In the complexities of Medicare claim submission, providers encounter various processes that play a vital role in the reimbursement journey. Here’s a breakdown of common definitions for different claim submission types:
1. Appeals:
An appeal is an independent review of the initial or revised determination, and it is the provider’s responsibility to initiate this process. There are five levels of appeal, with the first being a redetermination. Providers can find more detailed information in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29.
2. Postpayment Review:
After receiving payment for rendered services, providers may undergo a post-payment review, requiring the submission of supporting documentation. This review may lead to recoupment or adjustment of payment. Further details can be found in CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.5.
3. Prepayment Review:
Providers under prepayment review submit documentation for review before receiving payment for services already rendered. This process results in an initial determination. Additional information is available in CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.
4. Prior Authorization:
Prior authorization necessitates providers to submit documentation for approval before rendering a proposed service. Non-compliance leads to non-affirmation of the service. After service completion, the existing claim review processes and responses summarized in this document apply. CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.10, provides comprehensive information.
5. Reopenings:
Reopenings are separate from the appeals process and are at the discretion of the MAC (Medicare Administrative Contractor). MACs may revise an initial determination due to clerical errors or omissions. It’s important to note that submitting a reopening request does not impact the appeal timeframe. Refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 34, for detailed guidance.
6. Reopening for No Response Denials:
A reopening is conducted for claims denied for no response, indicating that no documentation was returned upon MAC request. The decision rendered on a reopening for no response serves as the initial determination. Providers can delve into CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.9, for further insights.
Understanding these common definitions is instrumental for providers navigating the complexities of the Medicare claim submission process, ensuring compliance, and facilitating efficient reimbursement procedures.
Source: https://www.ngsmedicare.com/
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