LEVEL 2 and 3 APPEALS- REconsiderations, ALJs · Web viewLEVEL 2 and 3 APPEALS-...
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LEVEL 2 AND 3 APPEALS- RECONSIDERATIONS, ALJS AND MAVEN JOB AID - HOME HEALTH INTRODUCTION Effective February 2016, all Home Health offices will be responsible for checking the Appeals Manager in Maven at least weekly for the determination of their submitted Appeals. The Medicare Administrator Contractors (MACs) and the Qualified Independent Contractors (QICs) have 60 days to make and document the review determination notify the agency. This process will take the place of any and all methods previously utilized. IMPORTANCE The collaborative effort on the part of the branch leadership and the Denials Management Team (DMT) is critical to the success of the appeal result. The Appeals Manager in Maven should be checked at least weekly. All Appeals are to be responded to timely and completely. Opportunity to respond to an Appeal is time limited. This should be done within 7 days of receiving the determination letter that will be delivered by the USPS. The findings will be either “Favorable”, Unfavorable” or “Partially Favorable”. Communication to the Denials Management Team is critical to ensuring that appropriate responses can be pursued. The Determination letter should be immediately emailed to: Denials Management – Home Health and then in Maven please REROUTE the claim to the Denials Management Team. At this point in the appeals process, the branch is waiting for the result of the LEVEL 1 or the Level 2 Appeal. The results of these appeals are mailed to the branch via USPS. If the branch does not receive a letter by the time the “DAYS UNTIL DECISION DUE” is ZERO in Maven, the agency should contact the Medicare Administrator Contractors (Macs) and the Qualified Independent Contractors (QICS) for their determination letter. You can find this “DAYS UNTIL DECISION DUE“ in the “IN PROCESS” section of Appeals Manager. Although time frame for submitting a Level 2 Appeal is 180 days and time frame for submitting the Level 3 Appeals is 60 days, it is imperative that the appeal determination be made within one calendar week (7 days) from receipt of the 1
Transcript of LEVEL 2 and 3 APPEALS- REconsiderations, ALJs · Web viewLEVEL 2 and 3 APPEALS-...
LEVEL 2 AND 3 APPEALS- RECONSIDERATIONS, ALJS AND MAVEN JOB AID - HOME HEALTH INTRODUCTIONEffective February 2016, all Home Health offices will be responsible for checking the Appeals Manager in Maven at least weekly for the determination of their submitted Appeals. The Medicare Administrator Contractors (MACs) and the Qualified Independent Contractors (QICs) have 60 days to make and document the review determination notify the agency. This process will take the place of any and all methods previously utilized. IMPORTANCE
The collaborative effort on the part of the branch leadership and the Denials Management Team (DMT) is critical to the success of the appeal result. The Appeals Manager in Maven should be checked at least weekly. All Appeals are to be responded to timely and completely. Opportunity to respond to an Appeal is time limited. This should be done within 7 days of receiving the determination letter that will be delivered by the USPS. The findings will be either “Favorable”, Unfavorable” or “Partially Favorable”. Communication to the Denials Management Team is critical to ensuring that appropriate responses can be pursued. The Determination letter should be immediately emailed to: Denials Management – Home Health and then in Maven please REROUTE the claim to the Denials Management Team. At this point in the appeals process, the branch is waiting for the result of the LEVEL 1 or the Level 2 Appeal. The results of these appeals are mailed to the branch via USPS. If the branch does not receive a letter by the time the “DAYS UNTIL DECISION DUE” is ZERO in Maven, the agency should contact the Medicare Administrator Contractors (Macs) and the Qualified Independent Contractors (QICS) for their determination letter. You can find this “DAYS UNTIL DECISION DUE“ in the “IN PROCESS” section of Appeals Manager.
Although time frame for submitting a Level 2 Appeal is 180 days and time frame for submitting the Level 3 Appeals is 60 days, it is imperative that the appeal determination be made within one calendar week (7 days) from receipt of the letter. This allows the Denials Management Team time to formulate the appeal letter, gather other documentation if needed, and submit the appeal within the allotted time. Leadership and managers should have a sense of urgency and help facilitate this process and meet the time frame outlined above.
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TARGET AUDIENCE
Leadership and Managers (Those with access to Maven) APPROXIMATE COMPLETION TIME
30-60 minutes OBJECTIVES • To be able to locate the Appeal in Maven in the “In Process”
Section of appeals manager– Determine how many days left until a decision should be
rendered by the auditing entity• Understanding when to contact the Medicare administrative
contractor (MAC) or the Qualified Independent Contractor • Understanding the time frame for rerouting the
Second and third level appeal to the denial management team
• Understanding the role of the Branch leadership and the Denials
Management Team• Review of rerouting the claim in Maven to the Denials
Management Team
RESOURCES AND REFERENCES:Power Point (Double Click) Graphic of Level 2 and Level 3 Process
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