Claim Reconsideration Requests and Corrected Claims
All claim requests for reconsideration and corrected claims must be received within 90 calendar days from the date of the Explanation of Payment (EOP). If a provider has a question or is not satisfied with the information they have received related to a claim they may reach out to Nebraska Total Care in the following ways:
- Submit a claim reconsideration request in writing using the Reconsideration Form with supporting documentation via mail to: Attn: Claim Reconsiderations, PO Box 5060, Farmington, MO 63640-5060 Nebraska Total Care shall process, and finalize all adjusted claims, requests for reconsideration and disputed claims to a paid or denied status 30 calendar days of receipt of the corrected claim, request for reconsideration or claim dispute. Below are the different reconsideration situations.
- First time disputing a payment/denial of a claim
- Provider has disputed payment/denial of the claim once before but has now made changes to their billing
- Dispute changes due to a change in denial/status of the claim
Claim Appeal
In order to file a claim appeal the provider MUST have received an unsatisfactory response to a request for claim reconsideration. Submit the following items when filing a claim appeal within 60 days of the adjudication date:
- Claim Appeal Form
- Original Request for Reconsideration letter and response
- Any supporting documentation supporting the appeal
If a provider’s submission of a corrected claim, request for reconsideration or claim appeal results in an adjusted claim, the provider will receive a revised Explanation of Payment (EOP). If the original decision is upheld, the provider will receive a revised EOP or letter detailing the decision and steps for next level appeal
Claim Reconsiderations Related to Code Auditing and Editing
If you disagree with a code audit or edit and request claim reconsideration, you must submit medical documentation (medical record) related to the reconsideration. If medical documentation is not received, the original code audit or edit will be upheld.
Claim disputes/reconsiderations
You have up to 180 days from claim payment date to request a reconsideration. You may request claim reconsideration if you feel your claim was not processed appropriately according to the Cigna claim payment policy or in accordance with your provider agreement. A claim dispute/reconsideration request is appropriate for disputing denials such as coordination of benefits, timely filing, or missing information. Payment retractions, underpayments/overpayments, as well as coding disputes should also be addressed through the claim dispute/reconsideration process. Cigna will review your request, as well as your provider record, to determine whether your claim was paid correctly In addition to the rights and responsibilities outlined
Practitioner Right to Appeal Adverse Re-credentialing Determinations
Applicants who are existing providers and who are declined continued participation due to adverse re- credentialing determinations (for reasons such as appropriateness of care or liability claims issues) have the right to request an appeal of the decision. Requests for an appeal must be made in writing within 30 days of the date of the notice.
All written requests should include additional supporting documentation in favor of the applicant’s appeal or reconsideration for participation in the network.
Payment appeal
A challenge or an “appeal” related to benefit/payment denials by the Medicare health plan that results in zero payment being made to the non-contracted Medicare health plan care provider. The first level of the Medicare appeal process is referred to as the reconsideration level. The Medicare health plan has 30 calendar days to review and respond to a claim payment dispute.
All requests for pre-service reconsiderations do require a signature of the appealing party on it. If there is not a signature, one must be obtained.
Appeal
Any of the procedures that deal with the review of adverse organization determinations on the health care services a member is entitled to receive or any amounts that the member must pay for a covered service. These procedures include reconsiderations by United Healthcare Dual Complete programs, an independent review entity, hearings before an ALJ, review by the Medicare Appeals Council, and judicial review.
Link – https://www.uhahealth.com/wp-content/uploads/provider-handbook.pdf
A preliminary reconsideration may result in a request for additional information. UHA will expedite both the request and the review. When the review has been completed, we will either reprocess the claim, in which case you will receive a new Remittance Advice, or we will inform you why we believe our original determination was correct. If the matter is not resolved to your satisfaction, you may appeal the decision as described in the “Appeals Process” section. You may also request a reconsideration of a claim by mailing or faxing a Provider Claims Action Request form to Customer Services.
Initiating a Claim Reconsideration Request
Beneficiaries or their authorized representatives can initiate a claim reconsideration request by submitting a written request to the Medicare Administrative Contractor (MAC) within 120 days of receiving the Medicare Summary Notice (MSN) that outlines the claim decision. The request should include the following information:
- The beneficiary’s name and Medicare number
- The specific service or item that was denied or underpaid
- The reasons for disagreeing with the initial claim decision
- Supporting documentation, such as medical records or provider statements
Claim Reconsideration Timelines
Upon receipt of the reconsideration request, the MAC will conduct a review of the claim. The Medicare program aims to provide a response within 60 days from the date of receipt of the request. However, in some cases, this timeline may be extended due to the need for additional information or extraordinary circumstances.
It’s important for beneficiaries to monitor the progress of their reconsideration request and follow up with the MAC if there are any delays in the review process. This can help ensure that the request is being handled in a timely manner.
In situations where the reconsideration decision is not favorable, beneficiaries have the right to further appeal the decision through the Medicare appeals process. This process involves several stages, including redetermination, reconsideration, a hearing before an administrative law judge, and review by the Medicare Appeals Council.
Beneficiaries should be aware of the specific deadlines associated with each stage of the appeals process to avoid missing important filing deadlines. Failure to adhere to these deadlines could result in the loss of the right to further appeal the claim decision.
