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medicare managed care appeals

MAXIMUS Federal Services, Inc.. Who We Are and What We DoIndependent Review EntityStaff includes Health Care Attorneys and NursesIndependent Medical Panel More than 20 years direct experience with Medicare managed care appeals. 2. Working with MAXIMUS. Sending CasesCase ProcessingEffectuation Advanced Appeal Issues

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medicare managed care appeals

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    1. Medicare Managed Care Appeals MAXIMUS Federal Services, Inc.

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    3. Working with MAXIMUS Sending Cases Case Processing Effectuation Advanced Appeal Issues – Valid Appeal 3

    4. Sending Cases – Part C Available to receive cases Monday – Saturday and most holidays Do not send via facsimile Expedited appeals – use NOI to confirm Standard appeals – MAXIMUS sends acknowledgement letters within two business days 4

    5. Case Processing – Preparing A Case File Three components: Reconsideration Background Data Form (RBDF) Case Narrative Supporting Documentation 5

    6. Case Processing – RBDF New version of the RBDF (12/09) available on www.medicareappeal.com Purpose? Case file initiation Case file adjudication Data collection 6

    7. Case Processing – RBDF and Case Narrative The RBDF and Case Narrative summarize: Who – Defines appellant, enrollee and relevant treating providers What – Describes the service(s) in dispute When – Provides dates of service involved and appeal processing dates Why there is a dispute – Gives the arguments of each party 7

    8. Case Processing – Supporting Documentation Supporting documentation includes: Documentation of valid requestor (Ex.: AOR, WOL) Organization Determination Notice Appeal request Medical records, if applicable EOC Not needed for dismissals EOCs on compact disc are acceptable 8

    9. Case Processing – Part C QIC The Part C QIC: Assesses the case Resolves key discrepancies by requesting additional information Renders a decision Decision letter sent to health plan via facsimile same day Mailed to appellant 9

    10. Effectuation – Part C Compliance statement sent with decision letter Use appeal number for appeal level at which compliance is required Check number/EFT number required for standard claim cases Send within 14 days of effectuation Reminder notices sent to health plan for missing information 10

    11. Sample Effectuation ReminderReport 11

    12. Effectuation – Part C Why is the case still on the report? Incomplete information Missing check/EFT number (standard claim case) Potential decision/effectuation conflict Partial overturn at two appeal levels Report Lag Effectuation received after report run; therefore may appear on subsequent report 12

    13. Effectuation – Part C How do I submit a Statement of Compliance? Mail to: 50 Square Dr., Suite 210, Victor, NY 14564 Fax: 585-425-5292 Scan and email: medicareappeal@maximus.com What if I have questions/concerns about the report? Call Customer Service: 585-425-5210 Fax: 585-425-5292 Email: medicareappeal@maximus.com 13

    14. Advanced Processing Issues – Valid Appeal Request 14

    15. Valid Requestors Valid requestors include: Enrollees Non-contract providers with a Waiver of Liability (WOL) Enrollee Estate Valid Representatives (Ex.: AOR, POA, legal guardianship, healthcare proxy) Treating physicians 15

    16. Valid Requestors – Required Documentation Representative Appt. of Representative, CMS Form 1696 POA, or other legally recognized relationship If missing, Plan to attempt to obtain Estate documentation Non-contract Provider Waiver of Liability If missing, Plan to attempt to obtain 16

    17. Valid Issues Enrollee liability Plan level organization determination Coverage issue Not a quality of care/service concern Not a grievance Timely Request Good cause evaluation Enrollee gets service during standard service reconsideration (MMCM, Chap. 13, Section 70.7.5) Does not apply to expedited requests 17

    18. Valid Recon Request Methods – Standard Claim Written Enrollee Representative - AOR, health care proxy, etc. Estate Representative Non-contract Provider – WOL Contract Provider – AOR (cannot use enrollee appeal process for contractual payment disputes) Oral Plan must document and verify oral requests 18

    19. Valid Recon Request Methods – Standard Service Written Enrollee Representative – AOR, health care proxy, etc. Contract or Non-contract Treating Physician Enrollee knows of appeal request No AOR required Oral Must document and verify oral requests 19

    20. Valid Recon Request Methods – Expedited Oral or Written Enrollee Physician Valid Representative Enrollee’s life, health, or maximum function is jeopardized Cannot involve claim payment 20

    21. Key Points Submit complete case file Use available forms www.medicareappeal.com Ensure valid appeal request Requestor Issue Method Questions: medicareappeal@maximus.com 21

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