TennCare Program Provider Independent Review Process An Information Guide for Providers of TennCare Services April 9, 2012.

Slides:



Advertisements
Similar presentations
Whats Going On At The Workers Compensation Division.
Advertisements

How does the FAT Procedure work? A Guide to Arbitration Procedures before the FIBA Arbitration Tribunal (FAT)
Resolving Consumer Problems
NYS Department of Health Office of Health Insurance Programs Bureau of Provider Enrollment REVALIDATION of Medicaid Providers An Overview.
OFFICE OF THE CHAPTER 13 TRUSTEE DEBTOR ORIENTATION HANDBOOK “STRIVING FOR FINANCIAL STABILITY THROUGH EDUCATION” FRANK M. PEES STANDING TRUSTEE.
THE COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN CONSUMER GRIEVANCE SYSTEM.
1. As a Florida KidCare community partner families entrust you to not only help them navigate the Florida KidCare system but to keep the information they.
REIMBURSEMENT FOLLOW-UP AND COLLECTIONS Chapter 7.
Protecting Enrollees’ Health Information under HIPAA Presented by the Michigan Department of Civil Service Employee Benefits Division Employee Benefits.
Medicaid1 SANDHILLS CENTER PARTICIPATING PROVIDER VIOLATIONS AND DISPUTE RESOLUTIONS (Medicaid & State Funded)
The Appeals Process by Gina chandler
16.1 Civil Cases.
Chapter 16 Lesson 1 Civil and Criminal Law.
Date Person/Business/Agent’s Name Address City, State, Zip RE: Briefly describe subject of letter (Ex: Refund of Repair Fees) To Whom It May Concern: I.
Texas Department of Insurance Jose Montemayor, Commissioner.
Module 13: Claims & Appeals. Module Objectives After this module, you should be able to: Identify claim basics and where to submit claims Recognize who.
Third Party Liability & Act 62 COORDINATION OF BENEFITS DGS ANNEX COMPLEX 116 EAST AZALEA DRIVE PETRY BUILDING #17 HARRISBURG, PA
The IRO Process & How It Relates to Workers’ Compensation Health Care Networks Presenter: Emery Lamar Robinson Title: Training Specialist IV Texas Department.
New Foreclosure Law in Maryland Presentation by the Maryland Department of Labor, Licensing and Regulation Friday, June 18, 2010.
TDCI TennCare Oversight Division Provider Complaint Process
1. Streamlines the UI claims process for employers faced with layoffs:  Permanent or temporary  Ten or more employees at one time 2.
SEMINAR NAIC/ASSAL/SVS REGULATION & SUPERVISION OF MARKET CONDUCT © 2014 National Association of Insurance Commissioners Complaint Handling.
Frequently Asked Questions. No, in fact DOCTUS considers itself a strategic extension of your organization. Hence, we deliver the work the way you do.
Workers Compensation Commission Sian Leathem Registrar 29 September 2008.
Effective Date: March 16, 2012 Representatives must submit the following electronically: Request for appeal forms i561 and i501 The Disability Report-Appeal.
If benefits are denied: Deadline is 60 days + mailing time Initial claim approvals are no more than 40%
1 Prompt Payment to Providers 28 TAC §§ Patricia Brewer Director of Project Oversight - Life Health & Licensing Texas Department of Insurance.
How does the BAT Procedure work? A Guide to Arbitration Procedures before the Basketball Arbitral Tribunal (BAT)
Civil Law. You are a basketball star who was late for practice. You rushed out your door, tripped over your neighbor’s dog, and broke your wrist. You.
Health Insurance in New York Laura Dillon, Principal Examiner New York Insurance Department Consumer Services Bureau One Commerce Plaza Albany NY
1 Georgia’s Child Support Program … what you need to know.
Module 13: Claims & Appeals. Module Objectives After this module, you should be able to: Identify claim basics and where to submit claims Recognize who.
Looking for Improper Medicare Payments in All the Right Places.
TDCI TennCare Oversight Division Provider Complaint Process A Summary for TennCare Providers April 18, 2013.
TennCare Program Provider Independent Review Process An Information Guide for Providers of TennCare Services February 17, 2011.
1 Writing Good Decision Notices July 2010 Chris Ellis, SPD Hearing Representative.
HP Provider Relations October 2011 Medical Review Team.
How to Select and Pre-screen a Home Improvement Contractor.
1 Department of Veterans Affairs Debt Management Center (DMC) School Tuition Debt Payment Procedures Nicole Haselberger Julie Lawrence.
August 28, 2009 Federal Emergency Management Agency Public Assistance Arbitration Process.
EDSE 539 Special Education Leadership in Schools Parent Rights and Relationships Dispute Resolution Remedies.
The Process of Appealing/Filing a Grievance for a Commercial Insurance Claim Steve Verno 1.
Insurance Payment Posting
Presented By Bailey Busdeker, CPSTS Recovery Resources September 24 th, 2015.
Copyright © 2013 HealthEquity, Inc. All rights reserved. HealthEquity and the HealthEquity logo are registered trademarks and service marks of HealthEquity,
Chapter 16.1 Civil Cases. Types of Civil Lawsuits In civil cases the plaintiff – the party bringing the lawsuit – claims to have suffered a loss and usually.
THE REVIEW PROCESS. 2 OVERVIEW Taxpayers’ Bill of Rights Request Departmental Review Review Process Documentation Conference Final Determination Other.
Section 1-5 Resolving Consumer Problems. Registering a Complaint Need to: – State the problem clearly – Decide the outcome you desire – Gather all relevant.
If you are dissatisfied with your purchase; you need to keep the following items:  Copy of receipts  Names of people you spoke to  Dates of attempted.
Unemployment Insurance Workshop September 2015 Leah Reeder, UI Technical Services Specialist Tyler Smith, UI Technical Services Specialist.
Print your Name Print your Street Address Print your City, State, and Zip Code Self-Represented Print Courthouse Street Address Print Courthouse City,
Setting up a Public Information Coordinator (PIC) System Lauren Downey, Office of the Attorney General Cary Grace, City of Austin Bob Davis, Texas Department.
Module 13: Claims & Appeals. 2 Module Objectives After this module, you should be able to: Explain who can file claims and where claims should be submitted.
Civil Law Civil Law – is also considered private law as it is between individuals. It may also be called “Tort” Law, as a tort is a wrong committed against.
Medicare Claims Appeal Procedures Lisa Bazemore Director of Consulting Services.
Local Government Liability Pool. What is Liability???
A Guide to Handling Unemployment Claims at the City of Portland Presented by Bureau of Human Resources.
1 Department of Veterans Affairs Debt Management Center (DMC) School Certifying Officials Workshop Presentation Julie Lawrence.
(202) King Street, Suite 650 Alexandria, VA WASHINGTON, DC DISABILITY QUALIFICATIONS.
1 Office of External Relations Dispute Process. 2 Customer must first contact the Company to allow the Company a chance to resolve problem. If the customer.
Person/Business/Agent’s Name Address City, State, Zip
Module 13: Claims & Appeals
Office of External Relations Dispute Process
ENROLLEE DUE PROCESS for Medicaid Managed CARE 42 CFR § 438 et seq.
Social Security Disability Benefits By Sara G. Khaki, Esq
Flexible Spending City of Bowling Green.
DRAFT - FOR REVIEW PURPOSES ONLY
Appeals in Public Retirement Cases
The Office of Open Records webinar will begin soon
CMS PDR 101 ICE Presentation 2014.
Presentation transcript:

TennCare Program Provider Independent Review Process An Information Guide for Providers of TennCare Services April 9, 2012

What is Independent Review? Independent Review is a process available for Providers to resolve claims payment disputes with TennCare Program MCCs. Submit a written Request to the Commissioner of Commerce & Insurance T.C.A. § (b) governs the Independent Review process. MCC = The 3 TennCare HMOs, the Dental Benefits Manager (DBM).

Who are Independent Reviewers? They are persons selected by a panel to hear disputes between TennCare MCCs and Providers. They act like judges in that they make decisions on claims disputes. Pursuant to T.C.A. § (b), the Selection Panel for TennCare Reviewers selects the Independent Reviewers. The Panel consists of two Provider representatives, one representative from each of the two largest TennCare HMOs, and the Commissioner of TDCI or the Commissioner’s designated representative. See T.C.A. § (b).

Who Pays Independent Reviewers? The MCCs pay the Independent Reviewers the fee amount set by the Selection Panel for TennCare Reviewers pursuant to T.C.A. § (b). However, if the Provider loses the Independent Review, the Provider is required to reimburse the MCC for the fee. So, it is the “Losing” party that is ultimately responsible for paying the Reviewer.

What makes an Independent Reviewer “Independent”? Reviewers are not selected by the MCC, the Provider, the Department of Commerce & Insurance (“TDCI”) or the TennCare Bureau. Reviewers’ compensation is not connected to the outcome of the reviews performed. Independent Reviewers are selected by the independent Selection Panel for TennCare Reviewers

What kinds of Claims can be sent to Independent Review? Claims for a TennCare Program service rendered to a TennCare enrollee; and the MCC partially or totally denied or recouped the claim or the MCC failed to respond to the claim by issuing an RA within 60 calendar days; and and the Provider requested reconsideration of the denial or recoupment in writing; and 30 days have passed since the MCC received the reconsideration request.

What are the Eligibility Limitations for Independent Review? Request must be received by the TennCare Oversight Division within 365 days of the initial denial or recoupment. Request must include a copy of the Provider’s request for reconsideration of the denial or recoupment. Non-contracted Providers must submit a check for $ with the Request. The claim(s) must not be involved in arbitration or litigation.

What Happens if my Request is not Eligible for Independent Review? When a Request does not meet eligibility requirements required by Tenn. Stat. Ann. § (b), the TennCare Oversight Division will generally process the Request as a Provider Complaint. The Division will send written notice to the Provider saying why the Request is not eligible for Independent Review and whether the Request is being processed as a Provider Complaint.

Can I Aggregate Multiple Claims into One IR Request? YES, if the specific denial reason involves one “common” question of fact or law. Can a Reviewer decide one claim and apply that decision to all claims? The mere fact that claims are not paid does not create a common substantive question of fact or law. The Reviewer makes the final determination as to whether claims are eligible for aggregation.

What happens if I request claims be aggregated when they are not eligible for aggregation? If a Reviewer determines that claims should not have been aggregated, a fee will be assessed for each claim that cannot be aggregated with another claim. The Reviewer will explain the reason for this determination.

Aggregated Request Issues Multiple claims denied for Medical Necessity are not eligible for aggregation. When an aggregated request contains claims for multiple enrollees (>5), the provider should submit electronic Excel Spreadsheets listing all of the enrollees with appropriate demographic data, including Name, DOB, SSN & DOS.

Who pays for the review? Contracted Providers (Par-Providers) The MCC always pays the Reviewer. If a contracted Provider loses the Independent Review, the Provider must reimburse the MCC the fee. If a losing Provider does not refund the MCC the fee, the TennCare Oversight Division may prohibit that Provider from future participation in the Independent Review process.

Who pays for the review? Non – Contracted Providers (Non-Par Providers) The MCC always pays the Reviewer. Non-contracted Providers must submit the Reviewer fee to the TennCare Oversight Division with the Request for Independent Review. If the non-contracted Provider wins the review, TDCI will reimburse the money held to Provider. If the MCC wins, TDCI will pay the MCC. (If the claim is not eligible for independent review, the fee will be returned to the non-contracted Provider.)

How much is the Independent Review fee? The Independent Review fee is $ per Independent Review Request. If claims are “aggregated” into one Independent Review Request, there is only one fee of $ (Remember that the Independent Reviewer makes the final determination of whether requests are appropriately aggregated. So the final number of fees per submitted request may increase.)

How can I request an Independent Review? Fill out the information requested on the Request for Independent Review Form and attach or enclose supporting documents. Be sure to include everything supporting your position. Send the Request to the following address: Compliance Office, TennCare Division TN Dept of Commerce & Insurance 500 James Robertson Parkway, 11 th Floor Nashville, TN

Where Can I Get the Request for Independent Review Form? The Independent Review Request Form is located on the Internet at: A provider may also call (615) to request the form.

Will I be contacted by the Reviewer? Yes. The Reviewer will contact the Provider and the MCC, by certified mail, return receipt requested or by date and time marked facsimile. The Reviewer will ask the Provider and the MCC to provide any additional written information and documentation that the Provider or MCC wants the Reviewer to consider.

How will I know who wins the Independent Review? The Reviewer will tell you. The Reviewer will write a decision and send a copy to the Provider, MCC, and the TennCare Oversight Division.

Can I Appeal the IR Decision ? Not exactly. T.C.A. § (b), says either party may file suit between the MCC and Provider, but not the Independent Reviewer, in any court having jurisdiction to review the Reviewer's decision. The suit must be filed within 60 days of the Reviewer’s decision. Any claim concerning a Reviewer's decision not brought within sixty (60) calendar days of the Reviewer's decision will be forever barred.

If I win, when will I get my money? The MCC must pay the Provider within 20 days of receipt of the Reviewer’s decision.

What if the MCC does not pay when I win? The Provider should contact TDCI by secure/encrypted , facsimile or surface mail if payment is not received within 20 days of receipt of the Reviewer’s decision. An should be sent to both: and A facsimile should be sent to: If your (or any attachment) contains any PHI, the must be sent by HIPAA compliance secure .

What will the TennCare Oversight Division do if the MCC does not pay as decided? The Division will require the MCC to show proof that the MCC has done what the Reviewer decided to avoid assessment of Liquidated Damages.