http://www.insuranceclaimdenialappeal.com/2016/03/medicare-appeal-some-common-question.html
Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service
Q: What are the reason code ranges for claims when they have denied?
A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.
Q: Can I resubmit or adjust a claim when an appeal is processing?
A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.
Revised fact sheet on the appeals process
The Medicare Appeals Process external pdf file fact sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf
Good cause for extension of the time limit for filing appeals
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.
Q: Can we resubmit a claim that was denied by the recovery audit contractor (RAC) if we determine the incorrect code was submitted?
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service
Q: What are the reason code ranges for claims when they have denied?
A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.
Q: Can I resubmit or adjust a claim when an appeal is processing?
A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.
Revised fact sheet on the appeals process
The Medicare Appeals Process external pdf file fact sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedicareAppealsProcess.pdf
Good cause for extension of the time limit for filing appeals
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.
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