Ways to Avoid a Medicare Appeal

Novitas Solutions reports receiving 1.7 million requests per year to correct minor errors or omissions of Medicare claim information. If it took an average of only 10 minutes for medical offices to find each error and submit the correction, that’s more than 15 years of wasted office staff time!

And that accounts only for the quick fixes, like correcting a code, date, or beneficiary’s Health Insurance Number, or adding a modifier. More complex redetermination requests (first stage of appeal of a denied claim) take more time. Many are avoidable, however. 

From Novitas Solutions, the Medicare payer for Texas, here are top ways to avoid a correction or appeal:

  • Verify all information pertaining to the service is correct and complete, as applicable: i.e., National Provider Identifier(s), date of service, place of service, number of services, billed amount for each service, and the like.
  • Become familiar with local coverage determinations (LCDs) and national coverage determinations (NCDs).
  • Append modifiers to services appropriately. Understand modifiers so you can use them correctly. For guidance, see Novitas’ complete listing of modifiers (some have links to educational material).
  • Document a repeat or duplicate service to reflect it is a distinct and separate service, e.g., when reporting modifier 76 (repeat procedure or service by same physician).
  • Submit supporting documentation with the claim when certain modifiers, e.g., 52 (increased procedural services) or 22 (reduced procedural services), are appended to the service or when an LCD or NCD indicates documentation is required.
  • Comply with requests for supporting documentation within the required timeframe.
  • Include the rendering physician’s legible signature on the supporting documentation.
  • Enter the concise description of an unlisted procedure code or “not otherwise classified” code.
  • Include information from the primary insurer when Medicare is the secondary payer.

For details, see the Novitas website. See also How to Correct Claim Errors by Clerical Error Reopening or Requesting a Redetermination. Note that for claim corrections that can’t be processed via Novitasphere or the automated phone line, you’ll will need to submit a Part B Redetermination and Clerical Error Reopening Request Form.

If you need help resolving a government or private payer claim, turn to TMA Hassle Factor Log program. In 2016, TMA program recovered $1.8 million in unpaid claims for TMA members. If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. 

Published Aug. 11, 2017

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Last Updated On

August 14, 2017

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