The ONLY Comprehensive Resource on Medicare Claims Appeals Process! Medicare Claims Appeals Process Handbook by Lester J. Perling List Price: $335.00   Eligible for Free Standard Shipping on U.S. Prepaid Orders Imprint: Aspen Publishers ISBN: 9780735564817 Looseleaf: 712 pages Publication Cycle: Supplemented annually Last Updated: 10/11/2012 Automatic Supplementation More Info. Available: Item ships in 3-5 Business Days

Anyone who submits Medicare claims and receives Medicare reimbursements needs to be fully prepared to follow the appeals process when claims are rejected and/or refunds are requested. Medicare Claims Appeals Process Handbook helps you understand - and explain - the process every step of the way. You'll know exactly what you can and can't do, the essential timeframes for pursuing appeals, where to send information, and how to proceed - at every level of the appeals process! The Medicare Claims Appeals Process Handbook will help you:Increase your likelihood of success in the claims appeal by lowering the possibility of procedural error and avoiding costly errors Navigate all four levels of the administrative appeal process Proceed to federal court if necessary Stay current with changing rules, regulations, and procedures Put best practices in place - immediately! Only Medicare Claims Appeals Process Handbook includes letters, forms, charts, and more - all designed to provide you with practical support throughout the process. Medicare Claims Appeals Process Handbook has been updated to include: Expanded material on electronic claims submission A sample denial of an “unusual circumstance” waiver request Information on medical necessity denials A new National Coverage Analysis (NCA) tracking sheet and proposed decision memo for MRIs Updated Medicare redetermination request forms Request for review of Administration Law Judge (ALJ) Medicare decision/dismissal Comparison of standard and expedited appeals processes Updated CMS appointment of representative form New material on the role of the Medicare administrative contractor A sample Medicare Summary Notice Important information on overpayment and suspension of payments Recent case law regarding exhaustion of administrative remedies Updated material on good cause for reopening View the Highlights for this title. 1. OVERVIEW OF CLAIMS PROCESSING SYSTEM Providers and Suppliers Defined Contractor Responsibilities Utilization Review Committee Decisions Submitting a Claim Medical Review Reasons for Claim Denials Waiver of Liability 2. THE ROLE OF NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS National Coverage Determinations Defined Procedures for Establishing New National Coverage Determinations Reconsideration of a National Coverage Determination Review and Appeals of National Coverage Determinations Local Coverage Determinations Defined Process for Developing New Local Coverage Determinations Local Coverage Determination Reconsideration Process Review and Appeals of Local Coverage Determinations 3. OVERVIEW OF THE NEW CLAIMS APPEALS PROCESS Summary of the Prior Appeals Process Legislative Changes to the Medicare Appeals Process Levels of Administrative Appeals Expedited Appeals Process 4. PROVIDER AND SUPPLIER APPEAL RIGHTS AND RULES FOR REPRESENTATION Provider and Supplier Appeal Rights Assignment of Appeal Rights Rules for Representation 5. INITIAL DETERMINATIONS The Role of the Medicare Administrative Contractor Initial Determinations 6. POST-PAYMENT AUDITS Post-Payment Review Overpayment Consent Settlement Recovery of Overpayment Interest Charges on Overpayments Waiver of Recovery of Overpayment 7. REDETERMINATIONS Rules for Filing Requests for Redetermination Parties to a Redetermination Procedures for Contractors Withdrawals and Dismissals of Requests for Redetermination Effect of Redetermination 8. QUALIFIED INDEPENDENT CONTRACTOR RECONSIDERATIONS Rules for Submitting a Request for Reconsideration Rules for Presenting Evidence Rules for Medical Necessity Determinations Criteria for Review Rules for Reviewers Rules for Issuing a Decision Escalating a Case from the Qualified IndependentContractor to an Administrative Law Judge Withdrawal or Dismissal of a Request for Reconsideration Effect of Reconsideration 9. ADMINISTRATIVE LAW JUDGE APPEALS Office of Medicare Hearings and Appeals Administrative Law Judge Jurisdiction Requirements to Establish the Right to an Administrative Law Judge Hearing Requirements for Filing a Request for Hearing Parties to an Administrative Law Judge Hearing Dismissals and Remands Disqualification of an Administrative Law Judge Amount in Controversy Requirement Time and Place for an Administrative Law Judge Hearing Issues at an Administrative Law Judge Hearing Prehearing and Posthearing Conferences Criteria for Administrative Law Judge Review Escalation Hearing on the Record Evidence Requirements Hearing Procedures The Administrative Law Judge Decision 10. MEDICARE APPEALS COUNCIL REVIEW Departmental AppealsBoard Cases Reviewed by the Departmental Appeals Board Medicare Appeals Council Review Rules for Granting or Dismissing a Request for Medicare Appeals Council Review Issues Regarding Evidence Escalation from the Medicare Appeals Council to Federal District Court Medicare Appeals Council Review Based on Centers for Medicare & Medicaid Services Referral The Medicare Appeals Council Decision Court Review Cases Remanded by a Federal District Court 11. JUDICIAL REVIEW Filing a Civil Action in Federal Court Federal Court Jurisdiction Judicial Review of National Coverage Determinations Judicial Review of Violations of the Administrative Procedures Act Expedited Appeals Process 12. QUALITY IMPROVEMENT ORGANIZATION REVIEWS Quality Improvement Organization Eligibility Requirements Coordination with Contractors Hospital Responsibilities Related to Quality Improvement Organization Review Quality Improvement Organization Medical Reviews Limitation on Liability Quality Improvement Organization Initial Denial Determinations, Diagnosis Related Group Assignment Changes, and Technical Denials Medicare Quality Improvement Organization Review of Diagnosis Related Group Changes Claim Reconsideration Procedures Administrative Law Judge Hearings Departmental Appeals Board Appeals Judicial Review Expedited Determinations and Reconsiderations Reopening of a Reconsidered Determination, an Administrative Law Judge Hearing Decision, or Medicare Appeals Council Decision 13. REOPENINGS Reopening vs. Appeals Time Frames for Reopening Rules for Reopening for Fraud or Similar Fault Guidelines for a Reopening Request Time Frame to Complete a Reopening Notice of a Revised Determination or Decision 14. THE RECOVERY AUDIT CONTRACTOR PROGRAM The RAC Demonstration Program The RAC Permanent Program Appeals of RAC Determinations Hospital Accounts Receivable Analysis (HARA) JoAnn Petaschnick Hospital Accounts Receivable Analysis (HARA) - the leader in A/R analysis for over 20 years - is a quarterly report of comprehensive data and expert analysis to help you measure and manage your facility's performance. HARA lets you measure your performance against hospitals of similar size more... Add to cart   |  Price: $899.00  |  PIN: SS10788123  |  Format: Paperback  Imprint: Aspen Publishers  Hospital Law Manual Nathan Hershey, Christopher Holt For more than 40 years, Hospital Law Manual has been known throughout the health care industry as the definitive guide to the legal responsibilities and liabilities of health care providers and institutions. Why? Because this comprehensive reference explains federal and state laws with clarity an more... Add to cart   |  Price: $2,149.00  |  ISBN: 9780912862057  |  Format: Looseleaf  Imprint: Aspen Publishers