Occasionally, claims submitted to WPS Medicare, Indiana’s Medicare Administrative Contractor, are processed incorrectly or denied because incorrect data was transmitted or WPS needs additional documentation. Updating WPS’s records by requesting a reopening or appeal is simple, especially when the most effective method for submitting the correction is selected.
For changes to the following data items, the WPS Medicare Clerical Error Reopening Request form can be submitted for as few as 1 and up to 5,000 lines of service for the same group PTAN: date of service, place of service, procedure code, a single modifier, quantity (not affecting charge amount), charge amount (not affecting quantity), or diagnosis.
Once the WPS Medicare Clerical Error Reopening form is completed, it should be emailed to WPS at ElectronicReopenings@wpsic.com. Once the adjustments have been completed, the requester will be sent an email with the completed spreadsheet showing the action taken on each line. Any incomplete or invalid requests also will be returned to the requester via email.
Reopenings also can be requested via telephone (877-674-5416) or fax (608-224-3504). For faxed requests, use the single Reopening Request form, which requires a separate form for each ICN from the remittance, along with the Fax Cover Sheet.
When dissatisfied with the outcome of the initial claim determination or overpayment decision, beneficiaries, providers, and suppliers have the right to file an appeal. There are five levels of the appeals process:
- Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).
- Reconsideration by a Qualified Independent Contractor (QIC)
- Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
- Departmental Appeals Board (DAB)/Appeals Council
- Judicial Review in Federal District Court
To begin the appeals process, use the Redetermination Request form. The following reasons would necessitate a redetermination rather than a reopening: claim submitted with wrong payee, claim changes that create an overpayment, disagreement with an overpayment request, denial resulting from a CERT, denial resulting from a provider enrollment issue, adding services that were not previously billed, add/change/delete certain modifiers, or complex claims that require additional documentation.
Completed forms must be filed within 120 days of the initial payment determination and can be faxed (608-224-3504) to WPS with the completed Fax Cover Sheet and any additional documentation or mailed to WPS at PO Box 8833, Marion, IL 62959-0914 (for Indiana Part B redeterminations).
For second level appeals (reconsideration) to dispute the redetermination, complete the Reconsideration Request form, attach additional documentation (such as a letter from the provider explaining why he/she feels the service should be covered), and mail it to C2C Solutions – QIC Part B North, PO Box 45208, Jacksonville, FL 32232-5029. Reconsiderations must be filed within 180 days of the receipt of the notice of redetermination.
When filing an appeal, attach only the documentation required by WPS for the redetermination.
- A Medicare EOB should never be attached. WPS can access that information directly in their system. Occasionally another payer’s EOB might be required if it affects the appeal.
- Rarely is a new claim form required. Typically all necessary information can be included on the redetermination form.
- If a claim is denied for medical necessity, check the diagnosis against the Local Coverage Determination (LCD) list to see if the diagnosis should just be changed rather than immediately attaching the entire medical record with an appeal on the original diagnosis.
- Be certain that you are providing documentation for the correct date of service and beneficiary.
- Clearly indicate on the redetermination form which section of the documentation supports your appeal.
- Do not appeal denied services that have a “B,” “I,” or “N” status indicator on the Medicare Fee Schedule, as these are always bundled or invalid for Medicare beneficiaries. Additionally, denied services that have a “0” CCI indicator for the pair will not be reconsidered even with the addition of a modifier.
A few denial scenarios require that a new claim be submitted to WPS rather than a reopening or appeal. Claims with the following claim adjustment reason codes on the remittance advice designate unprocessable claims and do not have appeal rights: CO-4, CO-16, and MA 130. These claims should be resubmitted with the required corrections to be considered for processing.
For more information, see the “Appeals” page of the WPS website.
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