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Appealing for Timely Filling During the PHE

Did you know that during the PHE of COVID-19 the blanket waivers that CMS has put into place to help with filling appeals for timely filling? Make sure you double check your state of course. This information can be found on the website. The COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers states that MACs and QICs that participate in the Fee for Service program, which also includes MA and Part D plans, is allowing extensions for appeals.

This is a huge relief for some private provider offices that may have lost valuable staff due to the pandemic.

The way this works is that a formal letter requesting an appeal extension in writing has to be submitted on a standard CMS form. This letter must state why the claim did not get to the payor in a timely manner and include specific information about the claim as stated below. 1 (42 CFR § 405.944)

  • Beneficiary's Name
  • Medicare #
  • Specific services/items and DOS for which the redetermination is being requested for
  • Name of the party/provider or the representative of the party/provider

In your request for an appeal extension you will need to include the reason for the extension. Like, a good faith effort to send the correspondence to the appropriate contractor in a timely manner. Some good faith effort examples include:

  • Party/Provider was prevented with serious illness from contacting the insurance company in person, writing or other personnel
  • Death or serious illness in his/her immediate family
  • Important records of the party/provider were destroyed or damaged by fire or other accidental cause
  • Contractor provided partly incorrect information about when and how to request a redetermination
  • The provider’s office never received notice of the determination or decision
  • Good faith effort to send the request to the correct contractor. However, the request did not reach the appropriate contractor in a timely filling manner. (42 CFR § 405.942)

Don't just write off your timely filling claims. Fight for your money and get reimbursement appropriately. Give Medical A/R Services a call and we can help you.