Text Size

  • Increase
  • Decrease
  • Normal

Current Size: 100%

ADRs and Appeals

Tips for Dealing with ADRs, Probe Edits, and the Medicare Appeals Process

Medicare Appeals Process Updates

  • New Electronic Appeals System for Level 4 Appeals... The Departmental Appeals Board’s Medicare Operations Division Electronic Filing System (MOD E-File) launched October 1, 2016. MOD E-File will enable appellants to file requests for review to the Medicare Appeals Council electronically. Appellants, parties, and the public can also use MOD E-File to check the status of appeals. Learn more about MOD E-File.
  • CR9683:  Medicare Appeals System (MAS) Level 1 Part A and Home, Heath, Hospice Onboarding Effort… This CR will provide the MACs with the communication plans, operational requirements, and business requirements they will need to utilize MAS to enter and track information regarding the progress and disposition of each Part A redetermination and reopening in accordance with CMS policy and regulations. The effective date of this guidance is November 29, 2016Read CR9683 (PDF).
  • CR9617 Adding a Foreign Language Tagline Sheet to Medicare Summary Notices… CMS is requiring Medicare Administrative Contractors (MACs) add a new last page to the Medicare Summary Notices (MSNs) which will contain foreign language taglines, in 15 different languages. This is required by the Final Rule for Section 1557 of the Nondiscrimination Provision of the Affordable Care Act. Implementation must occur 60 days after issuance. The effective date of this guidance is October 28, 2016Read CR9617 (PDF).
  • Proposed Rule on the Medicare Claims Appeals Process... HHS has issued a proposed rule that is a part of the Administration’s efforts to address the “unprecedented and sustained increase in the number of appeals” and to reduce the backlog of appeals cases currently pending at the Office of Medicare Hearings and Appeals.  NHPCO will be making comments and welcomes provider feedback on concerns that should be expressed in the NHPCO comment letter. Final comments are due August 29, 2016.
  • HHS Releases Primer on Medicare Appeals... In actions related to the publication of the proposed rule on Medicare appeals, HHS also released a “Primer on the Medicare Appeals Process” which provides extensive information on the subject. The Medicare Office of Medicare Hearings and Appeals reports a backlog of more than 880,000 appeals at the end of FY2015. Four primary drivers were identified for the increase in volume:  1) Increases in the number of beneficiaries; 2) Updates and changes to coverage and payment rules; 3) Growth in appeals from State Medicaid Agencies; and 4) National implementation of the Medicare Fee-for-Service Recovery Audit Program.
  • CMS Posts CR 9600: Appeals of Claims Decisions Update... The timeframe for forwarding misfiled redeterminations and reconsiderations requests to the appropriate contractor has been updated from 30 days to 60 days from the date the request was received in the corporate mailroom. CR 9600 also includes changes related to Medicare Secondary Payer claims and applicable plan determinations. Additionally, modifications have been made to the Reconsideration Request Form. CR 9600 (PDF) provides additional contact information for the appellant to facilitate communication between the Qualified Independent Contractor and the appellant.

Download complete ADR Tip Sheet

Key Points of ADRs, Probe Edits, and the Medicare Appeals Process:

  • The Centers for Medicare & Medicaid Services ("CMS") and its contractors have broad ability to perform pre-payment and post-payment medical reviews of hospice claims. Hospices most commonly find themselves dealing with pre-payment medical reviews through the Additional Document Request or Additional Development Request ("ADR") process initiated by their Fiscal Intermediary (“FI”) or Medicare Administrative Contractor (“MAC”).

  • Typically, these ADRs relate to a particular probe or edit conducted by the Intermediary.The probe or edit may be service-specific (e.g. non-cancer length of stay, general inpatient care, etc.), provider-specific, beneficiary-specific or diagnosis driven.

  • If claim payment is denied by the Intermediary after its ADR review (initial review determination), the hospice may choose to appeal that denial through the Medicare appeals process.The steps in the appeals process are:
    • Redetermination (reviewed by the Fiscal Intermediary)
      • Time Frames:
        • The appeal is due within 120 days of receipt of denial.
        • The Intermediary must issue a decision within 60 days of receiving the appeal.
    • Details about this level of review:
      • This is only a paper review.There is no opportunity to discuss the case with the decision-maker.While it is a step in the process, hospices may not receive a payment reversal at this level of review.
    • Reconsideration (reviewed by a Qualified Independent Contractor "QIC”)
      • Time Frames:
        • The appeal is due within 180 days of receipt of redetermination decision.
        • This is the last appeal step that “new” evidence can automatically be included as part of the review request.
        • The QIC must generally issue a decision within 60 days of receiving the appeal.
        • All written evidence must be submitted at this level.
      • Details about this level of review:
        • This is only a paper review.There is no opportunity to discuss the case with the decision-maker.While it is a step in the process, hospices may not receive a payment reversal at this level of review.
    • Administrative Law Judge ("ALJ")
      • Time Frames:
        • The appeal is due within 60 days of receipt of reconsideration decision.
        • The ALJ must generally issue a decision within 90 days of receiving a hearing request.
      • Details about this level of review:
        • This is the first opportunity to have a discussion with a decision-maker about the case.
        • The Office of Medicare Hearings and Appeals (OMHA) will schedule a telephone appeal.  Hospices may choose a telephone appeal or a video teleconference (VTC).  Success may be more likely if the ALJ can see the advocates for the hospice program. The ALJ Request Form does not contain a checkbox for a VTC request.  You will have to write this in and remind the administrative assistant who calls to schedule a hearing that this is the type of hearing you desire.
        • At the hearing, hospices may choose to have medical directors and nurses available to testify.  The medical director is particularly important if the clinical eligibility of a patient is at issue.  Administrative Law Judges have limited medical information and are always very happy to hear from doctors and nurses regarding clinical information.  Hospices are to submit all written evidence at the Reconsideration level.  However, they may submit additional written evidence to the ALJ as long as the ALJ finds “good cause” for the late submission.  Furthermore, even if the ALJ rejects the additional written evidence, the hospice is not precluded from discussing the contents of the additional evidence at the hearing, and the ALJ may permit the hospice to read the additional evidence into the record.
        • The hospice should approach the ALJ hearings as an opportunity to educate.  Some judges will know relatively little about hospice law or policy, so hospices should approach the hearing with the mindset that they will be educating the judge. 
    • Medicare Appeals Council*
      • Time Frames:
        • The appeal is due within 60 days of receiving the ALJ's decision.
        • The Medicare Appeals Council must issue decision within 90 days of receiving the request for review.
      • Details about this level of review:
        • This is generally a paper review.
        • The Medicare Appeals Council has the authority to go back and review all claims again, including a re-review of claims that have been decided at the ALJ level in certain circumstances.
        • The Medicare Appeals Council generally focuses its review on an ALJ decision where the ALJ misapplies the law or the facts of the case; in these cases, the hospice should appeal to the Medicare Appeals Council.
    • Federal District Court*
      • The appeal is due within 60 days of receiving the Medicare Appeal Council's decision.

(* Note that hospices do not typically appeal standard claim denial cases to the Medicare Appeals Council or to Federal District Court due to limitations on appeals at these levels.)

  • Tips and steps below will help a hospice minimize the disruption created by ADRs, and put the hospice in the best position to respond effectively to the ADRs and move off the probe or edit as soon as possible.In addition, when appealing a payment denial, the strategies and suggestions below will give the hospice the best chance of overturning the denial.

Tips for Dealing With ADRs and Probe Edits

NHPCO Regulatory team has developed some tips for dealing with ADRs and Probe

Download the Claims denial appeal grid.

Any questions about this information should be directed to regulatory@nhpco.org.