Medicare Medical Record Reviews & Levels Of Appeals Process

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The healthcare industry is experiencing a significant increase in Medicare Part A and Medicare Part B (Fee for Service) Medical Record Reviews by The Centers for Medicare and Medicaid Services (CMS). Typically, the process begins with an Additional Development Request (ADR) or a Targeted Probe and Education (TPE) seeking portions of the medical record that supports the rationale for skilled services under the Medicare Part A and Medicare Part B Insurance benefit.

The Centers for Medicare and Medicaid Services (CMS) contracts with Medicare Administrative Contractors (MACs) to assist with local claims processing and to review the first level appeals adjudication functions.

These Medical Record Reviews are prompted by an item on the UB-04, specific to the patient, such as the:

HIPPS Code
ICD-10 Code
RUG Level
Dates of Service

In these cases, the health care provider may receive requests for a few patients, in the range of 2 to 5 claims per provider.

Other times, the Medical Record Reviews may be part of a widely diffused request for items from the medical record to discover information about the billing practices or patterns of an organization. These types of reviews are known as “Probe Reviews” in which MACs may assess 20 to 40 claims per provider for “provider-specific” issues.

MACs also perform widespread prove reviews including around 100 claims per provider. These types of audits are triggered when there is a perceived outlier in the provider’s billing practice, such as an abrupt, sharp increase in billing for a specific procedure.

Although It is customary for providers to receive requests from MACs, providers need to pay close attention to these requests and ensure that there is an effective system in place to track timeliness and accuracy of the data submission. Even when providers submit all the requested data, it is not uncommon for the MAC to deny a portion of, if not the entire claim.

When any part of a claim is denied, the provider has the right to petition a second opinion. The appellant is the individual filing the appeal. (For procedures for conducting appeals of claims in Traditional Medicare, i.e., Medicare Part A and Part B, see Section 1869 of the Social Security Act and 42 C.F.R. Part 405 Subpart I.)

The claim appeals process has five levels:

LEVEL 1: Redetermination by a CMS contractor (carrier, fiscal intermediary or Medicare Administrative Contractor (MAC)).

LEVEL 2: Reconsideration by a Qualified Independent Contractor (QIC).

LEVEL 3: Hearings before an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals in the Department of Health and Human Services.

LEVEL 4: Review by the Appeals Council within the Department Appeals Board in the Department of Health and Human Services.

LEVEL 5: Judicial Review in federal district court.

Further relevant details on requesting appeals, for each of the five levels, is summarized below.

1. Redetermination (First Level of Appeal) Form CMS-20027

For the First Level of Appeal (traditional), the MAC is involved in deciding the results of the redetermination. The appellant (the individual filing the appeal) must file the request for redetermination with the contractor within 120 days from the date of receipt of the initial determination. The appellant should attach any supporting documentation to their redetermination request. Note: If a claim contains a minor error or omission, the claim may be corrected through the reopening process rather than the appeals process.

The request for a redetermination may be filed on Form CMS-20027.

Response:

The initial determination is the Medicare Summary Notice (MSN) issued to beneficiaries, and the Remittance Advice (RA) issued to providers and suppliers.

A minimum monetary threshold is not required to request a redetermination.

A decision will be rendered within 60 days of receipt of the redetermination request. The results will be communicated via a letter, Medicare Summary Notice (MSN) or a Remittance Advice (RA).

Note:

EXPEDITED Medicare Part A Redetermination (Notice of Discharge or Service Termination)

For the First Level of Appeal (expedited), the MAC is not involved in deciding the results of the redetermination. A Qualified Independent Contractor (QIC) is involved in deciding the results of the redetermination. The appellant must file the request for redetermination with the contractor by noon the next calendar day from the Notice of Discharge or Service Termination.

Response:

A decision will be rendered within 72 Hours of receipt of the redetermination request.

2. Reconsideration (Second Level of Appeal) Form CMS-20023

If the appellant is dissatisfied with the results of the redetermination, the appellant may enter the Second Level of Appeal and request a reconsideration to be conducted by a Qualified Independent Contractor (QIC).

The appellant must file a written reconsideration request within 180 days of receipt of the redetermination.

The Qualified Independent Contractor (QIC) reconsideration process allows for an independent review of an initial determination, which may include review of medical necessity issues by a panel of health care professionals.

In the request for reconsideration, the appellant should clearly explain the reason for disputing the redetermination decision. A copy of the Remittance Advice (RA) or Medicare Redetermination Notices (MRN), and any other useful documentation should be sent with the reconsideration request. Any evidence noted in the redetermination and all evidence relevant to the appeal must be submitted prior to the issuance of the reconsideration decision.

Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless the appellant demonstrates good cause for submitting the evidence late.

A request for a reconsideration may be made on the Form CMS-20023.

Response:

A minimum monetary threshold is not required to request a reconsideration.

A decision will be rendered within 60 days of receipt of the request for reconsideration.

Documentation that is submitted after the reconsideration request has been filed may result in an extension of the decision-making timeframe for the Qualified Independent Contractor (QIC).

If the Qualified Independent Contractor (QIC) cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an Administrative Law Judge Hearing (ALJ).

The decision will contain information regarding further appeal rights.

3. Administrative Law Judge Hearing (ALJ) (Third Level of Appeal) Form OMHA-104

If the minimum monetary threshold is met and remains in controversy following a Qualified Independent Contractor’s (QIC’s) decision, a party to the reconsideration may request an Administrative Law Judge Hearing (ALJ) hearing within 60 days of receipt of the reconsideration decision. The reconsideration decision letter provides details regarding the procedures for requesting an Administrative Law Judge Hearing (ALJ) hearing.

The request for an Administrative Law Judge Hearing (ALJ) may be filed on Form OMHA-104 which is called “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form.

Appellants must also send a copy of the Administrative Law Judge Hearing (ALJ) hearing request to all other parties to the QIC reconsideration.

Administrative Law Judge Hearing (ALJ) hearings are generally held by video teleconference (VTC) or by telephone.

If the appellant does not want a VTC or telephone hearting, the appellant may ask for an in-person hearing.
An appellant must demonstrate good cause for requesting an in-person hearing.
The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis.
Appellants may also ask the Administrative Law Judge Hearing (ALJ) to decide without a hearing (on-the-record).

Hearing preparation procedures are set by the ALJU. CMS or its contractors may become a party to, or participate in, an Administrative Law Judge Hearing (ALJ) hearing after providing notice to the ALJ and the parties to the hearing.

Response:

A minimum monetary threshold is required to request an Administrative Law Judge Hearing (ALJ). For calendar year 2022, the amount in controversy is $180.00.

The Administrative Law Judge Hearing (ALJ) will generally issue a decision within 90 days of receipt of the hearing request.

This timeframe may be extended for a variety of reasons including but not limited to:

The case being escalated from the reconsideration level,
The submission of additional evidence not included with the hearing request,
The request for an in-person hearing,
The appellant’s failure to send notice of the hearing request to other parties, and
The initiation of discovery if CMS is a party.

If the Administrative Law Judge Hearing (ALJ) does not issue a decision within the applicable timeframe, the appellant may ask the Administrative Law Judge Hearing (ALJ) to escalate the case to the Appeals Council level.

The monetary threshold to request an Administrative Law Judge Hearing (ALJ) hearing is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

4. Appeals Council Review (Fourth Level of Appeal) Form DAB 101

If a party to the Administrative Law Judge Hearing (ALJ) hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Appeals Council. The request for Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ’s decision and must specify the issues and findings that are being contested.

The request for an Appeals Council Review may be filed on Form DAB 101.

Response:

A minimum monetary threshold is not required to request an Appeals Council Review.

Appeals Council will issue a decision within 90 days of receipt of a request for review.

That timeframe may be extended for various reasons, including but not limited to, the case being escalated from an ALJ hearing.

If the Appeals Council does not issue a decision within the applicable timeframe, the appellant may ask the Appeals Council to escalate the case to the Judicial Review level.

5. Judicial Review in U.S. District Court (Fifth Level of Appeal) Form 1696

If the provider is dissatisfied with the Appeals Council’s decision, a party to the decision may request judicial review in federal district court. The appellant must file the request for review within 60 days of receipt of the Appeals Council’s decision and must specify the issues and findings that are being contested. The Appeals Council’s decision will contain information about the procedures for requesting judicial review.

Response:

A minimum monetary threshold is required to request a reconsideration. For 2022, the minimum dollar amount is $1,760. Appellant may be able to combine claims to meet this dollar amount.

The Judicial Review will issue a decision within 90 days of receipt of a request for review.

The monetary threshold to request a Judicial Review in U.S. District Court is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

In closing, HHI hopes this article helps clarify any confusion on the Medicare Medical Record Reviews and Appeals Process.

Harmony Healthcare International, Inc (HHI) is an internationally recognized, premier Healthcare Consulting firm that uses a systematic approach to addressing Compliance, Analysis, Audit, Regulatory, Rehabilitation, Reimbursement, Education, Efficiency and Survey areas of opportunity and areas of concern. The C.A.R.E.S.™ platform is originated and trademarked by Harmony Healthcare International, Inc (HHI).