Appeal Process

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  • A claim requires an appeal when it has been processed and denied by the payer and the issue cannot be corrected by simply resubmitting or correcting the claim.
  • The appeals process typically consists of two stages:
            1 - Reconsideration (first-level appeal)
            2 - Appeal (second-level appeal)
  • A second-level appeal should be submitted if the reconsideration (first-level appeal) is upheld.
  • There are 3 modes for submitting an appeal: fax, mail or portal. It is important to confirm the accepted submission modes with the insurance representative and you should give priority to fax and portal modes if it is acceptable as it takes less time to receive by payer.
  • Reconsideration and appeal has a time limit and it is different based on the insurance. So, it needs to be confirmed and submitted within the time limit.
  • When submitting an appeal for any denial, it is necessary to prepare a package that includes at least two documents.
            1 - General Letter or Insurance-Specific Appeal Letter
            2 - Supporting Documents
  • General Letter or Insurance-Specific Appeal Letter:
    • Many insurance companies have specific appeal letters that must be completed and submitted when filing an appeal. The first-level and second-level appeal letters may differ, so it is important to contact the insurance representative to confirm the requirements for both reconsideration and appeal letters. Sometimes, these information are also available on their portal.
    • An appeal letter generally includes the following sections:
      • Patient Information
      • Provider Information
      • Insurance & Claim Information
      • Reason for Submitting Appeal
    • If the insurance company does not provide a specific appeal letter or form, you will need to create a general appeal letter that includes all of the above information.
    • Below is the example of general appeal letter. You may modify the wording as needed or get client approval before using it.


  • Supporting Documents: These should include all supporting documents that strengthen your appeal. They will be reviewed by the insurance company and may help overturn the original decision.
    • Below are the denials and the corresponding supporting documents that can be attached when submitting an appeal.
      • TFL Denial: It requires POTF (Proof of Timely Filing) to be submitted. POTF can be any documents that prove the submission of claim within the timely filing limit of the insurance. The documents must include submission date and below documents can be used as POTF.
        • Clearinghouse Submission Report
        • Payer Acknowledgement / Acceptance Report
        • EDI Acceptance Screenshot
      • Medical Records Required or Insufficient Document Denial: This denial requires submission of the documents that can support the denial CPT.

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    Interview Questions - Part II

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    Waiver Of Liability

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    A waiver of liability can protect either the patient or the healthcare provider from financial risk, depending on who signs it, what it's intended for, and whether it’s initiated by the provider or the insurance company. There are two main types of waiver of liability commonly used in medical billing:

    1. Patient-Signed Waiver of Liability
    2. Provider-Signed Waiver of Liability

    1. Patient-Signed Waiver of Liability:
    • This waiver is similar to an Advance Beneficiary Notice (ABN) but is used for non-Medicare payers.
    • It is a written agreement provided by the healthcare provider to inform the patient that they may be financially responsible if the insurance denies the claim.
    • By signing this waiver, the patient acknowledges and agrees to pay for the service in the event of a denial.

    2. Provider-Signed Waiver of Liability:
    • This is a written agreement initiated by the insurance company and the provider must sign to confirm that the patient will not be billed for the service if the claim is denied.
    • Insurance companies typically request this waiver when the provider submits a final appeal for a denied claim.
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    Hospital Billing Codes

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    Revenue Codes: 
    • These codes describe the type & the location of the service.
    • For example: 0450 - Emergency Room General Services, 0300 – Laboratory General Services, etc.
    • These are 4 digis codes.
    • It is used in locator 42 on UB-04 form.

    Condition Codes:
    • These codes describe specific circumstances or situations of patient's care.
    • For example: 02 - Condition is employment related, 17 - Patient is homeless, etc.
    • These are 2 digits codes.
    • It is used in locators 18-28 on UB-04 form.

    Occurrence Codes:
    • These codes describe specific dates & events that occurred during patient treatment.
    • For example: 01 - Auto Accident Date, 02 - Date of illness or injury, etc.
    • These are 2 digits codes.
    • It is used in locators 31-34 on UB-04 form.

    Occurrence Span Codes:
    • These codes describe the span of the particular service or events provided to the patient.
    • For example: 77 - Hospital stay start date, 78 - Hospital stay end date, etc.
    • These are 2 digits codes.
    • It is used in locators 35-36 on UB-04 form.

    Value Codes:
    • These codes provide additional monetary information related to a patient's care or services.
    • For example: 01 - Patient's age, 18 - Number of covered days, etc.
    • These are 2 digits codes.
    • It is used in locators 39-41 on UB-04 form. 

    TOB (Type Of Bill):
    • TOB helps payers to quickly identify the claim type for processing and reimbursement.
    • These are 4 digits codes and each digit has a specific reason which is very important while submission.
    • 1st digit: It is always 0.
    • 2nd digit: Indicates type of facility. Examples - Hospital, RHC, SNF etc.
    • 3rd digit: Type of care. Examples - Inpatient, outpatient etc.
    • 4th digit: Indicates claim frequency. Examples - Original, adjustment etc.
    • It is used in locator 4 on UB-04 form.

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    How to work on Medicare denial - 22, 24 & 109

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    When working on these denials, it may create confusion sometimes because when you check eligibility on the Medicare portal or Medicare IVR, you find 2 options - MCO/HMO & MSP and it may be possible that the insurance is available in both tabs then it is difficult to find the correct primary insurance to bill the claim. This post will help to resolve the confusion. Please go through the complete post to have a clear understanding.

    1. Denial 24 (Covered under managed care plan) & 109 (Not covered by this payer):

    Scenario 1: On these denials, you need to refer to the MCO/HMO tab and the insurance available under this tab will be the primary insurance. After updating this insurance as primary, you do not need to keep the Medicare insurance as a secondary payer because the MCO/HMO plan pays on behalf of Medicare.

    Scenario 2: On denial 109, there is another possibility that you will not find any insurance under the MCO/HMO tab. In that case, there may be a possibility of the patient enrolled in Railroad Medicare then you will need to submit the claim to Railroad Medicare (Palmetto Railroad) with the same policy ID.

    2. Denial 22 (Other Payer Primary):

    Scenario 1: On this denial, you need to refer to the MSP tab and the insurance available under this tab will be the primary insurance. Once you find the primary insurance information then update it as primary insurance and keep Medicare insurance as a secondary payer. Note: Whenever you are making Medicare as secondary, always update the MSP code. Please visit the below link to learn more about the MSP code,

    https://www.arlearningonline.com/2020/01/msp-medicare-secondary-payer.html

    Scenario 2: There is another possibility that you will not find any insurance under the MSP tab. In that case, you can resubmit the claim to Medicare.

    Scenario 3: You may find multiple insurances in the MSP tab, in that case under each insurance name, you will find the MSP code of the insurance. This MSP code will help to identify insurance types. 

    MSP Codes:
    12 - Commercial insurance with health coverage for beneficiary with age 65 or above
     13 - Commercial insurance with Health coverage for End-Stage Renal Disease beneficiary
     14 - Auto Insurance
     15 - Worker Compensation
     41 - Black Lung Insurance
     43 - Commercial insurance with health coverage for beneficiary under age 65
     47 - Liability Insurance

    Example - You find 2 insurances under the MSP tab with MSP code 12 (Commercial insurance) & 14 (Auto insurance). In that case, you will need to identify the service whether it is related to health coverage or Auto injury. If it is related to health coverage then you will need to make primary insurance to an insurance that has MSP code as 12 and keep Medicare as secondary with MSP code 12. In the same way, if the service is Auto related injury then you will need to make Auto insurance as primary which is mentioned with MSP code 14 and Medicare as secondary with MSP code 14.

    3. Other Possible Scenarios:

    Sometimes, while checking the eligibility you can find a scenario where insurance is available in both MCO/HMO & MSP tabs. In that case, identifying the correct primary and secondary insurance is a little bit tricky. The below examples will help to identify the correct primary and secondary insurance.

    Example 1 - There is an insurance in the MSP tab with MSP code 43 (Commercial insurance) and another insurance is under the MCO/HMO tab.

    In such a scenario, you can make the insurance as primary which is available under the MSP tab and keep the insurance on secondary position which is available under the MCO/HMO tab. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)

    Example 2 - There is an insurance in the MSP tab with MSP code 15 (Worker Compensation) and another insurance is under the MCO/HMO tab.   

    In such a scenario, you need to identify whether a service is related to a work-related injury or not. If it is not then you do not need to bill the claim to WC, you can directly make the MCO/HMO plan as primary insurance. Do not need to keep Medicare as secondary and submit the claim to the MCO/HMO plan.

    If the service is related to work-related injury then you can make WC as primary and keep the MCO/HMO plan as secondary and submit the claim to worker comp. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)
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    Interview Questions - Part I

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    Tricare & VA Coverage

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    TRICARE (CHAMPUS):

    • It covers active and retired military personnel and their dependents, survivors and certain former spouses.

    VETERANS AFFAIRS / ADMINISTRATION (VA) (CHAMPVA):

    • Veteran - Veteran is a person who has served in the army, navy or air force, especially during a war.
    • It covers the spouse or child of a veteran who died on the duty or who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.

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