Reimbursement Review and Resolution Service

  • Issues with Insurance Reimbursements? TMA Can Help.

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    TMA’s free Reimbursement Review and Resolution Service goes to bat for members by helping to resolve issues related to insurance payments. Don’t waste your time filing appeal after appeal without resolution. Our team recovered more than $2.3 million for members last year.

    Looking for the Hassle Factor Log? You’re in the right place! The renamed Reimbursement Review and Resolution Service features additional staff experts to better serve our members.

  • Reimbursement Review and Resolution Service

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    TMA can help resolve issues with your payer network status, prompt-pay, and other reimbursement claims. Staff experts will work with your team to systematically navigate billing and coding requirements. We also meet directly with Medicare, Medicaid, health care payment plans, and large insurers to discuss specific problems that you bring to our attention.

    Request Reimbursement Services  
  • Submit a Reimbursement Review Form

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    The Texas Medical Association accepts submission to the Reimbursement Review and Recovery Service from current TMA members only. Download the Review Form which includes submission information. All physicians must also have a Business Association Agreement (BAA) on file with TMA.

    Reimbursement Review Form MembersOnlyRed

    Business Associate Agreement (BAA)

  • Review and Resolution Service – User Guide

    Please observe the following guidelines to help staff expedite processing while maintaining the integrity and credibility of the Reimbursement Review and Resolution Service (RRR).

    • General Guidelines 
       
      • The Texas Medical Association accepts Review Forms from current members only.
      • Review Forms may be faxed to (512) 370-1632 or submitted via secure file-drop; https://files.texmed.org/filedrop/RRR.
      • Unless you are submitting an “informational only” Review Form, please exhaust and document reasonable attempts to resolve your claim issues, including the appeals process, before submission. 
      • Clearly identify health plans and/or contractual relationships on the Review Form. 
      • Keep in mind that Medicare’s Correct Coding Initiative (CCI) determines bundling standards. 
      • Do not report slow-pay issues until 45 to 60 days after you have submitted the claim and you have received confirmation that the claim is being processed. 
      • TMA copies the physician on any letter we send a health plan regarding his or her RRR.  
      • TMA generally processes Review Forms within two to four weeks of receipt. TMA cannot guarantee a response from the health plan. 
  • Best Practices When Submitting Attachments

    Attachments should contain only the protected health information (PHI) that is relevant to the patient(s) for which a physician is submitting a Review Form. Physicians should delete all other patient information from the attachments. TMA will return to the practice any Review Forms that have non-pertinent PHI.

    Examples of frequently needed attachments are:

    • CMS-1500 claim forms
    • Remittance notices (e.g., EOBs, RAs, R&S reports) with definitions of comment indicators and/or denial messages
    • Copies of relevant prior correspondence to and from the health plan, including appeal letters and/or denial letters
    • Reports for proof of timely filing (e.g., batch acceptance reports from the payer or clearinghouse showing the payer accepted the claims)
    • Operative notes/Medical records
    • Patient insurance identification cards
    • Preauthorization/Referral forms  
    • Appeal
  • Informational-Only Review Forms 

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    TMA adds the following types of Review Forms to its database as “informational only”:

    • The Review Form was submitted to TMA expressly for “informational only” purposes.
    • The claim currently is being appealed with the health plan for the first time.
    • The claim is for services older than 12 months.
    • The physician office failed to follow-up on the claim in a timely manner.
    • The information submitted is a copy of a complaint filed with the Texas Department of Insurance.
    • The concern is not clear, legible, or understandable.
    • The Review Form contains unclear issues and /or conflicting information.
    • Physician billing errors are construed as payer hassles.
    • The Review Form lacks appropriate attachments.
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    TMA is helping to strengthen your practice by offering personal advice and creating a climate of medical success across the state. 

  • What could a TMA membership mean for you, your practice, and your patients?