Appeal Process Summarized

On Tuesday, May 5th, 2015, Barbara Wright facilitated a national webinar discussing the new Appeals process issued by CMS. This new process will streamline appeals on demand letters for applicable plans (liability insurance, no fault insurance and workers’ compensation insurance). This rule went into effect on April 28, 2015 and applies to demand letters issued after this date.

The process establishes a multilevel appeal process for applicable plans where recovery is pursued directly from the applicable plan. The demand letter and subsequent response letters will provide specific timeframes and/or other requirement to proceed to the next level of appeal.

  • Initial determination (MSP recovery demand letter)
  • Redetermination by the contractor (BCRC)
  • Reconsideration by Qualified Independent Contractor
  • Hearing by an Administrative Law Judge (ALJ)
  • Departmental appeals boards’ Medicare appeals Council
  • Judicial review

CMS has issued guidelines surrounding what can be appealed and what cannot. Examples of what cannot be appealed are: causation; who/what entity to pursue recovery from; reduction of attorney fees will not be allowed if the applicable plan is listed as the debtor. Examples of what can be appealed are: the amount of the demand; proof that the limits have been exhausted.

Below are some tips from CMS to follow:

  • Tip 1: If the responsible payer (debtor) does not respond in a timely manner all rights of appeal will be voided
  • Tip 2: Submit updated LOAs with cover letter noting the Case ID and reason for submitting
  • Tip 3: Do not use the word “Appeal” unless the correspondence is an appeal. For example, on negotiations for conditional payment estimates, the word appeal should not be used.
  • Tip 4: Be specific about what you are appealing. Provide documentation supporting your appeal
  • Tip 5: Interest will accrue every 30 days. Consider paying the amount that you are not appealing to avoid interest.

NOTE: It is assumed the demand letter is received 5 days after the letter was mailed unless otherwise proven.

NuQuest/Bridge Pointe is dedicated to guiding our customers through this process. We want to invite you to call us if you would like further information.

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