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The Only Company with Compliant Solutions for All of You

 

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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Dr. Jin Zhou (Joe) will Speak at

The Business of Medicare Advantage: Forum 2009

by WRG Research Inc

Afternoon Workshop E on Junauary 28,2009
January 28 - 30, 2009,
Washington, DC

Best Practices for Operations, Revenue Management, Policy, Marketing, Compliance, Strategy, Part D, SNPs and Dual Eligibles

 

Speakers - Agenda at Glance  -  Who should Attend  --  Why attend

 

 

E-mail Your Questions to ERISAclaim@aol.com

 

2009 GUIDE TO

New Medicare Claims Appeals Process

© 2005-9, Jin Zhou, ERISAclaim.com

 

Overviews at the bottom of this page

Coming soon, click here for BooK mailing list

 

Mission Statement

 

      One of the main goals for ERISAclaim.com is to assist Medicare’s 1.2 million physicians and other providers with the information they need from CMS and our unique but practical guidance with compliant strategy to correctly  appeal Medicare denied or delayed claims in accordance with Medicare rules and regulations, as intended by Congress, to receive reimbursements more quickly, and spend less time dealing with paperwork ultimately.

 

     In 2007, only 1.7% of the Part A claim denials were appealed, and only 1.6% appealed for Part B claim denials. [CMS Appeal Fact Sheet]

 

Provider Appeals of RAC Determinations

 

   "From the inception of the RAC demonstration through June 30, 2008, providers chose to appeal only 19.6 percent (102,705) of the RAC determinations. Overall, the data indicate that of all the RAC overpayments determinations (525,133), only 6.8 percent (35,819) were overturned on appeal (see Table SU7)." [CMS Update to 3 year of RAC Demo, 09/2008]

 

Winning Roadmap to Successful Medicare Appeals

© Jin Zhou, 2009, 11/16/2008

 

Why Medicare Is Always So confusing?

How and What Really Govern My Disputes and Appeal Rights?


You Shall Listen to, But Never Trust Your Opponents - Medicare Contractors Whom You Appeal to


Do Your Own Home Work, It's Your Money and Your Rights

 

You Shall and Must Study the Followings to Become a Medicare Claim Appeal Specialist:

  1. USC Statutory Codes - SSA + MMA from Congress;

  2. Federal Regulations from HHS;

  3. Medicare Manuals from CMS, With Rev. Date???

  4. CMS Transmittals from CMS, After Rev Date???;

  5. NCD's & LCD's

  6. MLN Articles;

  7. CMS Website Appeal Instructions;

  8. Local Contractor Website + Provider Educations

  9. Navigation and Explanation Artical, Charts and Maps from CMS, MLN and Local Contractors

  10. ALJ and MAC Decisions + Court Case Laws

  11. Winning Strategies from Medicare Claim Institute of America By Dr. Jin Zhou of www.ERISAclaim.com

What We Teach & Goals

 

1.      How To Fight Back Through Compliant Appeals?

2.      How To Defeat Statistical Sampling /Extrapolation - #1 Killer

3.      How To Defeat Medical Necessity With NCD & LCD - #2 Killer

4.      How To Defeat Poor Documentation Challenge - #3 Killer

5.      How To Defeat Poor Billing & Coding Challenge - #4 Killer

6.      How To Defeat & Defend Fraud Allegations - #5 Killer

 

So You May

1.      Pay Nothing Back;

2.      Get A Letter Of Apology from the RAC

 

So, What's So Different?

1.     Others Teach You How To Deal Or Cope With RAC To Become An Overpayment Slavery, To Pay More Back While You Feel Better And Safe;

2.      No One Can Truly 100% Prevent A RAC From Slapping You With A Huge Overpayment Demand;

3.      What You Learned From Others Can Never Undo What's Been Done In The Past And It Will Be Too Late And A Possible Fraud For You To Change Or "To Doctor" Any Records After Getting A RAC Overpayment Demand;

4.     We Teach You How To Beat The RAC By Putting The RAC On Defense To Find Their Violations And Fraud In Asking You For Any Overpayment, To Exercise Your Due Process As Intended By Congress And Provided In U.S. Constitution Because No One Could Be 100% Perfect In Compliance With Less Than 50% Accurate And Clear Medicare Rules And Billing Instructions;

5.     In Your Entire Healthcare Life, You Have Been Always Bending Backward Or Remaining Clueless  In Dealing With Medicare And Insurance Companies When They Denied Your Claims, And Asked Your For Money Back Under The Ghost Name Of "Anti-Fraud", But This Time You Can't Afford To Pay Back To Bailout $1 Trillion U.S. Healthcare Bubble, Much Bigger Than Mortgage, Credit Card, And Stock Market Bubble. The Congress Will Not Offer Another $1 Trillion Bailout Plan For U.S. Healthcare Industry, The Industry Is Counting On You To Bailout. You Badly Need "Joe, The Plumber" To Bail You Out From 2009 $1 Trillion U.S. Healthcare Bubble Prison, Aka, Your Financial Bankruptcy + Anti-Fraud Verdict.

6.     "Joe, The Plumber" For You, Dr. Joe (Zhou), "The RAC Invalidator" Will Bail You Out If You Believe This Above Assessment Is True In Reality.

 

How to Get Our Compliant Training & Education?

 

As Most RAC Overpayment Demand Could Be As Big As Your Monthly, Quarterly Or Even Yearly Income For Your Organization, All Of Our Trainings Are On Site and In House, Confidentially.

 

Costs:  

$5,000.00 Per Day + Speaker's Expenses, Minimum Two Days Per Program.

Contact: 

Jin Zhou

President

ERISAclaim.com

ERISA Claim Institute of America

Medicare Claim Institute of America

630-736-2974 (Office)

630-808-7237 (Mobile)

ERISAclaim@aol.com

 

2009 GUIDE TO

New Medicare Claims Appeals Process

© 2005-9, Jin Zhou, ERISAclaim.com

 

A Demystified Navigational Guide To CMS Web Site

With Active Hyperlinks to Documents from

both Internet CMS Web site and CD-ROM

On both New Medicare Claims Appeals Process and

Comprehensive Medicare Learning Tools

 

CMS Home > Outreach and Education > MLN Educational Web Guides > Appeals - Fee-For-Service

What's New

 Questions Glossary Acronyms
CMS Transmittals  CMS QPU         MLN  Articles  MLN Products

Appeals and Grievances

  1. Original Medicare (Fee-for-service) Appeals
  2. Medicare Managed Care Appeals & Grievances
  3. Medicare Prescription Drug Appeals & Grievances

 

Social Security Act, The Medicare Program

 

Medicare Modernization Act of 2003

 

CFR FFS Appeal:  42 CFR Parts 401 and 405   [eCFR, 401 & 405]

CFR MA Appeal: 42 CFR part 422, subpart M of the   [eCFR, 422 - 422.1 to 422.2276]
 

The CMS Online Manual System

FFS Appeal - Chapter 29 - Appeals of Claims Decisions - Medicare Manual
MA Appeal - Chapter 13 - Medicare Managed Care Manual

CMS Forms

NCCI Edits

MSP Recoveries

Overpayment

 

"MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER", CMS Press Release (October 18, 2004)

IMPLEMENTING A NEW MEDICARE CLAIMS APPEALS PROCESS -  CMS Fact Sheet CMS News (pdf) (March 01, 2005)

Comparison of Current and BIPA 521 Fee-For-Service Appeal ProcessesOpen a PDF file 

Qualified Independent Contractors (QIC) - CMS Fact Sheet

Appeals Process Diagram

MLN The Medicare Appeals Process Brochure

Fact Sheet: Original Medicare (Fee-For-Service) Appeals Data - 2007

 

CMS Medlearn Matters Articles on New Appeal

[  MM3530 ] [ MM3939 ]  [ MM3944 ] [ MM4019 ]

[MedLearn Provider-Specific Materials]  [MedLearn Complete Publications]

[MLN Matters Articles] [MLN Products] [MLN Educational Web Guides]

Provider Call Center Toll-Free Numbers Directory [PDF 1.52MB]

 

CMS New Appeal Process Related CR/Transmittals
{selected by & linked to ERISAclaim.com}

2006 deductibles: R31GI & MM4132

 

View and Download Medicare Appeals Forms

 

New CMS Appeal Rule Print Versions:

[CMS PDF- 511 Pages] [FR PDF- 80 Pages] [FR HMT] [Correction]

 

CMS Forms [CMS 20031] [CMS 1696] [CMS 20027] [CMS 20033]

 

Provider Customer Service Program - R15COM

 

CMS QIC Links: [www.FCSO.com]   [www.Maximus.com]  [www.q2a.com]

ALJ Decisions

HHS-DAB - Selected decisions of the MAC  [MAC Decisions]

In the case of Metro Home Care (Caretenders)

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Return to cms.hhs.gov Home Appeals Functional Guide

Fee-For-Service Providers       MLN Home

Display lists of Managed Care Providers         MLN Home

 

 

CMS Fact Sheet -  New Medicare Claims Appeals Process

CMS News - "Overhaul of the Medicare Claims Appeals System"

© 2005 - 6, Jin Zhou, ERISAclaim.com

 

2009 GUIDE TO
New Medicare Claims Appeals Process
CD Book
: $395
ERISA CD Book: $450
Holidays' Special -  ERISA CD & Medicare CD: $590

[More info on CD Books]       [Order CD Book]

 

 

Top 10 Links to

  1. Manuals
  2. Medicare Coverage Database
  3. Transmittals
  4. Medicare Provider-Supplier Enrollment
  5. MLN Matters Articles
  6. CMS Forms
  7. Quarterly Provider Updates
  8. MLN Products
  9. Medicare Coverage - General Information
  10. Health Plans - General Information

 

 

CMS: Medlearn Matters...Information for Medicare Providers


Information and Education Resources for Medicare Providers, Suppliers, and Physicians (adobe pdf 73Kb) Updated June 29, 2005

Background

 

"One of the goals of CMS is to give Medicare’s 1.2 million physicians and other providers the information they need to understand the program, be aware of changes, and bill correctly. By making information and education resources easily accessible, understandable, and as timely as possible, physicians and other providers will be better able to submit bills correctly the first time, receive reimbursements more quickly, and spend less time dealing with paperwork. All of this can result in more time to spend on patient care. We are committed to accomplishing this goal by offering Medicare physicians and other providers a variety of educational products and services and using various information delivery systems to reach the broadest and most appropriate audiences possible."

 

 

CMS Fact Sheet -  New Medicare Claims Appeals Process

CMS News - "Overhaul of the Medicare Claims Appeals System"

© 2005, Jin Zhou, ERISAclaim.com

CMS News: November 10, 2005
MEDICARE REDUCES IMPROPER CLAIMS PAYMENTS BY HALF

"Aggressive oversight and new improvement efforts have cut the number of improper fee-for-service Medicare claims payments by half in one year, from 10.1 percent in 2004 to 5.2 percent in 2005, a $9.5 billion reduction in improper payments......"

Breaking News:  Employer Must Reimburse Medicare

for Over Payments under MSP

 

Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

More on Medicare $ ERISA Page.

 

 

U.S. Court of Appeals for the D.C. Circuit to All Chiropractors

 

NO Appeal, No Lawsuit!!!

 

Amer Chiro Assn Inc vs. Leavitt, Michael O.

Released: 12/13/2005

"The jurisdictional question is more complicated. “No action against the United States, the [Secretary of Health and Human Services], or any officer or employee thereof shall be brought under [28 U.S.C. §] 1331 . . . to recover on any claim arising under” the Medicare Act. 42 U.S.C. §§ 405(h), 1395ii. Judicial review may be had only after the claim has been presented to the Secretary and administrative remedies have been exhausted. See 42 U.S.C. §§ 405(g), (h), 1395w-22(g)(5); Shalala v. Ill. Council on Long Term Care, Inc., 529 U.S. 1, 8-9 (2000); Heckler v. Ringer, 466 U.S. 602, 614-15 (1984); Weinberger v. Salfi, 422 U.S. 749, 763-64 (1975). This bar against § 1331 actions applies to all claims that have their “standing and substantive basis” in the Medicare Act. Ill. Council, 529 U.S. at 11, 17 (quoting Salfi, 422 U.S. at 761); see also Ringer, 466 U.S. at 615....."[page 5 of 8]

 

 

"To have such a claim heard, an enrollee could obtain the services of a chiropractor without first obtaining a referral. After the HMO refuses coverage because of the absence of a referral, the enrollee could file a grievance with the HMO, claiming that the referral requirement was illegal. See 42 U.S.C. § 1395w 22(g)(1)(A); 42 C.F.R. §§ 422.562(a)(1), .566(a). This would trigger the administrative process, at the end of which is judicial review of the Secretary’s final decision. See 42 U.S.C. § 1395w-22(g)(5); 42 C.F.R. § 422.612(a), (c). The chiropractor who provided the service could also mount an administrative challenge by “waiv[ing] any right to payment from the enrollee” and becoming the enrollee’s assignee. 42 C.F.R. § 422.574(b)." [page 6 of 8]

 

2009 GUIDE TO

New Medicare Claims Appeals Process

© 2005-6, Jin Zhou, ERISAclaim.com

 

Breaking News

New CMS Appeal Rules

effective on May 1, 2005 for Part A

effective on Jan. 1, 2006 for Part B

- New Way of Life for Healthcare Claims

 

Open a PDF file  Comparison of Current and BIPA 521 Fee-For-Service Appeal Processes 16KB New from CMS

Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-Appeals Transition - BIPA 521 Appeals) MM3530

Medicare Appeals Process - Social Security Online

 

 

Electronic Code of Federal Regulations:

Subpart I--DETERMINATIONS, REDETERMINATIONS, RECONSIDERATIONS, AND APPEALS UNDER ORIGINAL MEDICARE (PART A AND PART B)

 

No delays or postpones as you've heard

Implementation date: 04/25/2005, CMS Transmittal - R146OTN

 

 

New CMS Appeal Rule Print Versions:

[CMS PDF- 511 Pages] [FR PDF- 80 Pages] [FR HMT] [Correction]

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

 

Medicare New Appeal & Reimbursement Seminars

New Compliance & Challenges

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Seminar I

2 days

Seminar II

2 days

Seminar III

2 days

New Medicare Appeal Process & Mandates

v.

Former Process

 

Medicare Claims Processing Manual

Chapter 29 - Appeals of Claims Decisions

CMS Transmittal - R146OTN

New Medicare Appeal

 Strategies for

Reimbursement Success &

  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with ($183 million/y)

ERISA Claims Laws

 

CMS: January 2005 QPU - Regulations Published This Quarter

 

ALL PROVIDERS

REFERENCE NUMBER SUBJECT PUBLICATION DATE
CMS-4064-IFC
(PDF - 514 KB)


VIEW REGULATION SUMMARY

Medicare Program: Changes to the Medicare Claims Appeal Procedures 03/09/2005

 

2005 Program Transmittals

 

CMS Manual System

Department of Health & Human Services

Pub 100-04 Medicare Claims Processing

Centers for Medicare & Medicaid Services

Transmittal 678

Date: SEPTEMBER 23, 2005

CHANGE REQUEST 3944

"SUBJECT: Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for All Requests for Redetermination Received by FIs on or After May 1, 2005, And All Requests for Redetermination Received by Carriers on or After January 1, 2006). "

 

NEW/REVISED MATERIAL


EFFECTIVE DATE: FI Redetermination requests received on or after May 1, 2005 and Carrier redetermination requests received on or after January 1, 2006


IMPLEMENTATION DATE: FI - December 16, 2005 and Carrier redetermination requests received on or after January 1, 2006

 

CMS New Appeal Process Related CR/Transmittals

 

SIZE FILE Adobe PDF Icon Sorted in Decreasing Order  COMM DATE MANUAL SUBJECT IMPL DATE CR NUM
1374 kb R15COM 11/18/2005 PUB 100-09 Provider Customer Service Program 12/19/2005 4137
143 kb R131PI 11/10/2005 PUB 100-08 Medical Review Matching of Electronic Claims and Additional Documentation in the Medical Review Process 2/10/2006 4052
348 kb R724CP 10/21/2005 PUB 100-04 Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006). 1/1/2006 3939
164 kb R695CP 10/7/2005 PUB 100-04 General Appeals Process in Initial Determinations (Implementation Dates for FI Initial Determinations Issued on or After May 1, 2005, and Carrier Initial Determinations Issued on or After January 1, 2006). 1/9/2006 4019
42 kb R697CP 10/7/2005 PUB 100-04 Appeals of Claims Decisions: Redeterminations and Reconsiderations (implementation date May 1, 2005). 1/9/2006 3942
98 kb R702CP 10/7/2005 PUB 100-04 Manualization for Physician/Practitioner/Supplier Participation Agreement and Assignment Carrier Claims and Carrier Rules for Limiting Charge N/A 4030
109 kb R125PI 9/30/2005 PUB 100-08 Medical Review Additional Documentation Requests 12/30/2005 4022
468 kb R72MCM 9/30/2005 PUB 100-16 Changes in Manual Instructions for Benefits and Beneficiary Protections N/A N/A
63 kb R73MCM 9/30/2005 PUB 100-16 Changes in Manual Instructions for Intermediate Sanctions N/A
345 kb R687CP 9/23/2005 PUB 100-04 Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for FI Initial Determinations Issued on or After May 1, 2005 and Carrier Initial Determinations Issued on or After January 1, 2006) N/A 3939
266 kb R688CP 9/23/2005 PUB 100-04 Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Dates for All Requests for Redetermination Received by FIs on or After May 1, 2005, And All Requests for Redetermination Received by Carriers on or After January 1, 2006) N/A 3944
97 kb R123PI 9/23/2005 PUB 100-08 Chapter 3, MMA Section 935

I. SUMMARY OF CHANGES: This change implements portions of Section 935 of the MMA (entitled Recovery of Overpayments). Specifically, this CR explains to contractors their right to request documentation for a limited sample of submitted claims, after overpayments have been identified, in order to ensure the practice leading to the overpayments has ceased. This CR also specifies more clearly the number and method for selecting a probe sample.

10/24/2005 3703
115 kb R675CP 9/16/2005 PUB 100-04 Changes to Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Date October 1, 2005) 10/3/2005 3943
196 kb R679CP 9/16/2005 PUB 100-04 Medicare Redetermination Notice and Effect of the Redetermination N/A 4004
129 kb R120PI 8/26/2005 PUB 100-08 Correction to Change Request (CR) 3222: Local Medical Review Policy/ Local Coverage Determination Medicare Summary Notice (MSN) Message Revision N/A 3880
89 kb R643CP 8/12/2005 PUB 100-04 Nature and Effect of Assignment on Carrier Claims 11/14/2005 3897
216 kb R603CP 7/15/2005 PUB 100-04 Modification to the Appeals Language on the Medicare Summary Notice; Full Replacement of Change Request 3808 10/3/2005 3924
470 kb R146OTN 3/25/2005 PUB 100-20

Appeals Transition- BIPA Section 521 Appeals

4/25/2005 3530
87 kb R505CP 3/18/2005 PUB 100-04 Unprocessable Unassigned Form CMS-1500 Claims 7/5/2005 3500
56 kb R100PI 1/21/2005 PUB 100-08 Review of Documentation During Medical Review 2/22/2005 3644
61 kb R94PI 1/14/2005 PUB 100-08 Informing Beneficiaries About Which Local Medical Review Policy (LMRP) and/or Local Coverage Determination (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial 1/5/2005 3602

 

 

Medlearn Matters Articles Table

 


Article #

Article Release Date

Title

Related CR Number

Related CR Release Date

Related CR Effective Date

Related CR Impl. Date
MM3939 11/25/2005 Appeals of Claims Decisions: Redeterminations and Reconsiderations and Appeals Rights for Dismissals 3939 10/21/2005 01/01/2006, for appeals of initial determination of claims by Medicare carriers; 05/01/2005, for initial claim determinations by Medicare Fiscal Intermediaries (FIs) 12/16/2005, for FIs and 01/01/2006, for carriers
MM3944 11/25/2005 Appeals of Claims Decisions: Redeterminations and Reconsiderations 3944 09/23/2005 05/01/2005, for appeals of claims submitted to Medicare intermediaries and 01/01/2006, for appeals of claims submitted to carriers 12/16/2005, for Medicare intermediaries and 01/01/2006, for Medicare carriers
MM4019 11/23/2005 MMA – Changes to Chapter 29 – General Appeals Process in Initial Determinations
Revised: 11/18/2005
4019 10/07/2005 05/01/2005 01/09/2006
MM4052 11/25/2005 Medical Review Matching of Electronic Claims and Additional Documentation in the Medical Review Process
Revised: 11/24/2005
4052 11/10/2005 02/10/2005 02/10/2005
MM4019 10/13/2005 MMA – Changes to Chapter 29 – General Appeals Process in Initial Determinations 4019 10/07/2005 05/01/2005 01/09/2006
MM3942 10/13/2005 MMA - Changes to Chapter 29 - Appeals of Claims Decisions: Redeterminations and Reconsiderations (Implementation Date May 1, 2005) 3942 10/07/2005 05/01/2005 01/09/2006
MM3530 4/12/2005 MMA - Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-Appeals Transition – BIPA 521 Appeals) Revised: 4/12/2005 3530 03/25/2005 05/01/2005 04/25/2005

Provider Action Needed

STOP – Impact to You
"There is now a new level of the appeals process for Medicare Part A and Part B claims submitted to Medicare fiscal intermediaries (FIs). This new second level of appeal process is called a reconsideration (not to be confused with the previous first level of appeal for Part A claims). These new “reconsiderations” will be processed by Qualified Independent Contractors (QICs)."

 
 

 

We have for you now:

 

  1. Global View of New and Former Medicare Appeal Rules

  2. No. 1 Change You Must Know Before Anything Else

  3. One of the Most Significant Changes

  4.  Who is Bound By What? Compliance For Jackpot!

  5. Good-Bye to the Existing Medicare Part B "Fair Hearing"

  6. What's Urgent for Hospitals after May 1, 2005? Level I-II (QIC) Appeal - A Complete New Game!

  7. Successful Appeal under New CMS Appeal Rules: Get Started Now! - A Seminar You Can't Afford to Miss.

  8. No appeal rights if a claim returned as unprocessable for incomplete or invalid information.

  9. "the reopening regulations" make life a whole lot of easier when there is no need to appeal.

  10. "Escalation" to higher level for slow QIC (level II), "De Novo" review by MAC on ALJ (level III & IV), and "Expedited Access to Judicial Review" (Level IV), can we have too much protections?

  11. No delays or postpones as you've heard - Implementation date: 04/25/2005, CMS Transmittal - R146OTN


     

 

New CMS Rules:

Add a new subpart I, § 405.900 through § 405.1140

"Subpart I – Determinations, Redeterminations,

Reconsiderations, and Appeals Under Original Medicare

(Parts A and B)"

 

(go to the bottom of this page for more CMS Appeal Rules

for Fee-for-service and Managed Care (MA) programs

and CMS/MedLearn publications)

 

Electronic Code of Federal Regulations:

Subpart I--DETERMINATIONS, REDETERMINATIONS, RECONSIDERATIONS, AND APPEALS UNDER ORIGINAL MEDICARE (PART A AND PART B)

 

More Information is coming.....

 

ERISAclaim.com will report and develop a new appeal system & seminars to comply with and to be consistent with the new CMS Appeal Rules.

 

check back often, or

 

Please e-mail for further news & details

630-736-2974

 

New CMS Appeal Seminars

New Medicare Appeal Seminars

Conclusion or Confusion?

© 2005, Jin Zhou, ERISAclaim.com

 

"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.

 

ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

Based on our comprehensive and diligent study of this new Medicare appeal process, and our extensive experience in ERISA claim procedure practice, and "in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures," [page 2 of 511] it is our conclusion that our nation must recognize and create a new profession, separated from and/or in addition to traditional Coding and Billing personal:

 

"Medicare Appeals Specialist"

 

Guerrilla and weekend training without systematic and quality education will definitely fail in Medicare reimbursement because of its broad requirement and "Authorized Representative" practice with "a waiver of the assignee's right to collect payment...."

 

"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.

 

ERISAclaim.com:  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance

 

This is why Congress and CMS created QIC (="Appeal Specialists" with dual and "sufficient medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of 511]) separated FROM and in addition to Medicare Claim Processors (Medicare FI's & Carriers), (Among the major changes required by the BIPA amendments are--......Requiring the establishment of a new appeals entity, the qualified independent contractor (QIC), to conduct “reconsiderations” of contractors’ initial determinations (including redeterminations, [page 15-16 0f 511]).

 

And this is also why Congress enacted ERISA 30 years ago to require "an appropriate named fiduciary of the plan", § 2560.503-1(h) (1), rather than a claim processor or ASO (Administrative Services Only) TPA (Third-Party Administrator) to handle ERISA health claim appeals.

 

Conclusion or Confusion? Your choice and decision.

 

Jin Zhou, ERISAclaim.com, 03/08/2005

 

Medicare New Appeal & Reimbursement Seminars

New Compliance & Challenges

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Seminar I

2 days

Seminar II

2 days

Seminar III

2 days

New Medicare Appeal Process & Mandates

v.

Former Process

 

Medicare Claims Processing Manual

Chapter 29 - Appeals of Claims Decisions

CMS Transmittal - R146OTN

 

New Medicare Appeal

 Strategies for

Reimbursement Success

&

  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with($183 million/y)

ERISA Claims Laws

 

FYI

 On 511 pages

the word "new" was used 179 times,

"bound by" 7 times,

"medical necessity" 16 times

"full and early presentation of evidence" 8 times.

 

New CMS Rules:

Add a new subpart I, § 405.900 through § 405.1140

"Subpart I – Determinations, Redeterminations,

Reconsiderations, and Appeals Under Original Medicare

(Parts A and B)"

 

 

Implementing a New Medicare Claims Appeals Process (PDF 45K) (3 page)

 

 

Public Affairs Office

 

MEDICARE FACT SHEET

 

FOR IMMEDIATE RELEASE                 Contact: CMS Press Office

March 1, 2005                                      (202) 690-6145

 

"IMPLEMENTING A NEW MEDICARE CLAIMS APPEALS PROCESS

 

Background: In Section 521 of the Medicare, Medicaid and SCHIP Benefits mprovement and Protection Act of 2000 (BIPA), Congress required a major restructuring to improve the process that Medicare beneficiaries can use to appeal claims denials. The law includes a series of structural and procedural changes to the appeals process, including:

 

  • Uniform appeal procedures for both Part A and Part B claims;

  • Reduced decision-making time frames for most administrative appeals levels, as well as the right to escalate a case that is not decided on time to the next appeal level;

  • The establishment of new entities, Qualified Independent Contractors (QICs), to conduct reconsiderations of claims denials made by fiscal intermediaries, carriers, and quality improvement organizations;

  • Use of QIC review panels, which include medical professionals, to reconsider all cases involving medical necessity issues; and

  • A requirement for appeals-specific data collection by CMS......"

 

"Implementation

The statutory appeals provisions dramatically reduce the time frames for adjudicating fee-for-service Medicare claims appeals – a process that now can exceed 1,000 days must be reduced to 300 days. This change requires substantial overhaul of the appeals process – a complicated restructuring involving all levels of the Medicare appeals process. CMS has worked aggressively to implement these mandatory changes, culminating in this regulation."

 

Changes to the appeals process (PDF 646K) (511 pages)

 

"SUMMARY: Medicare beneficiaries and, under certain circumstances, providers and suppliers of health care services, can appeal adverse determinations regarding claims for benefits under Medicare Part A and Part B under sections 1869 and 1879 of the Social Security Act (the Act). Section 521 of the Medicare, Medicaid, and SCHIP Benefits Act of 2000 (BIPA) amended section 1869 of the Act to provide for significant changes to the Medicare claims appeal procedures. This interim final rule responds to comments on the November 15, 2002 proposed rule regarding changes to these appeal procedures, establishes the implementing regulations, and explains how the new procedures will be implemented. It also sets forth provisions that are needed to implement the new statutory requirements enacted in Title IX of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

 

DATES: Effective date: These regulations are effective on May 1, 2005. However, in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures, not all of these provisions can be implemented simultaneously. Please see section I.E. of the preamble for a full description of the implementation approach....."

 

More Information is coming.....

 

ERISAclaim.com will report and develop a new appeal system & seminars to comply with and to be consistent with the new CMS Appeal Rules.

 

check back often, or

 

Please e-mail for further news & details

630-736-2974

 

Medicare New Appeal & Reimbursement Seminars

New Compliance & Challenges

Seminar I

2 days

Seminar II

2 days

Seminar III

2 days

New Medicare Appeal Process & Mandates

v.

Former Process

New Medicare Appeal

 Strategies for

Reimbursement Success

&

  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with ($183 million/y)

ERISA Claims Laws

 

 


OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]

[http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]


The Office of Inspector General (OIG), Department of Health and Human Services
, June, 2001

 

 

*****************************************

1. Global View of New and Former Medicare Appeal Rules

© 2005, Jin Zhou, ERISAclaim.com

 

Changes to the appeals process (CMS)

(PDF 646K) (511 pages) [Page 40]

 

 

 

Comparison of Former and Current 1869 Fee-For-Service Appeals

[for better quality of this chart, click the above, go to Page 40]

 

 2. No. 1 change you must know before anything else)

© 2005, Jin Zhou, ERISAclaim.com

 

Changes to the appeals process (CMS)

(PDF 646K) (511 pages) [Page 77]

 

 

"authorized representative"

at § 405.902.

"Appointed representatives"

under § 405.910

"As mentioned in an earlier response, we added a definition of an "authorized representative" at § 405.902. Authorized representatives (for example, a legal guardian or someone with a power of attorney)  possess all the rights associated with the appeals process to the same extent as beneficiaries."

 

"Appointed representatives under § 405.910, including attorneys, may assist the beneficiary or another party with Medicare appeals, but they do not have any other rights or responsibilities with respect to the beneficiary or another party, and may not sign documents as the beneficiary or party. Thus, an appointed representative may not assign appeal rights under § 405.912 without the beneficiary’s or other party’s consent."

 

 

2. No. 1 change you must know before anything else

© 2005, Jin Zhou, ERISAclaim.com

 

 

Changes to the appeals process (PDF 646K) (511 pages)

 

Page 341 of 511

"Assignment of appeal rights means the transfer by a beneficiary of his or her right to appeal under this subpart to a provider or supplier who is not already a party, as provided in section 1869(b)(1)(C) of the Act.


Assignor means a beneficiary whose provider of services or supplier has taken assignment of a claim or an appeal of a claim.


Authorized representative means an individual authorized under State or other applicable law to act on behalf of a beneficiary or other party involved in the appeal. The authorized representative will have all of the rights and responsibilities of a beneficiary or party, as applicable, throughout the appeals process. "

 

page 259 - 362 of 511

 

§ 405.912 Assignment of appeal rights.


(a) Who may be an assignee. Only a provider, or supplier that--


(1) Is not a party to the initial determination as defined in § 405.906; and
(2) Furnished an item or service to the beneficiary may seek assignment of appeal rights from the beneficiary for that item or service.

 

(b) Who may not be an assignee. An individual or entity who is not a provider or supplier may not be an assignee. A provider or supplier that furnishes an item or service to a beneficiary may not seek assignment for that item or service when considered a party to the initial determination as defined in § 405.906.


(c) Requirements for a valid assignment of appeal right. The assignment of appeal rights must--
(1) Be executed using a CMS standard form;
(2) Be in writing and signed by both the beneficiary assigning his or her appeal rights and by the assignee;
(3) Indicate the item or service for which the assignment of appeal rights is authorized;
(4) Contain a waiver of the assignee's right to collect payment from the assignor for the specific item or service that are the subject of the appeal except as set forth in paragraph (d)(2); and
(5) Be submitted at the same time the request for redetermination or other appeal is filed.


(d) Waiver of right to collect payment.  (1) Except as specified in paragraph (d)(2) of this section, the assignee must waive the right to collect payment for the item or service for which the assignment of appeal rights is made.


If the assignment is revoked under paragraph (g)(2) or (g)(3) of this section, the waiver of the right to collect payment nevertheless remains valid. A waiver of the right to collect payment remains in effect regardless of the outcome of the appeal decision.


(2) The assignee is not prohibited from recovering payment associated with coinsurance or deductibles or when an advance beneficiary notice is properly executed.


(e) Duration of a valid assignment of appeal rights.


Unless revoked, the assignment of appeal rights is valid for all administrative and judicial review associated with the item or service as indicated on the standard CMS form, even in the event of the death of the assignor.


(f) Rights of the assignee. When a valid assignment of appeal rights is executed, the assignor transfers all appeal rights involving the particular item or service to the assignee. These include, but are not limited to--
(1) Obtaining information about the claim to the same extent as the assignor;
(2) Submitting evidence;
(3) Making statements about facts or law; and

(4) Making any request, or giving, or receiving any notice about appeal proceedings.

 

(g) Revocation of assignment. When an assignment of appeal rights is revoked, the rights to appeal revert to the assignee. An assignment of appeal rights may be revoked in any of the following ways:

(1) In writing by the assignor. The revocation of assignment must be delivered to the adjudicator and the assignor, and is effective on the date of receipt by the adjudicator.

(2) By abandonment if the assignee does not file an appeal of an unfavorable decision.

(3) By act or omission by the assignee that is determined by an adjudicator to be contrary to the financial interests of the assignor.

 

(h) Responsibilities of the assignee. Once the assignee files an appeal, the assignee becomes a party to the appeal. The assignee must meet all requirements for appeals that apply to any other party.

 

3. One of the most significant changes

© 2005, Jin Zhou, ERISAclaim.com


Changes to the appeals process (PDF 646K) (511 pages)

 

Page 20 of 511 ("full and early presentation of evidence" was used 8 times.)

 

"a. Requirement for Full and Early Presentation of Evidence
(Section 933(a))


"Section 933(a) of the MMA amends section 1869(b) of the Act to require providers and suppliers to present any evidence for an appeal no later than the QIC reconsideration level, unless there is good cause that prevented the timely introduction of the evidence. In this interim final rule with comment, we are adopting regulations to specify that in the absence of good cause, a provider, supplier, or beneficiary represented by a provider or supplier must present evidence at the QIC level. Evidence not presented by the parties at the QIC level cannot be introduced at a higher level of appeal. See § 405.956(b)(8), § 405.966(a), § 405.1018, and § 405.1122(c)."

 

MMA 933 Revisions to Medicare Appeals Process

 

4. Who is Bound By What?

Compliance For Jackpot!

© 2005, Jin Zhou, ERISAclaim.com


Changes to the appeals process (PDF 646K) (511 pages)

 

Page 169-170 of 511:

 

Thus, as revised, § 405.968 states that a QIC is not bound by LCDs, LMRPs, or CMS program guidance, but will give substantial deference to these policies if they are applicable to a particular case. Moreover, a QIC may decline to follow a policy if the QIC determines, either at party's request or at its own discretion, that the policy does not apply to the facts of the particular case. Thus, QICs will not review LCDs, LMRPs, or other CMS guidance. Rather, they will evaluate the applicability of the LCD, LMRP, or CMS guidance to a particular claim denial. Their decisions will not affect subsequent cases and are not precedential. A QIC does not have the authority to require CMS or a contractor to withdraw or revise its LCDs, LMRPs, or other guidance. This amended provision eliminates the burden imposed on appellants, including beneficiaries, to challenge CMS policies in the claim appeals process. (See section II.G.5 of this preamble for a related discussion of ALJ and MAC consideration of local coverage policies.)

 

page 393 of 511:

 

§ 405.968 Conduct of a reconsideration.

 

"(2) QICs are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but give substantial deference to these policies if they are applicable to a particular case. A QIC may decline to follow a policy, if the QIC determines, either at a party’s request or at its own discretion, that the policy does not apply to the facts of the particular case."

 

 

Page 477-478 0f 511:

 

§ 405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ and MAC.


(a) ALJs and the MAC are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but will give substantial deference to these policies if they are applicable to a particular case.

 

 

 

 

5. Good-Bye to the Existing Medicare Part B "Fair Hearing"

© 2005, Jin Zhou, ERISAclaim.com


Changes to the appeals process (PDF 646K) (511 pages)

 

Page 172-6 of 511:

 

"Comment: Although a few commenters agreed with the proposal that all QIC proceedings would be “on-the-record,”most commenters opposed this proposed policy and recommended that QICs be required to offer appellants an opportunity for a hearing, as has been the case under the existing Part B fair hearing process....."

 

"Response:......Taking into consideration all of the above information, we believe our proposal is consistent with the substantially revised appeals methodology, including faster decision-making time frames, physician reviewers, and lower amount in controversy thresholds. We believe that the Congress was fully aware of the historical meaning of the terms “reconsideration” and “hearing” and did not use them lightly in the new statute. Appellants retain the right to a hearing at the ALJ level, and this hearing will take place generally within the same time frame as a “fair hearing” under the previous Part B appeals process. Thus, we continue to believe that the statute does not intend or require that the QIC reconsideration process include an opportunity for a hearing. Finally, we note that QICs are not precluded from contacting appellants and obtaining
necessary information from them by phone or other means."

 

 

 

6. What's Urgent for Hospitals after May 1, 2005? Level I-II (QIC) Appeal - A Complete New Game!

© 2005, Jin Zhou, ERISAclaim.com


Changes to the appeals process (PDF 646K) (511 pages)

 

Page 34 of 511:

 

 

§ 405.940 Right to a redetermination..........[375]

§ 405.944 Place and method of filing a request for a

    redetermination...........................[378]

§ 405.960 Right to a reconsideration..........[388]

§ 405.962 Time frame for filing a request for a

    reconsideration...........................[388]

§ 405.964 Place and method of filing a request for a

    reconsideration...........................[389]

§ 405.966 Evidence to be submitted with the

    reconsideration request...................[390]

§ 405.968 Conduct of a reconsideration........[392]

§ 405.970 Time frame for making a reconsideration.

                                      ........[395]

§ 405.972 Withdrawal or dismissal of a request for a

    reconsideration...........................[398]

§ 405.974 Reconsideration.....................[401]

§ 405.976 Notice of a reconsideration.........[402]

§ 405.978 Effect of a reconsideration.........[405]

 

 

Changes to the appeals process (PDF 646K) (511 pages)

 

II. Analysis of and Responses to Public Comments

8. Reconsiderations (§ 405.960 through § 405.978)

                                ..........[144-165]

9. Conduct of a Reconsideration (§ 405.968 and

   § 405.976).............................[166-188]

 

 

Implementing a New Medicare Claims Appeals Process (PDF 45K) (3 page) (CMS, 03/01/2005)

 

".....The law includes a series of structural and procedural changes to the appeals process, including:

 

  • Uniform appeal procedures for both Part A and Part B claims;

  • Reduced decision-making time frames for most administrative appeals levels, as well as the right to escalate a case that is not decided on time to the next appeal level;

  • The establishment of new entities, Qualified Independent Contractors (QICs), to conduct reconsiderations of claims denials made by fiscal intermediaries, carriers, and quality improvement organizations;

  • Use of QIC review panels, which include medical professionals, to reconsider all cases involving medical necessity issues; and

  • A requirement for appeals-specific data collection by CMS......"

 

 

7. Successful Appeal under New CMS Appeal Rules: Get Started Now! - A Seminar You Can't Afford to Miss.

Fraud Health Care Cards

 

 

 

 

 

 

 

 

1.     Effective May 1, 2005 for Part A Claims;

2.     Must Decide, after May 1, 2005,  for Appointed or Authorized Representative Status;

3.     "Waiver of right to collect payment.  ...... the assignee must waive the right to collect payment for the item or service for which the assignment of appeal rights is made."

OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]  Testimony of Lewis Morris [PDF]

 

 

8. No appeal rights if a claim returned as unprocessable for incomplete or invalid information.

Unprocessable Unassigned Form CMS-1500 Claims, [MM3500] [R505CP]  Revised: 3/18/2005

 

"A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal rights." [R505CP]

 

New CMS Rules [FR HMT] [Page 11474]

    "Clean claim means a claim that has no defect or impropriety (including any lack of required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under title XVIII within the time periods specified in sections 1816(c) and 1842(c) of the Act."

 

 

 

9. "the reopening regulations" make life a whole lot of easier when there is no need to appeal.

New CMS Rules [FR HMT] [[Page 11423]]

 

"Section 937 of the MMA requires that the Secretary develop a means of allowing providers and suppliers to correct minor errors or omissions to claims submitted under the programs under title XVIII without initiating an appeal. The statute specifies that this process be available no later than December 8, 2004. We have revised Sec. 405.980 to allow providers and suppliers to make these corrections through the reopenings process. See Sec.  405.927 and Sec.  405.980."

 

 

 

New CMS Rules [FR HMT] [[Page 11451]]
 

"b. Distinguishing Between Reopenings and Appeals
"....Response: As we stated in the proposed rule, ``requests for adjustments to claims resulting from clerical errors must be handled through the reopenings process. Therefore, when a contractor makes an adjustment to a claim, the contractor is not processing an appeal, but instead, conducting a reopening'' (67 FR 69327). Moreover, section 937 of the MMA subsequently amended the Act to specify that in the case of minor errors or omissions that are detected in the submission of claims, CMS must give a provider or supplier an opportunity to correct that error or omission without the need to initiate an appeal."

 

 

 

10. "Escalation" to higher level for slow QIC (level II), "De Novo" review by MAC on ALJ (level III & IV), and "Expedited Access to Judicial Review" (Level IV), can we have too much protections?

 

New CMS Rules [FR HMT] [[Page 11454]]
 

"b. Escalation

(1) General Application
    One of the most significant changes required under section 521 of BIPA is the introduction of an appellant's right to escalate a case to an ALJ if a QIC fails to make a timely reconsideration, or to the MAC if an ALJ hearing does not produce a timely decision on an appeal of a QIC reconsideration."

 

New CMS Rules [FR HMT] [[Page 11469]]
 

"Establishing a requirement for ``de novo'' review when the MAC reviews an ALJ decision made after a hearing."

 

 

New CMS Rules [FR HMT] [[Page 11422]]
 

"2. Process for Expedited Access to Judicial Review (Section 932 of the MMA)
    Section 1869(b) of the Act provides for expedited access to judicial review in situations involving Medicare claims appeals. Section 932 of the MMA amends section 1869(b) of the Act by requiring a review entity to respond to a request for expedited access to judicial review in writing within 60 days after receiving the request."

 

 

11. No delays or postpones as you've heard - Implementation date with transition: 04/25/2005, CMS Transmittal - R146OTN

CMS Manual System Department of Health & Human Services (DHHS)
Pub. 100-20 One-Time Notification Centers for Medicare & Medicaid Services (CMS)
Transmittal 146 Date: MARCH 25, 2005
 

CHANGE REQUEST 3530

SUBJECT: Appeals Transition- BIPA Section 521 Appeals

"I. SUMMARY OF CHANGES: The purpose of this CR is to notify Fiscal Intermediaries (FIs) about the upcoming transition to the new second level appeal process. "

 

IMPLEMENTATION DATE: April 25, 2005

 

"III. FUNDING: Medicare contractors shall implement these instructions within their current operating budgets."

Download CMS Transmittal - R146OTN  for more details

 

 

*********************************************

 

 

Medicare Secondary Payer: Improvements Needed to Enhance Debt, GAO Says (U.S. Government Accountability Office)

Excerpt: "Last year, employer-sponsored group health plans ... were responsible for most of the nearly $183 million in outstanding Medicare secondary payer (MSP) debt. MSP debts arise when Medicare inadvertently pays for services that are subsequently determined to be the financial responsibility of another. The Centers for Medicare & Medicaid Services ... administers Medicare with the assistance of about 50 contractors that, as part of their duties, are required to recover MSP debt."

 

Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

 

ERISAclaim.com: "employer-sponsored group health plans" = "ERISA-regulated benefit plans", both self-insured and fully-insured (through purchase of insurance) health plans, (ERISA - Title 29, Chapter 18.  Sec. 1002.)

 

MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)

 

CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)

 

 

CMS News on Wheelchair and Medical Necessity

August 24, 2005:  CMS ISSUES UPDATED REGULATIONS FOR POWER WHEELCHAIR AND POWER OPERATED VEHICLE CLAIMS


December 15, 2004: MEDICARE OPENS NATIONAL COVERAGE DETERMINATION TO MAKE SURE BENEFICIARES WHO NEED WHEELCHAIRS GET THEM

 

October 18, 2004: MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER

“We are working toward completing our overhaul of the Medicare claims appeals system by October 1, 2005 to better serve Medicare beneficiaries, providers, physicians, and other health care providers.”

"Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include:
  • Finalizing the transfer of responsibility for the third level appeals conducted by Administrative Law Judges from the Social Security Administration to the Department of Health and Human Services by October 1, 2005.

  • Developing a new appeal-specific data system that will allow authorized users to track  individual appeals in real time.

  • Establishing an Administrative QIC that will oversee the distribution of case-files, develop appeals processing protocols, conduct training of the QICs, and the dissemination of information on QIC appeals decisions to the public

  • Implementing a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers.   The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision.

Issuing the final regulations needed to implement the new uniform appeals procedures, including the rules QICs and other appeals entities by the end of the year."

 

Maximum Comfort, Inc v. Tommy G. Thompson

(06/30/2004, United States District Court for the Eastern District of California)

 

RenCare Ltd vs. Humana Health Pln TX (5th Cir. 12/30/2004)

 

 

Medicare New Policy: Medical Necessity in Emergency/Critical Care

 

On November 5th, CMS issued a modification to the Medicare Integrity Manual for "Payment for Emergency Medical Treatment and Labor Act (EMTALA) and new policy in making emergency room medical decision terminations", and "Instructs that for an item or service provided by a hospital or critical access hospital pursuant to section 1867of the Social Security Act (EMTALA) on or after January 1, 2004, FIs must make determinations of whether the item or service is reasonable and necessary on the basis of information available to the treating physician or practitioner (including the patient’s presenting symptoms or complaint) at the time the item or service was ordered or furnished by the physician or practitioner (and not only on the patient’s principal diagnosis). The frequency with which an item or service is provided to the patient before or after the time of the service shall not be a consideration."

 

"The FIs shall reopen claims for ED services provided on or after January 1, 2004 that were previously denied prior to the issuance of this instruction if the provider so requests."

 

CMS Manual System Department of Health & Human Services (DHHS)

 

Pub. 100-08 Medicare Program Integrity Centers for Medicare & Medicaid Services (CMS) Transmittal 86 Date: NOVEMBER 5, 2005 CHANGE REQUESTS 3437

http://cms.hhs.gov/Transmittals/downloads/R86PI.pdf

 

Medlearn Matters Articles Table


Article #

Article Release Date

Title

Related CR Number

Related CR Release Date

Related CR Effective Date

Related CR Impl. Date
MM3437 10/28/2004 MMA - Payment for Emergency Medical Treatment and Labor Act (EMTALA)- Mandated Screening and Stabilization Services 3437 10/22/2004 11/22/2005 11/22/2005

 

MM3437: MMA - Payment for Emergency Medical Treatment and Labor Act (EMTALA)-Mandated Screening and Stabilization Services

 

"Provider Action Needed

While voluntary, it is to the provider’s benefit to bill presenting symptoms or complaints in addition to the principal diagnosis. To ensure you are paid appropriately for your services, you may use Form Locator 76 of the UB-92 claim form to bill for the ICD-9-CM code that represents the patient’s reason for the visit. Although only one diagnosis code for the reason for the visit may be recorded in Form Locator 76, at the provider’s discretion additional diagnoses not inherent in the final diagnosis may be reported in Form Locators 68 through 75. Providers may use these fields when billing for items or services, including diagnostic tests, performed under EMTALA, and/or when billed with Revenue Codes 45X, 0516, or 0526 to ensure appropriate payment. We support hospitals’ efforts to educate physicians on documentation to support correct coding, and contractors should assist hospitals in providing this education when requested.

 

This instruction is pursuant to Section 1867of the Social Security Act (EMTALA) for services provided on or after January 1, 2004."

 

Final Rule: CMS-1063-F Medicare Program: Clarifying Policies Related to the Responsibilities of Medicare-participating Hospitals in Treating Individuals with Emergency Medical Conditions (PDF 711Kb) (262 pages)

"ACTION: Final rule.

SUMMARY: This final rule clarifies policies relating to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions who present to a hospital under the provisions of the Emergency Medical Treatment and Labor Act (EMTALA)."

MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER October 18, 2004

“We are working toward completing our overhaul of the Medicare claims appeals system by October 1, 2005 to better serve Medicare beneficiaries, providers, physicians, and other health care providers.”

 

42 CFR Ch. IV (10-1-04 Edition) (GPO Access)

Title 42--Public Health

(This index contains parts 400 to 429)

CHAPTER IV--CENTERS FOR MEDICARE
& MEDICAID SERVICES,
DEPARTMENT OF HEALTH AND
HUMAN SERVICES

 

405 Federal health insurance for the aged and disabled
921 Provider Education and Technical Assistance
931 Transfer of Responsibility for Medicare Appeals
932 Process for Expedited Access to Review
933 Revisions to Medicare Appeals Process
934 Prepayment Review
935 Recovery of Overpayments
937 Process for Correction of Minor Errors and Omissions without Pursuing     Appeals Process
939 Appeals by Providers when there is no Other Party Available
940  

 

Revision to Appeals Timeframes and Amounts
940A Mediation Process for Local Coverage Determinations
952 Revisions to Reassignment Provisions
 

TITLE III—COMBATTING WASTE, FRAUD, AND ABUSE

301  Medicare Secondary Payor (MSP) Provisions

 

CMS QIC Links

www.FCSO.com

www.Maximus.com

www.q2a.com

 

CMS: Contact Your Carrier/Fiscal Intermediary

 

via Toll-Free Numbers and Websites -- A listing of the new toll free numbers that CMS has installed at Medicare contractor sites

US Map

 

 

Medicare Program: Review of National Coverage Determinations and Local Coverage Determinations (CMS-3063-F) (PDF, 838 KB)

Last Modified on Thursday, September 16, 2004

 

2009 GUIDE TO

New Medicare Claims Appeals Process

© 2005-6, Jin Zhou, ERISAclaim.com

 

A Demystified Navigational Guide To CMS Web Site

With Active Hyperlinks to Documents from

both Internet CMS Web site and CD-ROM

On both New Medicare Claims Appeals Process and

Comprehensive Medicare Learning Tools

 

New CMS Home > Outreach and Education > Medlearn Products > Appeals - Fee-for-Services Providers

 Questions Glossary Acronyms
CMS Transmittals     CMS QPU         HOPPS CCI    Physicians CCI

 

New Medicare Claims Appeals Process - CMS Fact Sheet

"Overhaul of the Medicare Claims Appeals System" - CMS News

 Comparison of Current and BIPA 521 Fee-For-Service Appeal ProcessesOpen a PDF file 

Qualified Independent Contractors (QIC) - CMS Fact Sheet

 

CMS Medlearn Matters Articles on New Appeal

[  MM3530 ] [ MM3939 ]  [ MM3944 ] [ MM4019 ]

[MedLearn Provider-Specific Materials]  [MedLearn Complete Publications]

 

CMS New Appeal Process Related CR/Transmittals
{selected by & linked to ERISAclaim.com}

 

View and Download Medicare Appeals Forms

 

New CMS Appeal Rule Print Versions:

[CMS PDF- 511 Pages] [FR PDF- 80 Pages] [FR HMT] [Correction]

 

Provider Customer Service Program - R15COM

 

CMS QIC Links: [www.FCSO.com]   [www.Maximus.com]  [www.q2a.com]

 

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Appeals Functional GuideReturn to cms.hhs.gov Home

Fee-For-Service Providers       MLN Home

Display lists of Managed Care Providers         MLN Home
Open References ListsReferences
Open Manuals ListsManuals
Open Forms ListsForms
Open Education ListsEducation

What Physicians and Other Suppliers Should Know About Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)
Open Related Information ListsRelated Information
Open Other Appeals Processess ListsOther Appeals Processes

Open Current Issue ListsCurrent Issues

Open a PDF file New Enrollee Rights, New Provider Responsibilities in MA Program - Article (Updated Jan 2005)
Open References ListsReferences
Open Manuals ListsManuals
Open Forms ListsForms
Open Education ListsEducation
Open Related Information ListsRelated Information
Open Other Appeals Processess ListsOther Appeals Processes

Medicare Managed Care
APPEALS AND GRIEVANCES

Medicare Learning Network Logo

Provider-Specific Materials

CMS/MedLearn Complete Publications

CMS Releases New Educational Guide on Remittance Advice (RA) Notices:

Medlearn Matters Number: SE0540, 06/24/2005

R743CP (CR 4123) 11/4/2005 Update

Understanding the Remittance Advice (RA): A Guide for Medicare Providers, Physicians, Suppliers, and Billers (June 2005) (PDF format 3.1MB) New

ERISAclaim.com - CMS New Appeal Rules:
"Overhaul of the Medicare Claims Appeals System"

© 2005, Jin Zhou, ERISAclaim.com

 

2009 GUIDE TO

New Medicare Claims Appeals Process

 

CMS Fact Sheet -  New Medicare Claims Appeals Process

CMS News - "Overhaul of the Medicare Claims Appeals System"

 

 Comparison of Current and BIPA 521 Fee-For-Service Appeal ProcessesOpen a PDF file 

Qualified Independent Contractors (QIC)

 

CMS Medlearn Matters Articles on New Appeal

[  MM3530 ] [ MM3939 ]  [ MM3944 ] [ MM4019 ]

 

View and Download Medicare Appeals Forms

 

Provider Customer Service Program - R15COM

 

New CMS Appeal Rule Print Versions:

[CMS PDF- 511 Pages] [FR PDF- 80 Pages] [FR HMT]

 

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Physician Information Resource [PRIT Issues]

Regulations.gov

Medicare.gov site Flag Logo   Home |  Screen Reader Version |  Español
The Official U.S. Government Site for People with Medicare
Help |  Frequently Asked Questions |  Mailing List |  Search Tools

CMS QIC Links

www.FCSO.com

www.Maximus.com

www.q2a.com

 

Medicare Appeals Forms

 

All CMS Forms For your convenience links to CMS program forms, Optional Forms, Standard Forms, SSA Forms and HHS Forms are also provided here.

 

Medicare Appeals Forms

Form Number Form Information
CMS-1696 Appointment of Representative

View Form in Adobe PDF (Size: 10 KB)
CMS-1965 Request for Hearing - Part B Medicare Claim

View Form in Adobe PDF (Size: 9 KB)
CMS-20034A/B, CMS-5011A/B Beginning on July 1st, please follow the instructions below when filing your Request for Medicare Hearing before an Administrative Law Judge (ALJ).
 

If your reconsideration determination was issued by a Qualified Independent Contractor (QIC) please use form CMS-20034A/B

View Form in Adobe PDF (Size: 38 KB).

If your reconsideration or fair hearing determination was issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) please use form CMS-5011A/B

View Form in Adobe PDF (Size: 41 KB).

CMS-10003-NDMC Notice of Denial of Medical Coverage for Medicare + Choice Plans

View Form in Adobe PDF (Size: 31 KB)
View Instructions in Adobe PDF (Size: 22 KB)
CMS-10003-NDP Notice of Denial of Payment for Medicare + Choice Plans

View Form in Adobe PDF (Size: 25 KB)
View Instructions in Adobe PDF (Size: 22 KB)
CMS-20027 Medicare Redetermination Request Form

View Form in Adobe PDF (Size: 27 KB)
CMS-20031 Transfer (Assignment) Of Appeal Rights

View Form in Adobe PDF (Size: 40 KB)
CMS-20033 Medicare Reconsideration Request Form

View Form in Adobe PDF (Size: 27 KB)

 

 

 

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

 

ERISA Not Insurance
 

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

Aetna ERISA Settlemnt with 950,000 MD's

 

Department of Labor

 
"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.

Most private sector health plans are covered by the

 Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

 

 

 

 

 

View CMS Chart Series

 

CMS Facts & Figures

 

CMS offers various Chart Series with recent data on spending, operations, and quality of care in CMS programs. The Chart Series also offer some information on the nation´s health care system, and CMS internal operations.

 

Each of the sections covers a different topic, and is available to view or download as a PowerPoint presentation (.ppt file, recommended) or in Adobe Acrobat (.pdf) format.

 

 

HHS Press Release:
 

2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

HHS FAQ "Questions On Charges For The Uninsured" (PDF)

HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

 

OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"


National Correct Coding Initiative Edits - Version 11
 

National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.3


2003 Improper Medicare Fee-for-Service Payments Report

 

CMS Announces Revisions to Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004

 

Medicare Announces 2004 Physician Fee Schedule and Payment Policy Changes

CMS Files for Download for Medicare Payment Systems

 

CMS Finalizes Appeals Process for Medicare Coverage Decisions

 

2003.12.10: HHS Announces Immediate Steps to Make Medicare-Approved Drug Discount Card Programs Available Next Spring

 

42 CFR Parts 403 and 408
Medicare Program; Medicare Prescription
Drug Discount Card; Interim Rule and Notice (pdf) (89 pages)

 

Revision of Billing Instructions for Purchased Services
 

Regional Offices Link


WPS Medicare Part B - 2005 Medicare Payment Information Available from CD-Rom

 

 

 

 

 

 

CERT  Reports

Improper Medicare Fee-For-Service Payments Report and Update Archive

 

2004 Improper Medicare Fee-For-Service Payments Report

 

Short Report (859 KB)

 

Long Report (1.04 MB)
Long Report Appendix (2.29 MB)

 

First Update Report (356 KB)

 

Second Update Report(369 KB)

 

2003 Improper Medicare Fee-For-Service Payments Report

 

Short Report

(923 KB)

 

Long Report

(2.29 MB)

 

Medlearn Matters Provider Education

Coding and Reimbursement for Consultations in Medicare

03/25/2005

 

Unprocessable Unassigned Form CMS-1500 Claims
03/21/2005

 

DEMONSTRATION TO WORK TOWARD ASSURING ACCURATE MEDICARE PAYMENTS

March 28, 2005

"TESTS ABILITY OF RECOVERY AUDIT CONTRACTORS TO TRACK OVER AND UNDER PAYMENTS"

 

What Physicians and Other Suppliers Should Know About Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)

 

CMS: Notice of New Interest Rate for Medicare Overpayments and Underpayments (R63FM) IMPL DATE: 2/8/2005

 

CMS: Revision to the Beneficiary Notification Process when Recovery is Sought from the Provider (R70FM) IMPL Date: 6/27/2005

 

New Remittance Advice (RA) Message for Referred Clinical Diagnostic / Purchased Diagnostic Service Duplicate Claims (R571CP )

 

Breaking News:  Employer Must Reimburse Medicare Over Payments under MSP

 

Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

 

 

 

 

CMS Carriers Manual

Carriers Manual-Part 3

 

Chiropractic Services

 

2250. CHIROPRACTIC SERVICES - GENERAL
2251. COVERAGE OF CHIROPRACTIC SERVICES
2251.1 Manual Manipulation
2251.2 Utilization Guidelines
2251.3 Necessity for Treatment
2251.4 Location of Subluxation
2251.5 Treatment Guidelines

 

Outpatient Physical Therapy and Speech Pathology Services

 

2206. CONDITIONS FOR COVERAGE OF OUTPATIENT PHYSICAL THERAPY OR SPEECH PATHOLOGY SERVICES
2206.1 Physician’s Certification and Recertification
2206.2 Outpatient Must be Under Care of Physician
2206.3 Outpatient Physical Therapy or Speech Pathology Services Furnished Under Plan
2206.4 Requirement That Services Be Furnished on an Outpatient Basis

 

2207. CODING PHYSICIAN SPECIALTY
2207.1 Coding Type of Supplier and Nonphysician Provider
2210. PAYABLE PHYSICAL THERAPY (PT)
2210.1 Restorative Therapy
2210.2 Maintenance Programs
2210.3 Application of Guidelines

 

[PDF] CR3016: CMS Manual System
... CHANGE REQUEST 3016 I. SUMMARY OF CHANGES: Dentists, podiatrists, and optometrists
are added to the definition/list of physicians who may opt out of Medicare. ...

 

MM3016    MMA-Private Contract Manual Change to include Dentists, Podiatrists, and Optometrists in the Definition/List of Physicians Who Can Opt Out of Medicare

 

New Chiro Demo

Expansion of Coverage of Chiropractic Services Demonstration (CMS)

Special Alert:
(as of 9/19/05)

Provision of Physical Therapy Services Incident to a Chiropractor

April 06, 2005 -

MEDICARE IMPLEMENTS DEMONSTRATION TO EXPAND COVERAGE OF CHIROPRACTIC SERVICES

 

MEDICARE CHIROPRACTIC SERVICES DEMONSTRATION
FINAL DESIGN REPORT,

Click here. (pdf. 532kb)

April 27, 2005

 

  1. Federal Register Notice (.pdf 57 kb)
  2. Press Release (.pdf 58 kb)
  3. Chiropractor Medlearn Matters Article
  4. Laboratory Medlearn Matters Article
  5. Radiology Medlearn Matters Article
  6. Chiropractor Power Point Presentation (.pdf 177 kb)
  7. Beneficiary Fact Sheets

  1. Demonstration Geographic Areas
  1. Diagnosis and Procedure Codes (.pdf 135 kb)
  2. Frequently Asked Questions and Answers (pdf. 18kb)

 

05/06/2005

INSTRUCTIONS RELEASED -- MID-QUARTER

Transmittal 34 ... This instruction affects Comprehensive Outpatient Rehabilitation Facilities, Outpatient Physical Therapy, Skilled Nursing Facilities, Physicians and Non-Physician Practitioners.
View the complete text of Transmittal 34
(PDF - 366 KB)

 

MM3648 (Revisions to the Medicare Benefit Policy Manual (Pub 100-02), Chapter 15, Sections 220 and 230 Regarding Therapy Services)

 

SE0533 (Further Clarification of CR3648, Which Revised the Medicare Benefit Policy Manual (Pub 100-02), Chapter 15, Regarding Therapy Services)

 

National Correct Coding Policy Manual for Part B Medicare Carriers -- Version 10.3

 

"O. Chiropractic Manipulative Treatment" [page 14 of 18]

 

United States of America v. Thomas Bruce Vest,
also known as T. Bruce Vest, doing business as Doctors Clinic

"Second, the Government presented 36 patients who testified that during their visits to the Doctors Clinic, they did not report many of the symptoms and past conditions that Vest recorded on their medical records."

Fraud And Abuse

Fighting Fraud & Abuse

 

MM3449 Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy, Full Replacement of CR 3063 Revised: 11/19/2004

 

CR3449 (10/08/2004)

 

CMS Documentation Guidelines — Evaluation and Management Services

 

R125PI    CR4022

"Medical Review Additional Documentation Requests"

 

R123PI - CR3703

9/23/2005

 

"Chapter 3, MMA Section 935

I. SUMMARY OF CHANGES: This change implements portions of Section 935 of the MMA (entitled Recovery of Overpayments). Specifically, this CR explains to contractors their right to request documentation for a limited sample of submitted claims, after overpayments have been identified,"

 

CMS 2004 Transmittals 90-CR3569: Prepayment Review of Claims for MR Purposes (pdf)

 

"Contractors shall not initiate non-random prepayment medical review of a provider or supplier based on the initial identification by that provider or supplier of an improper billing practice unless there is a likelihood of a sustained or high level of payment error."

 

CMS 2005

Transmittal 120 --

CHANGE REQUEST 3880

"Correction to Change Request (CR) 3222: Local Medical Review Policy/ Local Coverage Determination Medicare Summary Notice (MSN) Message Revision"

"E. Distinguishing Between Benefit Category, Statutory Exclusion and Reasonable and Necessary Denials"

 

R13SOM: Revisions to Chapter 2, "The Certification Process," Appendix E-- "Providers of Outpatient Physical Therapy or Outpatient Speech Language Pathology (OPT/OSP) Services," and Appendix K-- "Comprehensive Outpatient Rehabilitation Facilities"

 

Medicare Program Integrity Manual

 

Chapter 3: Verifying Potential Errors and Taking Corrective Actions (pdf) (Zipped Word File)

 

 

Medical Review Strategy

 

"In addition to carry-over of several of the FY 2004 focuses, the new FY 2005 focus areas will be:

  • Chiropractic services
  • Level of consultations
  • Follow-up consultations

 

Transmittal 34

 

General Coverage of Physician Services***NCP

PHYS-001

 

Physician Visits, Documentation and Interpretation of Test Results***NCP

PHYS-002

 

Incident To a Physician's Professional Service in the Office or Clinic***NCP

PHYS-004

 

Outpatient Physical Therapy, Occupational Therapy and Speech-Language Pathology

PHYSMED-001

 

Coding Guidelines:
"...7. *The date the patient was last seen and the UPIN of the attending physician must be listed in Item 19 on the CMS-1500 form or the electronic equivalent."

 

Physical Medicine and Rehabilitation Procedures and Modalities

PHYSMED-009

 

Neuromuscular Electrical Stimulation (NMES)

PHYSMED-011

 

Illinois WPS Medicare Part B - Provider Education - Claim Information

 

Seminar Schedule

"WPS is frequently asked if we offer Continuing Education Units (CEUs) for our programs. We are happy to announce that......"

 

Seminar Materials

 

 

CMS (HCFA) 1500 Claim Form Instructions (pdf - 72 pages; 695KB)

 

Timely Filing of Claims

 

Unprocessable Claim Guidelines

 

How to Appeal a Claim Determination

 

 

Chiropractic Care Educational Guidebook (pdf - 95 pages; 476KB)

 - Jan. 2005

 

WPS Medicare Part B - Chiropractic FAQs

 

WPS Medicare Part B - 2005 Medicare Payment Information Available from CD-Rom

 

 

Medicare Part B WPS Search on "chiropractic care" 

 

Teleconferences

 

 

WPS Communiqué

 

Virginia TrailBlazer Part BHome Page

 

1500 Claim Form/Unprocessable Claim Form Instructions

 

Top 10 Billing Errors

 

General Principles of Documenting Patient's Medical Records

 

Provider Outreach and Education (Educational issues)

 

Audio Training

Chiropractic Services

 

CMS 1500 Claim Form Instructions

 

Part B Problem Solving Guide Adobe PDF or the TrailBlazer Medicare Part B Mid - Atlantic Important Contacts Adobe PDF.

 

Iowa Noridian Medicare: Provider Homepage

 

Noridian Medicare: Provider: Publications: Medicare B: Medical Policies

 

Chiropractic Services Policy

 

Chiropractic BBM July 2003

 

Chiropractic Care

 

Documentation

 

Diagnosis Criteria

 

x-ray

 

Advanced Beneficiary Notice

 

Questions and Answers

 

Chiropractic Demonstration Project

 

Appeals

Recoupment

EDI

Education

 

Telephone Appeals Changing Hours

5/11/2005

 

Medicare Part B Appeal

 

Documentation

 

Fraud and Abuse

 

Medicare Part B: Medicare Chiropractic Billing

Medicare Part B Workshop
 

Medicare B News Bulletins and LMRPs-LCDs(1994 to Current)     

 

 

NM Welcome To Arkansas Medicare Services

 

Fee Schedules

 

How to Complete the CMS-1500 Form

 

Helpful Hints for Filing Claims

 

Maine National Heritage Insurance Company

 

National Heritage Insurance Company is the Medicare Part B contractor for California, Maine, Massachusetts, New Hampshire, and Vermont, serving 5.5 million beneficiaries and 178,000 healthcare providers.

 

Physical Therapy Documention Books

Writing Soap Notes: With Patient/Client Management Formats by Ginge Kettenback, Ginge, MS, Pt Kettenbach (Paperback)

 

CMS Contractors

Medicare Provider Customer Service - Learning Resources

 

Claims Processing Manual Table of Contents

 

Medlearn Quick Reference Guides

 

Documentation Guidelines — Evaluation and Management Services

 

Medicare Learning Network - Coding Educational Resource Web Guide

 

ICD-9-CM Official Coding Guidelines

ICD-9-CM Official Guidelines for Coding and Reporting
Effective April 1, 2005 Narrative changes appear in bold text The guidelines have been updated to include the V Code Table

 

ICD-9-CM Conversion Table

 

Effective October 1, 2004

 

 

Other Coding Resources:

 

 

Training Materials & Courses

 

Fraud And Abuse

Fighting Fraud & Abuse

Fraud Schemes and Related Information

United States of America v. Thomas Bruce Vest,
also known as T. Bruce Vest, doing business as Doctors Clinic

"Second, the Government presented 36 patients who testified that during their visits to the Doctors Clinic, they did not report many of the symptoms and past conditions that Vest recorded on their medical records."

Contractor Instructions

 

Medical Review

"Most medical review doesn't require medical records"

 

MR Home

PI Manual

LMRP

Tech. Asst.

Links

CMNs

 

National Correct Coding Initiative (NCCI)

 

[PDF] MODIFIER -59 ARTICLE:

Proper Usage Regarding Distinct Procedural Service

 

 

HOPPS CCI EDITS

 

Physicians CCI EDITS

 
NCCI Policy Manual for Part B Medicare Carriers
Medicare Claims Processing Manual (Sec. 20.9)
NCCI FAQs
NCCI Edits Program Transmittals

   
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