Fwd: FI Denial

[Ldawja]

Because this was a post payment review, you should check with Mutual to see if you had "rebuttal" right of appeal.  It is unique to some postpayment reviews.   If not, you have 120 days from your remittance date to do a reconsideration level of appeal.  A new reviewer looks at the record and makes a new decision.   I went to Mutual of Omaha's website and found this area that will give you more info about appeals, http://www.mutualmedicare.com/appeals/filinganappeal.html.   If you ever get another Additional Development Request (ADR) - prepay or postpay, the website also has an area that specifies exactly what they want to see in response to a medical review request for a Part A SNF PPS claim:   A hardcopy version of each MDS related to the billing period being reviewed Documentation to support each of the HIPPS code(s) billed, including notes related to each of the assessment reference date(s) Documentation to support each of the look back periods which may fall outside the billing period under review Documentation to support the dates of service billed Documentation up to 30 days prior to the first assessment reference date Documentation may include but is not limited to: Physician Certifications and Recertifications Hospital discharge summaries Transfer forms Physician orders and progress notes Patient care plans Nursing notes Rehabilitation therapy notes Treatment records Vital sign records Weight records Medication records All other documentation supporting the beneficiaryâs need for the skilled services being provided in the SNF If the claim was rehab related, the rehab documentation should include: 700/701 Evaluation forms or in-house equivalent to include: Physician order(s) Signed and dated certification by physician Date of evaluation Start of care date Medical diagnosis Treatment diagnosis Onset date Current level of function Prior level of function Treatment plan with long and short term goals Previous therapy administered to include: Date Diagnosis for treatment Modalities administered Progress notes detailing service provided for each date of service billed ------------ In a message dated 4/19/2004 8:04:51 PM Eastern Daylight Time, [EMAIL PROTECTED] writes: We had a claim for post pay review which took place Nov 1 -Nov 10.This patient was on rehab,then Omra due to acute renal failure[ref dialysis,96 yrs of age.I won't go into the particulars because I was too busy to investigate after Bus office called me.The patient went on inpatient hospice on Nov 11th.The FI denied claim,not reasonable and necessary.This has never happened to me ,what is our appeal process?I seem to remember that the facility Adminis needs to write a letter requesting reconsideration.They,I think would ask for documentation as to why we feel we have a valid claim.Anyone have this happen recently.My FI is Mutual of Omaha.It is easy to beat yourself over a lost claim.

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We had a claim for post pay review which took place Nov 1 -Nov 10.This patient was on 
rehab,then Omra due to acute renal failure[ref dialysis,96 yrs of age.I won't go into 
the particulars because I was too busy to investigate after Bus office called me.The 
patient went on inpatient hospice on Nov 11th.The FI denied claim,not reasonable and 
necessary.This has never happened to me ,what is our appeal process?I seem to remember 
that the facility Adminis needs to write a letter requesting reconsideration.They,I 
think would ask for documentation as to why we feel we have a valid claim.Anyone have 
this happen recently.My FI is Mutual of Omaha.It is easy to beat yourself over a lost 
claim.

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