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Tag Archives: Appeals

Appeals Coordinator – Provider Needed

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Please see the Job posting below. If you are in the Hampton Roads are (Virginia). Please Apply.

Optima Health – Va Bch

766122369 Appeal & Complaint Dept

Job Description

Responsible for the investigation and documentation of member appeals and grievances in compliance with State law, applicable rules and regulations and provider and group agreements. Works closely with the Plan’s Medical Directors who are responsible for all decision regarding clinical appeals/ grievances and the Appeals Manager who is responsible for non-clinical appeals and grievances.

Employment Status

Full time

Shifts

First (Days)

Requisition Id

114883BR

Job Posting

Optima Health is hiring an Appeals Coordinator
to join our team in Virginia Beach, VA.

Hours/Shift: 8-5p

Monday – Friday, Day shift, 40 hours/wk.

*Provider Appeal Coordinator positions require CPC Certification within 1 year of eligibility

Department/Position Overview:

We are seeking an experienced, professional Appeals Coordinator to help support our Optima leadership and our efforts to fulfill our mission on a daily basis. Professional, well-balanced, self-directing yet a collaborative team player with an unsurpassed administrative talent and keen sense of proactivity to drive a positive work environment are ideal. Additional key qualities include but are not limited to: multitasking, attention to detail, effective communication, and strong organizational skills to maintain multiple calendars from multiple leaders. Ability to sit for long periods of time performing job functions and strong Microsoft Office experience is a must.

Medical Billing and Coding Forum

Appeals Backlog Gone in 4 Years: Medicare

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By law, the Administrative Law Judge level of Appeals has 90 days to resolve appeals submitted to the ALJ level.  However, the Department of Health and Human Services (HHS) Office of Hearings and Appeals (OMHA) has been unable to keep up with the number of appeals submitted to them which has lead to a huge […]

The post Appeals Backlog Gone in 4 Years: Medicare appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Coding- Denials and Appeals Specialist Oklahoma City, OK

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Job Opening!!!! Apply at www.okheart.com

Oklahoma Heart Hospital
Coding – Denials and Appeals Specialist
Location US-OK-Oklahoma City

Shift Monday – Friday Days Full-Time Days

Responsibilities
The Coding and Denial Specialist is responsible for assisting in coding and compliance issues. Generating and reviewing payment discrepancy reports on an ongoing basis for all Medicare and Managed Care contracts. Reviews denials and write-offs from third party payers. Will be responsible for generating appeal letters to send the payer to dispute the denial or underpayment identified. Act as a resource for Charge Entry to assist with coding questions to ensure charges are entered correctly. Performs all work with accord to the mission, vision and values of Oklahoma Heart Hospital.

Qualifications

Education: High School graduate or equivalent required. Bachelor or Associate Degree Preferred.
Licensure/Certifications: Must possess C.C.S, C.P.C, RHIT or RHIA
Experience: At least one (1) year of experience in billing, auditing, medical coding experience.

Medical Billing and Coding Forum

Coding- Denials and Appeals Specialist Job Opening Oklahoma City, Ok

Posted on by
Job Opening!!!! Apply at www.okheart.com

Oklahoma Heart Hospital
Coding – Denials and Appeals Specialist
Location US-OK-Oklahoma City

Shift Monday – Friday Days Full-Time Days

Responsibilities
The Coding and Denial Specialist is responsible for assisting in coding and compliance issues. Generating and reviewing payment discrepancy reports on an ongoing basis for all Medicare and Managed Care contracts. Reviews denials and write-offs from third party payers. Will be responsible for generating appeal letters to send the payer to dispute the denial or underpayment identified. Act as a resource for Charge Entry to assist with coding questions to ensure charges are entered correctly. Performs all work with accord to the mission, vision and values of Oklahoma Heart Hospital.

Qualifications

Education: High School graduate or equivalent required. Bachelor or Associate Degree Preferred.
Licensure/Certifications: Must possess C.C.S, C.P.C, RHIT or RHIA
Experience: At least one (1) year of experience in billing, auditing, medical coding experience.

Medical Billing and Coding Forum

Appeals for Contractual Exclusions

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Good Morning
I am a biller at a plastic surgery practice and I need alittle help with an appeal on an Emergency Room surgery that is being denied as contractual exclusion for a cosmetic procedure that the patient had over 10 years ago. The patient presented to the ER with severe back pain shooting down both legs, ASIA syndrome, and had multiple granulomas all through out her buttocks and thighs. We took her to surgery and started to remove the granulomas. There had to be 2 more surgeries to remove them all and close the wounds. The patient was aware that there would be some deformities after the surgery. This by all means was not a cosmetic procedure and we did not perform the orginal surgery 10 years prior. I have written appeals, so has the patient, we have sent before and after photos and included all medical records. We even had a peer to peer and their doctor agrees about medical necessity but is denying for contractual exclusion. They are stating that they do not cover any problems that arise from a cosmetic procedure no matter how long ago it was. I am stumped. Is there somewhere we can appeal over Aetna?? Any government office we can contact??? Any help would be appreciated!!!!

Thank you for any advice you can give!!

Medical Billing and Coding Forum

Good cause for extension of the time limit for filing appeals

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The time limit for filing a request for redetermination may be extended in certain situations. Generally, providers, physicians, or other suppliers are expected to file appeal requests on a timely basis. A request from the provider, physician, or other supplier to extend the period for filing the request for redetermination would not be routinely granted.

Note: A finding by the contractor that good cause exists for late filing for the redetermination does not mean that the party is then excused from the timely filing rules for the reconsideration.

Good cause may be found when the record clearly shows, or the beneficiary alleges, that the delay in filing was due to one of the following:

• Circumstances beyond the beneficiary’s control, including mental or physical impairment (e.g., disability, extended illness) or significant communication difficulties;

• Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (the Centers for Medicare & Medicaid (CMS), the contractor, or the Social Security Administration) to the beneficiary (e.g., a party is not notified of her appeal rights or a party receives inaccurate information regarding a filing deadline);

Note: Whenever a beneficiary is not notified of his/her appeal rights or of the time limits for filing, good cause must be found.

• Delay resulting from efforts by the beneficiary to secure supporting evidence, where the beneficiary did not realize that the evidence could be submitted after filing the request;

• When destruction of or other damage to the beneficiary’s records was responsible for the delay in filing (e.g., a fire, natural disaster);

• Unusual or unavoidable circumstances, the nature of which demonstrates that the beneficiary could not reasonably be expected to have been aware of the need to file timely;

• Serious illness which prevented the party from contacting the contractor in person, in writing, or through a friend, relative, or other person;

• A death or serious illness in his or her immediate family; or

• A request was sent to a government agency in good faith within the time limit, and the request did not reach the appropriate contractor until after the time period to file a request expired.

Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. Also, good cause does not exist where the provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

See also: Time Limits for Each Level of Appeal


Coding Ahead

Take Commercial Appeals to a Higher Level

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Claim denials cost the medical industry over $ 1 million, annually. How much of that comes from your practice? You spend time interpreting sometimes confusing health plan benefits and coverages and wordy coding guidelines. You go through time-consuming prior authorization processes. And you sign up for a payer’s electronic funds transfer and post claims per their […]
AAPC Knowledge Center