appendix j: tar and claims process flow charts · the request for extension of stay (18-2) tar...

Medi-Cal Treatment Authorizations and Claims Processing, Appendices J1

Appendix J: TAR and Claims Process Flow Charts

Process Flow Charts Legend

Paper based Archive

Incoming/Outgoing Mail

Fax Machine

Decision Point

Sort or Batch Process

Process

Database

Open Incoming Mail

Telephone

Writing of Information

Folder

Typing of Information

Decision

Courier

Administrative Law Judge

Legal Decision

Delivered by Courier


Figure J1. TAR Non-on-site (Mail-in) Review Process

P R O V ID E R

S ort

D H S

A djudicate T A R

SortM ail T A R

E D S

Sortand batch

B atch B atch B atch

A rchiveT A R

W ritecom m ents

on T A R

T A RD ecision

E nter decision andinitia ls in to

C A -M M IS D atabase

E nter T A Ridentify ing

inform ation in toC A -M M IS D atabase

E nter com m ents in toC A -M M IS D atabase

T A R

C ourier

1

2

3

4

7

7 .5 10

11

12

6 5

8 9

7 .6

O pen m ail


Table J1. TAR Non-on-site (Mail-in) Review Process Description Number Description

General The non-on-site (mail-in) adjudication process is used for all TAR types.

1A The provider completes the TAR (50-1) with the following information and delivers it with relevant attachments to the field office:

type of service requested; retroactive service; Medicare eligibility; provider phone number; provider name and address; provider number; patient name, address, telephone number, gender, age, date of birth; patient Medi-Cal identification number; patient status (home, board and care, SNF/ICF, acute hospital); diagnosis description and ICD-9-CM code (optional); medical justification; specific services requested, units of service, procedure or drug code,

quantity, charges; and physician or provider signature, title, and date.

1B The provider completes the Request for Extension-of-Stay (18-1) TAR form with the following information:

(Hospital Information) original authorization number; admit date; authorization expiration; emergency admit; provider number; provider phone number; provider name; provider address;

(Patient Information) patient Medi-Cal identification number; patient name, gender, age, date of birth; Medicare status; number of days requested; retroactive eligibility; discharge date; admitting diagnosis description;

(Physician Information) current diagnosis, including ICD9-CM code (optional); description of current condition requiring extension, with relevant events

(such as progress notes and physician orders); planned procedures; and physician or provider signature, title, and date.


Number Description Additional pages are included when the stay is lengthy and more justification is needed.

1C The provider completes the Long-Term Care Treatment Authorization Request (20-1) TAR with the following information for subacute, long-term care, intermediate care, and the developmentally disabled:

(Provider Information) retroactive; provider phone number, name, and address; provider number; medical record number; patient name; Medi-Cal identification number; admit date; Medicare status; date, gender, and date of birth; admit from; Social Security claim number (optional);

(Physician Information) period of care requested, from and to dates; primary diagnosis code; current diagnoses; daily medications (optional for subacute); patient’s general condition, limitations, and nursing procedures required:

- bedridden; - totally incontinent; - spoonfed; - confined to wheelchair; - ambulatory with assistance; - ambulatory;

diet; attending physician’s last visit; patient’s authorized representative; physician name and phone number; physician Medi-Cal identification number; and physician signature and date.

2 DHS clerical staff opens the envelopes and date stamps all TARs. Incomplete TARs are identified and returned to the provider. Misdirected TARs are identified and forwarded to DHS clerical staff.

3 EDS FOAG clerical staff: sort and batch the TARs, including:

- TAR forms (such as Extension of Hospital Stay [18-1] or Treatment Authorization Request [50-1]);

- urgent or nonurgent service;


Number Description - prior authorization or retroactive service; - adjudicator type (such as med-tech or physician); and - misdirected TARs.

attach a different colored batch cover sheet for each of the batches; and add a Document Control Number (DCN).

4 EDS FOAG data entry staff log the TAR into CA-MMIS by entering the Tar Control Number (TCN) and DCN.

If a duplicate TCN is found, a new TCN is assigned. A provider accessing the Provider Telephone Network (PTN) system at this

time would be informed that the TAR has been received. Misdirected TARs are logged into the system with a decision of deferred,

and returned to DHS clerical staff.

5 EDS FOAG clerical staff places TAR batches in exchange area.

6 DHS supervisor or consultant (DHS nurse or medical consultant) picks batches up from exchange area.


Figure J2. TAR On-site Review Process

PR O V ID ER D H S ED S

Com plete? A djudicate TA R

Send TA R to fieldoffice

Enter intoCA -M M IS D atabase

N o

Y es

A rchiveTA R

TA R

TA R

Return TA R toProvider

Is Patientdischarged?

A djudicate TA R atnext on-site visit

N o

Y es

1

2

3

4

5

6

7

8

Providercom pletes TA R


Table J2. TAR On-site Review Process Description

Number Description

General The on-site adjudication process is only used for concurrent or retroactive hospital stays using the Request for Extension of Stay (18-1) TAR form. In most cases the hospital will provide a space with a telephone for the on-site review nurse. The concurrent and retrospective charts are made available in the space awaiting review. In some cases, the nurse will need to find the charts for concurrent review.

1 The provider completes the TAR with the following information: (Hospital Information) original authorization number (if necessary); admit date; authorization expiration; emergency admit; provider number; provider phone number; verbal control; provider name; provider address;


(Physician Information) current diagnosis, including ICD9-CM code (optional); description of current condition requiring extension, with relevant

events (e.g., lab, x-ray reports); planned procedures; and physician or provider signature, title, and date.

A POS form is attached to demonstrate Medi-Cal eligibility. Additional pages are included when the stay is lengthy and more justification is needed.

2 If the TAR is incomplete, the DHS nurse will return the TAR to the provider or assist the provider in filling it out.


Number Description

3 The DHS on-site nurse that adjudicates the TAR: reviews the chart; writes comments on TAR; consults with a variety of professionals, including the provider and

DHS MDs; has no access to the CA-MMIS system in the field and is unable to

check for duplicates or previous patient history; and may call into the office to have someone access the CA-MMIS

system.

4 DHS on-site nurse returns a copy of the TAR with a decision to the provider.

5 TARs deferred for more information, or when the patient has not been discharged, are returned to the provider for adjudication at next on-site visit.

6 DHS on-site nurse or provider brings or sends the TARs to the field office.

7 EDS FOAG data entry staff receive the on-site reviewed TARs and enter all information into the CA-MMIS database. Staff do the following:

stamp TARs with Document Control Number (DCN) and date; perform all data entry steps:

- enter TAR and Document Control Numbers; - enter decision and consultant initials; - enter highlighted comments on the TAR; and

update TAR to the TAR Update File. The provider may bill for services based on that TAR.

8 EDS FOAG clerical staff archive completed TARs.


Figure J3. TAR Fax Review Process

P R O V ID E R D H S E D S

T A R

A djud icate T A R

F ax com pleted T A Rto P rovider

E n ter in toC A -M M IS D atabase

T A R

A rch iveT A R

Is Patien t still inhosp ita l?

N o

Y es

H old T A R in file

3

1

2

4

5

6

7


Table J3. TAR Fax Review Process Description

Number Description

General The fax adjudication process is only used for concurrent hospital stays using the Request for Extension of Stay (18-2) TAR form. The field office creates a TAR schedule, allocating time slots to various hospitals. During that time slot the hospital will fax TARs and respective documentation.

1 The provider completes the 18-2 TAR with the following information: (Hospital Information) original authorization number; admit date; authorization expiration; emergency admit; provider number; provider phone number; provider name; provider address;


(Physician Information) current diagnosis, including ICD9-CM code; description of current condition requiring extension, with relevant

events (such as physician orders and progress notes); planned procedures; and physician or provider signature, title, and date.

Additional pages are included when the stay is lengthy and more justification is needed.

2 DHS clerical staff delivers TAR to DHS nurse.

3 DHS nurse adjudicates TAR: writes comments on TAR; consults with a variety of professionals, including the provider and DHS

medical consultants; and has access to the CA-MMIS system and is able to check for duplicates

or previous patient history throughout the adjudication process.

4 DHS clerical staff faxes TAR back to the provider.

5 If the patient has not been discharged, the TAR will be held in a file and re-adjudicated as concurrent review during the next fax TAR time slot for that


Number Description hospital.

6 If complete, EDS FOAG data entry staff receive the fax-reviewed TARs and enter all information into the CA-MMIS database:

stamp TARs with Document Control Number (DCN) and date. perform all data entry steps:

- enter TAR and DCN; - enter decision and consultant initials; and


7 EDS FOAG clerical staff archive completed TARs. Approved TARS are filed without attachments. Modified, or denied TARS are filed with attachments. Deferred TARs are filed with attachments.


Figure J4. TAR Medical Case Management (MCM) Process


F ax

N o

A d jud ica te T A RY es

E n ter d ec isio nand in itia ls in to

C A -M M ISD atab ase

E n ter T A R in toC A -M M ISD atabase

A rch iv e T A R

T A RP ro v id er

sign atu re onT A R ?

F ile T A R in M C Mchart

E n ter in to M C Md atabase

T A R

F ax

T A R

1

2

3

4 5

6

4

8

9

7

3

1

4 .3

S ign T A RW rite

com m ents


Table J4. TAR Medical Case Management (MCM) Process Description

Number Description

General A patient is referred to Medical Case Management (MCM) from discharge planners, home health agencies, DHS nurses, medical consultants, the patient’s physician, or an ER physician. Once a patient is approved for MCM, the MCM nurse creates a chart and develops case management goals for the patient. As part of the MCM process, the nurse facilitates the approval of all TARs for that patient.

1 The provider or the MCM nurse completes the 50-1 TAR form with the following information:

type of service requested; retroactive service; Medicare eligibility; provider phone number; provider name and address; provider number; patient name, address, telephone number, gender, age, date of birth; patient Medi-Cal identification number; patient status (home, board and care, SNF/ICF, acute hospital); diagnosis description and ICD-9-CM code; medical justification; specific services requested, units of service, procedure or drug code,

quantity, charges; and physician or provider signature, title, and date.

2 If the TAR is incomplete, the MCM nurse attempts to fill out the TAR in consultation with the provider.

3 The MCM nurse ensures that the provider signature is on the TAR. If not, the MCM nurse faxes it to the provider for signature and the provider returns the fax.

4 MCM nurse adjudicates TAR: writes comments on TAR; consults with a variety of professionals, including the provider and DHS

medical consultant; and nurse enters adjudication decision in CA-MIMMS database.

5 MCM nurse files the TAR in the MCM patient chart.

6 MCM nurse enters TAR information in the MCM database.

7 TAR is faxed to the provider.

8 EDS FOAG data entry staff receive the on-site reviewed TARs and enter all information into the CA-MMIS database:

stamp TARs with Document Control Number (DCN) and date; perform all data entry steps;

- enter TAR and DCNs; - enter decision and consultant initials;


Number Description - enter highlighted comments on the TAR; and


9 EDS FOAG clerical staff archive completed TARs.


Figure J5. TAR First-Level Appeal Process


T im ely?

N o

M ail ou t

A p pea ld ec isio n

T A R(if g ran ted)

E n ter inap p ea l

d a tabase

R eq uest T A RY es

A dm in istra tiv eD en ia l

S up erv iso rR ev iew

A d m in istra to rR ev iew

L og d ec isio n inap p ea l

d a tabaseT A R

E n ter T A R in toC A -M M ISD atabase

A rch iv eT A R

O pen m ail

T y p e D ecision

R etriev eT A Rfro m

arch ive

A p pea l

M ed ica lC on su ltan t

R ev iew

Is T A Rinc lud ed in g ran ted

app ea l?Y es

R eq uest T A Rfrom P ro v id er

N o

A rch ive ap peal

1 23

4

5

6

8

91 0

1 1

1 2

1314

1 51 6

1 7

7

R eview erw rites

decis ion


Table J5. TAR First-Level Appeal Process Description

Number Description

General A provider may appeal an unfavorable TAR decision by filing an appeal at the Medi-Cal field office.

1 The provider requests an appeal on a denied or modified TAR.

2 DHS clerical staff open and identify the appeal. Some appeals may be mis-identified as TARs and are returned to this step from the TAR process.

3 DHS clerical staff log the appeal into the appeal database.

4 If the appeal is not timely, the DHS clerical staff generate an administrative denial form letter.

5 DHS clerical staff request TAR from archive.

6 EDS FOAG clerical staff retrieve TAR from archive and forward to DHS word processing staff.

7 The DHS supervisor distributes appeals to a reviewer (DHS nurse or medical consultant).

8 Reviewer writes appeal decision: performs extensive research on the appeal, including possible on-site

visits; explains the appeal decision; and if TAR is included and appeal is reversed, adjudicates and approves

TAR.

9 The supervisor reviews the decision.

10 The medical consultant reviews the decision. This step varies the most by field office. Depending on the office, the medical consultant reviews all appeals, the nurse consults with the medical consultant while researching the appeal, or the medical consultants only see appeals with overturned or modified decisions.

11 DHS clerical staff type the decision.

12 The administrator reviews the decision.

13 DHS clerical staff log the decision into the appeals database.

14 If a TAR is included on a reversed appeal, the TAR is given to EDS FOAG clerical staff to enter into CA-MMIS and archive.

15 If a TAR is not included on a reversed appeal, the TAR is requested from the provider on the appeal decision letter.

16 DHS mails the decision to the provider with a TAR if a TAR is included in a granted appeal.

17 DHS clerical staff archive the appeal.


Figure J6. TAR Fair Hearing Process

B E N E F IC IA R Y / D S S D H S E D S

R eq uest fo rF air

H earin g

P repare F a irH earing fo ld er

R equ est T A Rfro m arch ive

C an F airH earing be reso lved

o r w ith draw n?N o

D iscussw ith

B enefic iary o r P ro v id er

Y esA dm in istra to rR ev iew

T yp e dec is ion

R etrieve T A Rfro m

arch iv e

F airH earingP o sition

S tatem ent

D ecisio n filed inF a ir H earing

fo lder

Is F air H earin gg ran ted?

R equ est T A Rfrom P ro v id er

N on O n-S iteT A R P rocess

T A RA rchive F a ir

H earin g fo ld er

Y es

N o

D ecision

A dm in istra tiv eL aw Ju d ge m ak es

a dec is ion

P rep areP o sition

S ta tem en t

12

3 .1 3 .2

4

5

6

7

8

9

1 0

13

1 1 & 1 214

1 7

1 6

1 5

M ail o u t

O p en m ail


Table J6. TAR Fair Hearing Process Description Number Description

General The recipient may appeal an unfavorable TAR decision by applying for a fair hearing through the Department of Social Services (DSS).

1 The recipient requests a fair hearing through the DSS. DSS forwards a fair hearing request to the Medi-Cal field office.

2 DHS clerical staff open and identify the fair hearing request.

3 The DHS word processor: prepares fair hearing folder; and requests TAR from archive.

4 EDS FOAG clerical staff retrieve TAR from archive and forward to DHS word processing staff.

5 DHS nurse determines if fair hearing can be resolved or withdrawn. This may require significant research to gain an understanding of the fair

hearing request. The nurse may confer with the medical consultant.

6 If fair hearing request can be resolved, the consultant: explains to recipient or provider that this is not a fair hearing request, or

explains that the TAR will be approved if fair hearing is withdrawn; works with the provider or the Administrative Law Judge (ALJ); and requests a TAR from the provider for services to be approved.

7 If fair hearing cannot be resolved or withdrawn, the consultant: performs additional research, possibly including an on-site; and prepares a position statement explaining the Medi-Cal field office’s

decision.

8 The DHS word processor types the position statement.

9 The administrator reviews the fair hearing decision including: the position statement and necessary attachments; and the conditional withdrawal letter.

10 The fair hearing decision (position statement or withdrawal letter) is mailed out to DSS and the recipient.

11 At the time of the fair hearing, the consultant is available in person, by pager, or by telephone. This practice varies significantly by field office and the perceived “strength” of case.

12 The ALJ makes a decision, which is sent to the field office.

13 The decision is filed in the fair hearing folder.

14 If the fair hearing request is granted, the field office will request a TAR from the provider, which goes through the non-on-site TAR process, is approved, and is returned to the provider.

15 DHS clerical staff files a copy of the TAR in the fair hearing folder.


Number Description

16 If the fair hearing request is denied, no further action is taken.

17 DHS clerical staff archive fair hearing request folder.


Figure J7. TAR Update Transmittal (TUT) Process


E nter T U T in toC A -M M IS D atabase

P repare T U T Superv isorrev iew o f T U T

M ail Screen P rin t o fT A R to P rovider

S creen m ail fo rcorrec tion requests

S creenPrin t

1

1

2 3 4 5

7

A rchiveT U T

ScreenPrin t

6

8


Table J7. TAR Update Transmittal (TUT) Process Description

Number Description

General The TAR Update Transmittal (TUT) form is used to process corrections on a TAR.TARs can only be TUT’ed as long as they are active in the master file.

1 The provider requests a correction through mail or fax.

2 DHS clerical staff screen incoming mail and faxes for corrections.

3 DHS clerical staff: request original TAR, if necessary; and prepare a TUT form based on the correction.

4 DHS nurse or supervisor approves TUT.

5 EDS FOAG data entry staff: perform an update on the original TAR using the information on the TUT

form.

6 EDS FOAG data entry staff print a screen of the TAR indicating the change.

7 EDS FOAG clerical staff mail the print screen to the provider.

8 EDS FOAG clerical staff archive completed TUTs. In most cases, these are archived with the TAR, although some offices archive TUTs separately.


Figure J8. TAR Pharmacy Fax Review Process

P R O V ID E R

T A R

T A R

6 . R x

R e g u la r

E D S C H A N G E O R D E R S T A F F

S o rt

D is tr ib u te to sa te llitea n d c o n su lta n ts

D is tr ib u te toP ro v id e rs

D H S /E D S P H A R M A C E U T IC A LC O N S U L T A N T S

A d ju d ic a te T A R

E D S F O A G

A rc h iv eT A R

B a tc h

E n te r d e c is io n a n din itia ls in to

C A -M M IS D a ta b a se

E n te r T A Rid e n tify in g

in fo rm a tio n in toC A -M M IS D a ta b a se

E n te r C o m m e n tsin to C A -M M IS

D a ta b a se

1 2 3

4

5

6 .1 & 6 .2

6 .3

6 .4

8

9

1 0 & 1 1

7

W ritec o m m e n ts


Table J8. TAR Pharmacy Fax Review Process Description

Number Description

General Pharmacy TARs are faxed into the Medi-Cal pharmacy offices fax machines on 50-2 TAR forms.

1 The provider completes the TAR with the following information and faxes it to the pharmacy office:

type of service requested; retroactive service; Medicare eligibility; provider phone number; provider name and address; provider number; patient name, address, telephone number, gender, age, date of

birth; patient Medi-Cal identification number; patient status (home, board and care, SNF/ICF, acute hospital); diagnosis description and ICD-9-CM code; medical justification; specific services requested, units of service, procedure or drug

code, quantity, charges; and physician or provider signature, title, and date.

2 EDS change order staff receive the faxes from the fax machine with a time and date stamp and then:

identify incomplete TARs and label them as “Batch 3”; sort the TARs:

- regular Rx TARs (for drugs not on the “contracted” list); - 6-Rx TARs (for drugs that are the seventh “contract” drug

requested for a beneficiary in a one-month time period) screen and eliminate duplicate TARs by quickly entering the TAR

Control Number (TCN) in the CA-MMIS system; and identify TARs for special projects (such as HGH).

3 EDS FOAG clerical staff: batch the TARs in groups of five (the batches receive a different

color batch cover sheet based on the day of the week); add a Document Control Number (DCN); log the TAR into CA-MMIS by entering the TAR Control Number

(TCN) and DCN; - if a duplicate TCN is found, the TAR is pulled from the batch

and automatically denied; - a provider accessing the Provider Telephone Network (PTN)

system at this time would be informed that the TAR has been received;

log “Batch 3” TARs (incomplete TARs) into the system with a decision of “deferred,” and return to EDS change order staff who fax them back to the providers.


Number Description

4 EDS FOAG data entry staff key in TAR information. A provider accessing the PTN system at this time would be informed that the TAR is in “work” status.

5 EDS change order staff pick up the batches and prepare them for distribution. Staff:

identify fair share for each consultant (the fair share is determined every morning at approximately 8 a.m. when management identify the following: - total number of TARs remaining from the previous day and new

TARs received that morning; - the number of consultants expected to be in the office

adjudicating TARs that day; - the total number of TARs is divided by the total number of

consultants; distribute a subset of TARs to the Stockton office consultants; and fax the remaining TARs to the satellite office consultants.

6 In both the Stockton and satellite offices: DHS or EDS pharmaceutical consultant adjudicate the TAR for medical necessity. Consultants:

pull up the TAR and the following information: - eligibility screen; - patient profile screen; - TAR history screen;

evaluate any attachments; write comments on the TAR;

- highlight comments that EDS FOAG data entry staff will enter; enter into CA-MMIS system;

- decision; - initials;

A provider accessing the PTN system at this time would receive the decision on the TAR.

7 In both the Stockton and satellite offices: EDS change order staff:

pick up the batches from each consultant; and distribute TARs to EDS FOAG data entry staff.

8 In both the Stockton and satellite offices: EDS FOAG data entry staff:

confirm the decision in the CA-MMIS is the same as the decision on the TAR form; and

enter the highlighted comments into CA-MMIS. A provider accessing the PTN system at this time would receive the decision and the reasons for the decision.

9 In both the Stockton and satellite offices: EDS change order staff or DHS clerical staff fax the TAR back to the


Number Description provider.

10 In the satellite office: EDS change order staff or DHS clerical staff return the TARs to the Stockton office for archiving.

11 EDS clerical staff archive TARs and any relevant attachments.


Figure J9. Claims Process

ProviderIntermediary

PaperComputer

MediaClaims

ProviderCommunication

ExceptionReport

RecordingProcess

Optical Character Recognition/ KeyData Entry/ Computer Media Claims

Input Edits

Reject

InputFile

Accept

CrossoverEdit

DiagnosisEdit

ProcedureEdit

ProviderEdit

RecipientEdit

TAREdit

DAILY SPLIT

CriteriaSets

ManualClaims

Adjudication(and Automated

TransactionGenerator)

Suspense

DailyAdjudication

Process

Fail

DailyAdjudicated

Claims

Pass

WeeklyAdjudication

Process

Fail

Pass

Paid/DeniedAdjudicated

Claims

FinancialProcessRemittance

Activity

StateController’s

Office

ManagementReporting

File Update

Mgt. Reports

Weekly Edits

SkeletalHistory

TARMaster

Share of Cost

Daily Edits

MMIS Table

Health AccessProgram

TAR

Share of Cost

Proof ofEligibility

Eligibility(Fame)

Provider

Procedure

Formulary

Diagnosis

1

2

8

3

9

1012

7

4 5

6

11


Table J9. Claims Process Description Number Description

General A provider submits a claim for payment of services that were rendered.

1 A provider will complete a claim form and deliver it to the EDS Claims Center. A claim comes through the mail, through electronic media (diskette, internet, or modem), or through a POS system.

2 Hardcopy claims are scanned using OCR or data entered into CA-MMIS.

3 OCR claims are manually corrected if needed.

4 Paper claims are recorded on a magnetic tape and processed by an outside service to create microfilm images.

5 CMC claims are recorded on Computer Output to Laser Disc (COLD).

6 Claims are validated prior to entry into CA-MMIS.

7 Claims are run through daily adjudication.

8 Claims that suspend are adjudicated by a claims examiner, and are sent back through the daily adjudication process.

9 Claims go through a weekly adjudication process evaluating items such as share of cost, or frequency edits.

10 Claims go through the weekly financial process generating a payment tape.

11 The payment tape is sent to the controller’s office.

12 A check or an electronic funds transfer(EFT) and a remittance advice are sent to the provider.


Figure J10. Claims Inquiry Form (CIF) Process

PR O V ID ER ED S

CIF

Is claim inhistory file?

Is there an erroron CIF?

Is the errorcorrected?

Claim s Process

N o

Y es

Claim s exam inerperform s corrections

Y es

N o

CIF Denialletter

Y esProcess CIF against

history file

O pen m ail

N o H istoryletter

N o

CIF Denialletter

M ail out

N o H istoryletterM ail out

Enter C IF intoCA -M M IS

H istory

12

3

4

5

6

7

8


Table J10. Claims Inquiry Form (CIF) Process Description Number Description

General The Claims Inquiry Form (CIF) is used to process corrections on a claim.

1 A provider completes a Claims Inquiry Form (CIF) and mails it in to the claims center.

2 The CIF is entered into the computer system through optical character recognition (OCR) or key data entry (KDE).

3 The CIF is processed against the edits and audits in CA-MMIS.

4 If there are no errors, the CIF is processed against the history file.

5 If there is history, then the CIF is adjudicated in the claims system.

6 If there is no history, a “no history” letter is generated and mailed to the provider.

7 If there are errors, a claims examiner will correct the errors and then process it against the history file.

8 If the errors can not be corrected by the claims examiner, a CIF denial letter will be generated and mailed to the provider.


Figure J11. Claims Appeal Process

PROVIDER EDS

Appealoverturned?

No

Yes

ClaimsProcess

AdjudicateAppeal

Enter inAppeal

database

Generate appealacknowledgement

letter

Mail out Professional review needed?

Yes Generateprofessionalreview letter

ProfessionalReview

Mail out

No

Mail out

Resubmitclaim for

processing inCA-MMIS

Generatereprocessingclaim letter

Mail out

Open letter

Reprocessingclaim letter

Denialletter

Underprofessional

review

Acknowledge-mentletter

Appeal

Generatedenialletter

1 23

4

5

6 7

8

9

10


Table J11. Claims Appeal Process Description Number Description

General The appeal process is used to appeal a denied or a paid claim.

1 The provider completes an appeal form and mails it to the EDS Claims Center.

2 nto the Appeal database.

3 An appeal acknowledgement letter is generated and mailed to the provider.

4 The claims examiner adjudicates the appeal, evaluating the following: Timeliness of appeal Eligibility of recipient Legibility of attachments and documentation

Evaluates the documentation to demonstrate that the claim associated with the appeal should be reversed.

5 The claims examiner evaluates if professional review by a clinician (e.g., doctor or a nurse) is needed.

6 A letter indicating that the appeal is under professional review is generated and mailed to the provider.

7 The appeal is reviewed by a professional reviewer.

8 If the appeal is overturned, a letter is mailed to the provider indicating that the claim associated with the appeal is resubmitted for claim processing.

9 The claim is resubmitted for processing.

10 If the appeal is denied, a denial letter is generated and mailed to the provider.

appendix j: tar and claims process flow charts · the request for extension of stay (18-2) tar...

Documents