Welcome back to the final article in our short series on resolving Medicare denials. If you missed the previous posts on reopening claims or resubmissions and appeals, you may want to go back and read those first. Otherwise, let’s wrap it up with a practical discussion about the strategy of making a choice in the context of procedural differences unique to each resolution option.
Engagement Time (shortest to longest)
Suppliers have a limited amount of time to engage each of the escalation options. After a certain point, the age will limit the available options. For example, if a post payment review recoups a two-year-old claim, the date of service will be too old to resubmit, but the denial breathes new life into the appeal and reopen pathways. Some denials can only be appealed, and if suppliers fail to escalate the appeal within 120 days of the denial, they must write off the balance.
Engagement times are as follows:
Processing Time (shortest to longest)
In terms of processing time, telephone reopenings and claim resubmissions offer clear advantages when compared to written reopenings and appeals. Preparing any written document just takes longer in most cases.
General processing times are as follows:
The nature of the denial, however, may narrow the field of available options. Some denials can only be appealed (See Denial Types below).
Supplier Preparation Time (shortest to longest)
Preparation time is a finite resource, and as such, suppliers should consider it thoughtfully. Clearly, we should keep prep time minimal, but suppliers cannot afford to pursue an option that doesn’t fix the problem. Appeals take the most time to prepare, but they may be the only means to resolve the denial, if not the best means to get the point across.
Typical preparation times are as follows:
Denial Types
Sometimes the characteristics of the denial itself can limit escalation options.
Rejected claims do not have appeal or reopen rights. They must be resubmitted. These claims typically present on EOBs with a MA130 remark code.
Medical necessity denials, on the other hand, cannot be reopened or resubmitted. They must be appealed. Examples of medical necessity denials include CO-50 (medical necessity), CO-150 (level of service), and CO-151 (frequency of service). If the supplier doesn’t appeal the denial within 120 days of the EOB notification, they must write off the open balance.
And so, a basic understanding of each option … the situations in which it applies, the effort required to execute … goes a long way toward an efficient billing operation. At the risk of sounding clichéd, work smarter, not harder.
Engagement Time (shortest to longest)
Suppliers have a limited amount of time to engage each of the escalation options. After a certain point, the age will limit the available options. For example, if a post payment review recoups a two-year-old claim, the date of service will be too old to resubmit, but the denial breathes new life into the appeal and reopen pathways. Some denials can only be appealed, and if suppliers fail to escalate the appeal within 120 days of the denial, they must write off the balance.
Engagement times are as follows:
- Appeal – Suppliers only have 120 days from the denial date to engage a formal appeal.
- Resubmit – Suppliers have one year from the date of service to resubmit a claim.
- Reopen – Suppliers have one year from the last denial date to request either a telephone or written reopening (even if the date of service is now past timely filing).
Processing Time (shortest to longest)
In terms of processing time, telephone reopenings and claim resubmissions offer clear advantages when compared to written reopenings and appeals. Preparing any written document just takes longer in most cases.
General processing times are as follows:
- Telephone reopening – The MACs often process requests in as few as five days.
- Resubmit – Electronic claims often process in 14 days.
- Written reopening – The MACs often process requests within 15-30 days.
- Appeal – The MACs often process requests in 30-45 days.
The nature of the denial, however, may narrow the field of available options. Some denials can only be appealed (See Denial Types below).
Supplier Preparation Time (shortest to longest)
Preparation time is a finite resource, and as such, suppliers should consider it thoughtfully. Clearly, we should keep prep time minimal, but suppliers cannot afford to pursue an option that doesn’t fix the problem. Appeals take the most time to prepare, but they may be the only means to resolve the denial, if not the best means to get the point across.
Typical preparation times are as follows:
- Resubmit – 1-2 minutes to fix the error in the billing system.
- Telephone reopening – 10 minutes to engage the customer service representative and make the change.
- Written reopening – 15 minutes to prepare the document and fax the request.
- Appeal – 20-30 minutes to assemble documentation, make the case, and fax the request.
Denial Types
Sometimes the characteristics of the denial itself can limit escalation options.
Rejected claims do not have appeal or reopen rights. They must be resubmitted. These claims typically present on EOBs with a MA130 remark code.
Medical necessity denials, on the other hand, cannot be reopened or resubmitted. They must be appealed. Examples of medical necessity denials include CO-50 (medical necessity), CO-150 (level of service), and CO-151 (frequency of service). If the supplier doesn’t appeal the denial within 120 days of the EOB notification, they must write off the open balance.
And so, a basic understanding of each option … the situations in which it applies, the effort required to execute … goes a long way toward an efficient billing operation. At the risk of sounding clichéd, work smarter, not harder.
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