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submitting appeals, but also the deadlines in halting the recoupment process associated with Medicare overpayments. Although it is not technically one of the official levels of appeal, we will start with the timeframe for requesting a reopening. A reopening allows you to reopen a Medicare claim and correct minor clerical errors (e.g., wrong date of service, wrong number of units, etc.). You have one year from the date on your remittance advice, the date Medicare adjudicated the claim, to request a reopening for any reason. If the one-year deadline has passed, there is a small possibility you may be able to file a reopening if you can demonstrate a “good cause” for the need to reopen the claim. (See sidebar, “Showing Good Cause.”)
Showing ‘Good Cause’ After Missing a Deadline What constitutes “good cause?” If a reopening or appeal request is going to be reviewed after a missed deadline, here are the circumstances that may fall into the good cause category, which you will need to document: • Incorrect or incomplete information about the claim and/ or appeal was furnished by official sources (CMS, the contractor, or the Social Security Administration) to the facility; or, • There were unavoidable circumstances that prevented the facility from timely filing a request for redetermination. Unavoidable circumstances include situations that are beyond the facility’s control, such as major floods, fires, tornadoes, and other natural catastrophes. If these conditions have been met and documented, then you may have good cause for missing a deadline. A good cause exception may not be used when a missed deadline is the fault of your billing company (or any other entity hired by you to conduct business operations on your behalf). Also, negligence by you or your employees or being a new company, and not understanding the rules completely, are not valid reasons for a good cause extension.
There are several deadlines associated with the five official levels of appeals. The first level is the redetermination, and the clock for the redetermination deadline starts with receiving the official notice of denial, the recoupment request, or the initial determination of the claim. The official notice of initial determination is presumed to be received five days after the date provided on the notice unless you can show a different date. The request for redetermination must be filed within 120 days after you receive the notice. If you don’t file a redetermination within the 120-day window, you may not proceed to the next level because your appeal will not be processed unless you can show good cause.
Next up is the second level of appeal, the reconsideration: You have 180 days to file a reconsideration request. The 180 days begin with the receipt of the redetermination results notice; once again, 180 days is a hard deadline, and nothing can be filed after that timeframe unless you show good cause. The last three levels of the appeals process—the administrative law judge, the Departmental Appeals Board/ Medicare Appeals Council review, and the federal court review—all have the same deadlines. All of the appeals must be filed within 60 days of the official receipt of outcomes, the official letter from the previous level. If at any point you cannot meet the 60-day deadline, your appeal requests will be dismissed (unless you can document and demonstrate good cause). The exception to this is taking your appeal to the final level, the federal court review: If you cannot make the deadline, your appeal rights have ended. If during the appeals process you receive an overpayment/recoupment
demand letter, there are a few deadlines to remember. First is the deadline to make sure that you are not being charged any interest on the amount being recouped. If you repay Medicare within 30 days of receiving the overpayment demand letter, you will not have to pay any interest to Medicare. The next important deadline is the 40-day deadline: If after 40 days of receiving the overpayment demand letter no payments are made against the recoupment amount, Medicare will begin to offset your future claims until the recoupment amount and the interest have been paid in full. If you wish to delay the recoupment process, the offsetting of future claims, you have 30 days from when you first receive the overpayment/recoupment demand letter to take action. To delay any recoupment from starting, you must file your redetermination request (the first level of appeal) within 30 days of receiving the demand letter, rather than the traditional 120-day timeframe. If the request for a redetermination is O&P ALMANAC | APRIL 2015
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