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​Don’t agree with a Recovery Auditor Determination?

Posted by Linda Collins | February 19, 2015

Don’t agree with a Recovery Auditor Determination?
You receive an audit on one of your claims. Because you are an avid R&R reader, you understand all the required documentation to submit for review. Despite your compliance, you receive a denial letter. What do you do next?

  1. Contact the Recovery Auditor to Request a Discussion Period - The discussion period offers the opportunity for the supplier to provide additional information to the Recovery Auditor. We recommend you request the discussion period immediately upon receipt of the denial notice. Many times, when additional documentation and explanations are submitted to support the claims, there are positive resolutions.
  2. Initiate a Redetermination – The Redetermination is the Level One appeal, part of the appeal process outlined by CMS. This appeal will go to the Medicare Administrative Contractor (MAC) for your region. You may initiate the Redetermination with the MAC at the same time you initiate the discussion period with the RAC. You have 120 days from the date of the denial letter to request a redetermination with the MAC. However, remember, unless an appeal is filed within 30 days, the monies will be recouped. Keep your money by initiating the appeal process in a timely manner.

What does this mean for you?

Be prepared to act quickly when you receive an adverse audit decision. Make your request for a discussion by submitting the appropriate documentation, cover letter, explanations along with a fax form. The fax cover sheets for the Recovery Auditors are here:

Performant, Region A, Discussion Period Submission Form

CGI, Region B, Discussion Period Submission Form

Connolly, Region C, Discussion Period Submission Form

HDI, Region D, Discussion Period Submission Form

Begin the appeals process with the MAC by filing a Redetermination. You will submit the same documentation and cover sheets you submit to the RACs. Use the following forms to initiate the Redetermination:

NHIC, Region A, Redetermination Request Form

NGS, Region B, Redetermination Request Form

CGS, Region C, Redetermination Request Form

Noridian, Region D, Redetermination Request Form

Act fast, take advantage of the discussion period, appeal, and keep your money.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]