we will have to appeal it as the ASC. I can’t figure out how to fight this.

Thank you kindly,
Chelsa T. CPC, CPB

Medical Billing and Coding Forum