Welcome back to our short series on options for resolving Medicare denials. If you missed last week’s article on reopening claims, you can catch up here. Otherwise, let’s talk about two more options: resubmitting and appealing claims.
When to Resubmit a Claim
As a general rule, if claims can be reopened, they can also be resubmitted as long as the service date is timely and the original claim denied. Resubmissions of partially paid claims, however, will deny as a duplicate; these corrections must proceed through the reopenings channel. Resubmission ultimately reduces the biller’s time investment because it is often faster to resubmit a claim than to navigate the IVR to speak with a service representative. Suppliers should resubmit claims that deny for:
Ideal candidates for resubmission:
All the denials from the reopenings list (where the service date is timely and the MACs denied payment).
16 denials with N265 and N276 remark codes (missing information PECOS name errors). Correct the physician’s first initial and last name in your billing system to match the PECOS record, then resubmit the claim.
16 denials with an M60 remark code (missing information missing CMN). Confirm the CMN is not missing critical elements, then reattach the CMN, and resubmit the claim.
107 denials (service not identified). Add a narrative: “For use with patient owned DME (HCPCS) delivered on (month/year),” and resubmit the claim.
176 denials (prescription not current). Add a narrative: “Please extend the CMN to allow for remaining payments due to break in service,” and resubmit the claim.
The fine print: Suppliers must resubmit all rejected claims with an MA130 remark code. After the supplier links the missing element and resubmits the claim, the DME MACs usually process the claim within 14 days of receipt. Contractually, the DME MACs can take up to 30 days to process a claim, but they rarely take that long. Suppliers must resubmit claims within 365 days of the date of service. Suppliers cannot resubmit medical necessity denials or partially paid claims.
When to Appeal a Claim
Suppliers should formally appeal denials related to:
Ideal candidates for appeals:
50 denials (medical necessity). When Medicare audits suppliers, medical reviewers often find errors in the supporting medical records. Always call to find out why the claim denied and what medical record is at fault. Appeal the decision with records that fill in the gaps.
150 denials (level of service not supported). Look up same or similar history on the Medicare portal to determine if the patient received a similar item from your company and another supplier within the useful lifetime. Appeal the decision if you have documentation to support the previous product failed after the useful lifetime (generally 5 years) or if loss, theft, damage, or change in the beneficiary’s medical condition can justify the early replacement.
151 denials (frequency of service). This denial typically applies to recurring supplies with frequency limitations. Determine how many units are billable in a 3-month period and look up same or similar on the Medicare portal to determine when the patient received a similar product. Appeal the decision if you have documentation to support the claim does not overlap a prior product or if loss, theft, damage, or change in condition can justify the early service.
The fine print: The DME MACs usually process appeals within 30-45 days. Contractually, the MACs have up to 60 days to process appeal requests. Suppliers must file the initial appeal within 120 days of the original remittance date.
Next week, we will talk about strategies for optimizing the use of each of the denial resolution strategies.
When to Resubmit a Claim
As a general rule, if claims can be reopened, they can also be resubmitted as long as the service date is timely and the original claim denied. Resubmissions of partially paid claims, however, will deny as a duplicate; these corrections must proceed through the reopenings channel. Resubmission ultimately reduces the biller’s time investment because it is often faster to resubmit a claim than to navigate the IVR to speak with a service representative. Suppliers should resubmit claims that deny for:
- Missing:
- Narratives (e.g. patient owned equipment or miscellaneous code).
- Primary payment information.
- Pricing modifiers (e.g. NU, RR, KH, KI, KJ).
- Certificates of Medical Necessity (CMNs).
- Facility details (e.g. when the place of service is not 12 “home”).
- Expired or invalid procedure codes.
- Expired or invalid diagnosis codes.
- Physician PECOS error.
- Critical elements that cause rejection (look for an MA130 remark code).
Ideal candidates for resubmission:
All the denials from the reopenings list (where the service date is timely and the MACs denied payment).
16 denials with N265 and N276 remark codes (missing information PECOS name errors). Correct the physician’s first initial and last name in your billing system to match the PECOS record, then resubmit the claim.
16 denials with an M60 remark code (missing information missing CMN). Confirm the CMN is not missing critical elements, then reattach the CMN, and resubmit the claim.
107 denials (service not identified). Add a narrative: “For use with patient owned DME (HCPCS) delivered on (month/year),” and resubmit the claim.
176 denials (prescription not current). Add a narrative: “Please extend the CMN to allow for remaining payments due to break in service,” and resubmit the claim.
The fine print: Suppliers must resubmit all rejected claims with an MA130 remark code. After the supplier links the missing element and resubmits the claim, the DME MACs usually process the claim within 14 days of receipt. Contractually, the DME MACs can take up to 30 days to process a claim, but they rarely take that long. Suppliers must resubmit claims within 365 days of the date of service. Suppliers cannot resubmit medical necessity denials or partially paid claims.
When to Appeal a Claim
Suppliers should formally appeal denials related to:
- Medical necessity (missing medical records from an audit).
- Missing policy-specific modifiers (KX, CG modifiers).
- Missing or invalid Advance Beneficiary Notice or modifier combination (GA, GK modifiers).
- Diagnosis codes that do not support medical need.
- CMN errors and denied CMNs.
- Excessive quantities.
- Same or similar equipment.
Ideal candidates for appeals:
50 denials (medical necessity). When Medicare audits suppliers, medical reviewers often find errors in the supporting medical records. Always call to find out why the claim denied and what medical record is at fault. Appeal the decision with records that fill in the gaps.
150 denials (level of service not supported). Look up same or similar history on the Medicare portal to determine if the patient received a similar item from your company and another supplier within the useful lifetime. Appeal the decision if you have documentation to support the previous product failed after the useful lifetime (generally 5 years) or if loss, theft, damage, or change in the beneficiary’s medical condition can justify the early replacement.
151 denials (frequency of service). This denial typically applies to recurring supplies with frequency limitations. Determine how many units are billable in a 3-month period and look up same or similar on the Medicare portal to determine when the patient received a similar product. Appeal the decision if you have documentation to support the claim does not overlap a prior product or if loss, theft, damage, or change in condition can justify the early service.
The fine print: The DME MACs usually process appeals within 30-45 days. Contractually, the MACs have up to 60 days to process appeal requests. Suppliers must file the initial appeal within 120 days of the original remittance date.
Next week, we will talk about strategies for optimizing the use of each of the denial resolution strategies.
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