Attention: All Providers
Effective November 9, 2010, Medicaid introduced the NCCI edits into the Medicaid claims processing system. These edits were set as “informational” edits. On March 23, 2011, these edits were set to deny for any services that do not meet the NCCI edit criteria and were furnished on or after October 1, 2010.
The use of applicable modifiers will be critical in successful implementation of the NCCI procedure to procedure edits. Once a claim or line item on the claim has been denied for an NCCI procedure to procedure edit, then the claim cannot be adjusted by the provider. If a claim is denied for an NCCI Medically Unlikely Edit (MUE), the provider can resubmit the claim with the correct units as long as the units are equal to or lesser than the NCCI MUE edit allows. If the units are more than the NCCI MUE edit allows, then an appeal must be requested.
NCCI procedure to procedure edits are coding edits, and are based on coding principles. The Medicaid NCCI Coding is available on the CMS NCCI website at ttp://www.cms.gov/MedicaidNCCICoding/01_Overview.asp#TopOfPage
If the NCCI edit responsible for an NCCI denial has a modifier indicator of “0”, an appeal can NEVER overturn the denial. These claims are final and no appeal is applicable except for an administrative law judge who can determine that the denied column two code should be paid. These instances will be rare.
If the NCCI edit responsible for an NCCI denial has a modifier indicator of “1” or is for an MUE, an appeal can be submitted.
All NCCI denials begin with an error code “59nn”. To validate a claim denied for an NCCI error code, download the remittance advice from the web-portal which contains the Medicaid specific error codes.
Individual claim denials may be appealed at three levels. The levels, listed in order, are:
1. Redetermination Request
2. Administrative Review
3. Fair Hearing
If all appeals have been exhausted and the claim denies, the provider cannot collect from either the recipient or his/her sponsor or family. This denial is a provider liability.
First Level of Appeal: Redetermination Request
The Alabama Medicaid Agency contracts with a fiscal agent (HP Enterprise Services {HPES}) to process and pay all claims submitted by providers of medical care, services, and equipment authorized under the Alabama Title XIX State Plan. HPES will also be responsible for the redeterminations, which is the first level of appeals and adjudication functions.
A redetermination is an examination of a claim and operative notes/medical justification by HPES personnel. The provider has 60 days from the date of receipt of the initial claim determination to request a redetermination. The provider must complete the attached HP Enterprise Services Request for NCCI Redetermination Review form. The request for a redetermination must include:
· Completed NCCI Redetermination Review form
· Corrected Paper Claim for the procedure codes that denied
· Operative Notes/Medical Justification
Send the request for redetermination review along with all supporting documentation to:
HP Enterprise Services
Request for NCCI Redetermination
PO Box 244032
Montgomery, AL 36124-4034
HPES will normally issue a decision via the remittance advice within 90 days of receipt of the redetermination request. The ICN region for the redetermination request will begin with ‘91’. For example: 9111082123456.
Second Level of Appeal: Administrative Review
When the redetermination request results in a denial by HPES, the provider may request an administrative review of the claim. A written request for administrative review must be received by the Alabama Medicaid Agency within 60 days of the date of the redetermination denial from HPES.
To request an Administrative Review, the provider must complete the attached Alabama Medicaid Form 403 - Request for National Correct Coding Initiative (NCCI) Administrative Review. The request should clearly explain why you disagree with the redetermination denial.
The request for an administrative review must include
Completed Form 403 - Request for National Correct Coding Initiative (NCCI) Administrative Review
Correct Paper Claim for the procedure codes that denied
Copy of previous request for redetermination correspondence sent to HPES
Copies of all relevant remittances advices or HPES’ redetermination denial notification
Copy of any other useful documentation
Send the request for administrative review along with all supporting documentation to:
NCCI Administrative Review
Alabama Medicaid Agency
Attn: System Support Unit
501 Dexter Avenue
P. O. Box 5624
Montgomery, AL 36103-5624
Documentation that is submitted after the Administrative Review request has been filed may result in an extension of the time required to complete the review. Further, any documentation noted in the redetermination as missing and any other evidence relevant to the appeal must be submitted prior to the issuance of the Administrative Review decision. Documentation not submitted at the Administrative Review level may be excluded from consideration at subsequent levels of appeal unless you show good cause for submitting the documentation late.
This information will be reviewed and a written reply will be sent to the provider within 60 days.
Third Level of Appeal: Fair Hearing
When the administrative review does not resolve the issue, the provider has the option to request a fair hearing. A written request must be received within 60 days of the date of the administrative review decision. The request must identify any new or supplemental documentation. Send the written request for a fair hearing to:
Alabama Medicaid Agency
Attn: Office of General Counsel
501 Dexter Avenue
P. O. Box 5624
Montgomery, AL 36103-5624
If you have further questions, contact the Provider Assistant Center at 1-800-688-7989 or (334) 215-0111.
Request for NCCI Redetermination Review
HP Enterprise Services
PO Box 244032
Montgomery AL 36124-4032
Complete ALL Fields Below - Print or Type
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ICN #
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Date of Service
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Recipient Name
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Recipient Medicaid Number
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Provider Name
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Provider NPI Number
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NCCI Denial Code(s)
1. 2. 3. |
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Date of Denial
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Required Attachments (check box to indicate which attachment is being submitted with request):
Corrected paper claim submitted with procedure code(s) that denied along with specific reports (see below):
□ Anesthesia report for denied procedure codes in the range: 00100 – 01999
□ Operative report for denied procedure codes in the range: 10000 – 69999
□ Radiology report for denied procedure codes in the range: 70000 – 79999
□ Pathology or Laboratory report for denied procedure codes in the range: 80000 – 89999
□ Medical report for denied procedure codes in the range: 90000 – 99605
Comments:
Signature of either the provider or his/her representative
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Date
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Address
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City, State and Zip code
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Telephone Number, including area code
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Signature
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Alabama Medicaid Agency
Request For National Correct Coding Initiative (NCCI) Administrative Review
This form is to be completed only when the Redetermination Request results in a denial by the Fiscal Agent.
Section A
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__________________________________ _Print or Type_____________________________________________
Provider’s Name Provider Number
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Recipient ‘s Name Recipient’s Medicaid Number
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Date of Service ICN
________________________________________________________________________________________________________I do not agree with the Redetermination denial by the Fiscal Agent Dated: ___________________
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Section B
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My reasons are:
________________________________________________________________________________________________________
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________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Section C
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Signature of either the provider or his/her representative
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Provider Signature Representative Signature
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Address Address
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City, State and ZIP Code City, State and ZIP Code
________________________________________________________________________________________________________
Telephone Number Telephone Number
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Date Date
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Form 403 Alabama Medicaid Agency
Created 3-21-2011
NCCI Administrative Review and Fair Hearings
Alabama Medicaid Provider Manual
Title XIX Medical Assistance State Plan for Alabama Medicaid provides that the Office of the Governor will be responsible for fulfillment of hearing provisions for all matters pertaining to the Medical Assistance Program under the Title XIX. Agency regulations provide an opportunity for a hearing to providers aggrieved by an agency action.
For policy provisions regarding fair hearings, please refer to Chapter 3 of the Alabama Medicaid Agency Administrative Code.
When a redetermination request results in a denial by the Fiscal Agent, the provider may request an NCCI administrative review of the claim. A request for an NCCI administrative review must be received by the Medicaid Agency within 60 days of the date of the redetermination denial from the Fiscal Agent. In addition to a clean claim, the provider must send a copy of the redetermination denial, all relevant Remittance Advices (RAs) and previous correspondence with the Fiscal Agent or the Agency in order to demonstrate a good faith effort at submitting a claim and supporting documentation. This information will be reviewed and a written reply will be sent to the provider.
Send requests for NCCI Administrative Reviews to the following address:
NCCI Administrative Review
Alabama Medicaid Agency
Attn: System Support Unit
501 Dexter Ave.
P.O. Box 5624
Montgomery, AL 36103-5624
NOTE:
If all NCCI administrative remedies have been exhausted and the claim denies, the provider cannot collect from either the recipient or his/her sponsor or family.
If the NCCI Administrative Review does not result in a favorable decision, the provider may request a fair hearing.