Medical Billing Forum
Billing => Billing => : supertaz93 January 31, 2012, 11:40:44 PM
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I submitted a claim to Medicare and it came back that the patient was enrolled in hospice (PR-B9). When remit came I verified through CSNAP and patient was enrolled in hospice. I was reviewing the account for collections and discovered that the patient was not in hospice for this date of service (I checked CSNAP again). I submitted a redetermination and was denied because it was past 120 days. In their explanation of why my appeal was denied, they state "In this case, we did not find good cause for filing your request late." Do I have grounds to take this to the next level of appeal?
I agree that this was after 120 days, but if they made changes to their eligibility system, then they should have reprocessed my claim and I should not have needed to appeal. This also seems crappy if I can't go to the next step because what would keep them from doing this all the time to get out of paying claims.
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From what you have described, I would take it to the next level because the circumstances made it such that you wouldn't know you should have appealed in the 120 days. It appeared to be denied correctly at first. I can't guarantee they will pay, but personally I would take the time to appeal.
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If you can contact the hospice provider and find out the date that they (the hospice provider) updated Medicare. There is a form that the hospice provider has to submit to Medicare, so if you can find out what date that was submitted and get a letter from the hospice provider. This might help you with you next step in your appeal.