PROVIDER COMMUNICATION:
A GUIDE TO POST APPEALS AND RE-OPENING REQUESTS
Purpose:
This communication should be used as an instructional guide on how t o submit re-opening
requests and appeals to Care Improvement Plus.
Medical Record FAQs
Q: Does Care Improvement Plus accept Electronic Medical Records?
A: Yes, the enhanced Care Improvement Plus Provider Portal allows providers to provide requested
medical records for post payment reviews by uploading electronic health records in the secure
provider portal. A detailed Electronic Medical Record Guide is located on the Provider Portal with
detailed instructions on how to submit records electronically.
Please note as of 1/1/2016 this portal will no longer support uploading Medical Records for claims.
Please follow the specific Medical Record submission instructions on the medical record request
correspondence you received.
Q: Will Care Improvement Plus work with 3rd party copy vendors that facilities utilize for
medical records?
A: Yes. Care Improvement Plus is currently contracted with many third party medical record
vendors. If you use a vendor that is not contracted with Care Improvement Plus you can submit the
vendor information to us by calling Provider Services at 1-866-679-3119. Please allow up to 120
days for completion of this process, as this will involve a direct contract between Care Improvement
Plus and the vendor and timeframes may vary. Please note, during this timeframe, providers should
ensure that all medical records are submitted directly to Care Improvement Plus within the timeframe
requested in the letter to avoid recoupment.
Q: How can a provider submit a request for reimbursement for copies made specific for a post
payment review?
A: To receive reimbursement for medical records, the provider will need to complete the Request
f o r Payment Medical Records Form, which can be obtained by going to the Care Improvement
Plus website, in the Provider Forms section:
https://www.careimprovementplus.com/providers/Forms.aspx. The provider must fax the completed
form to 1-888-370-5222.
Q: How much will Care Improvement Plus reimburse a provider for medical record copies for
Revised 11/02/2015
Page 1
post payment reviews?
A: Care Improvement Plus reimburses providers .12 per page up to $25.00 maximum for both copies
and mailing fees. Original Medicare does not require Medicare Advantage Plans to reimburse
providers for medical record copies for the purposes of post payment review, however, to lessen the
burden on providers, Care Improvement Plus provides compensation for copies.
https://www.federalregister.gov/articles/2003/12/05/03-30096/medicare-program-photocopyingreimbursement-methodology
Payment Disputes, Re-openings and Appeals
If a provider disagrees with a post payment review decision made by Care Improvement Plus,
the provider may request a review of the denial decision. Review requests are either Payment
Disputes, Re-openings or Appeals. The below sections explain the difference between the
three, and when each is appropriate. Providers have 60 days to file payment disputes and
appeals, and 1 year to request a re-opening. If a request is received after the aforementioned
timeframe, it can be denied for failure to timely file.
Situation
Payment Dispute - A provider
believes that CIP has processed a
claim incorrectly by reimbursing the
incorrect payment
Appeal - A post payment review was
conducted on a claim and it was
determined to be not medically
necessary
Payment Dispute - Medical records
were reviewed, and it was determined
that incorrect coding was submitted to
Care Improvement Plus.
Action
Verbally request a
payment dispute
Send to
CIP by calling
provider services at
1-866-679-3119
Timeframe
Within 60
days of the
determination.
Providers should
request an appeal in
writing.
CIP via mail or fax
Within 60
days of the
determination
1. Providers can
submit a
corrected claim.
2. Providers can
submit a
payment dispute
Within 60
days of the
original CIP
determination
C2C - Provider submitted a payment
dispute to CIP, but still disagrees with
the decision.
Providers can submit
to the Medicare
contractor.
1. CIP via regular
claim
submission.
2. CIP by calling
provider
services at 1866-679-3119
Send the payment
dispute to C2C.
Within
180 days
of the CIP
determination
Payment Disputes:
Provider payment disputes include any decisions where a non-contracted provider contends that
the amount paid by CIP for a covered service is less than the amount that would have been paid
under original Medicare. Provider payment disputes also include instances where there is a
disagreement between a non-contracted provider and the organization about the plan’s
decision to pay for a different service than that billed, often referred to as down-coding of
claims. Payment disputes do not include instances in which CIP denies a Part A claim because
the services should have been billed under Part B. Such disputes are subject to the appeals
process.
Revised 11/02/2015
Page 2
Care Improvement Plus Submission
Payment Disputes can be submitted to CIP via phone or mail.
1. To submit a payment dispute via phone, providers can contact provider services at 1866- 679-3119.
2. To submit a payment dispute via mail, providers can mail requests
to: Care Improvement Plus
Attn: Reconsideration Requests
6514 Meadowridge Rd. 1st Floor
Elkridge, MD 21075
An appeal can be filed if a re-opening is reviewed and the provider still disagrees with the
determination, however a provider should not submit or request a re-opening and an appeal at the
same time. If the denial is upheld upon re-opening, it is then appropriate for the provider to file an
appeal. The provider will have 60 days from the notification to file an appeal.
Appeals:
If a claim is processed and/or reviewed and is determined to not meet Medicare medical necessity or
receives a reconsideration upheld denial, providers can appeal that decision by submitting a written
appeal via fax or mail, including all applicable documentation, to CIP within 60 days from the date of
the adverse determination letter.
1. Appeals submitted via mail, may be sent to:
United Healthcare
Attn: Appeals and Grievance Department
PO Box 6106, MS CA 124-0157
Cypress, CA 90630
2. Appeals submitted via fax, should be sent to:
1-888-517-7113
Appeal reviewers consist of nurses and physicians independent from the group that made the original
denial decision. Appeals should include the following:
1. A statement indicating factual or legal basis for appeal
2. A
signed
Waiver
of
Liability
form
(located
here:
http://www.careimprovementplus.com/pdf/Waiver_of_liability_statement.pdf )
3. A copy of the original claim
4. A copy of the decision letter and/or remittance notice showing the claim denial
5. Any additional information, clinical records or documentation supporting the provider’s
position.
CIP will review the adverse determination and all accompanying documentation within 60 days of
the appeal receipt, provided all required documentation is received. Care Improvement Plus will send
a written decision within sixty (60) days. If the initial decision is overturned, in whole or in part, a
check will be sent following the decision if payment for the service at issue has already been
recouped.
Appeal Levels:
CMS requires Non-Contracted providers to submit to CIP a signed Waiver of Liability (WOL) form
Revised 11/02/2015
Page 3
with an appeal, holding the enrollee harmless regardless of the outcome of the appeal. If CIP does not
receive the WOL within the 60 day provider appeal timeframe, the case will be forwarded to the
independent review entity (Maximus) with a request for dismissal. The CIP time frame for acting on
an appeal request begins when the properly executed WOL and other documentation is received.
There are five levels of appeal for non-contracted providers.
1. First Level of Appeal – Initiated by the Provider - The first level of appeal is with the Plan
(CIP). Claims are reviewed by a group of nurses and physicians, independent from the
reviewers who made the initial adverse determination. If CIP upholds the denial decision, the
appeal will automatically be forwarded to an Independent Review Entity (Maximus) for
review and the decision letter will be mailed to the provider.
2. Second Level of Appeal –Automatic for adverse determinations upheld by the planRedetermination by an Independent Review Entity (IRE). If the Plan upholds the original
adverse determination, Care Improvement Plus must submit the case file to Maximus within
60 calendar days from the date the completed appeal was received by the plan.
3. Third Level of Appeal - Initiated by the Provider – If the provider is dissatisfied with the
IRE’s decision, the provider may appeal to an Administrative Law Judge (ALJ), if the amount
in dispute meets a federally defined minimum ($140.00 in 2013). The appeal must be
submitted in writing and filed with the entity specified in the IRE’s reconsideration notice
within 60 days of the Second Level Appeal determination.
4. Fourth Level of Appeal - Initiated by the Provider - If the provider is dissatisfied with the
ALJ’s decision, the provider may appeal to the Medicare Appeals Council. The request must
be submitted within 60 days of the Third Level Appeal determination.
5. Fifth Level of Appeal - Initiated by the Provider - A Judicial Review in Federal District
Court, this can only be submitted if the amount in dispute meets a federally defined minimum
($1,400 in 2013). The appeal must be submitted within 60 days of the Fourth Level Appeal
determination.
Payment Disputes, Appeals and Re-Openings FAQsQ: What is the difference between a Re-opening and an Appeal?
A: A Re-opening is used to contest a technical denial for missing records or clerical errors.
Appeals are used to contest denials based on issues such as not meeting medical necessity or coding
standards.
Q: What is the difference between a payment dispute and an Appeal?
A: A payment dispute is the process use to address situations in which the provider believes the
amount the plan paid for a service is less than the amount Medicare fee-for-service would have paid.
It includes instances in which the plan has down coded the claim. However, it does not include
instances in which the plan denied payment under Part A because the services should have been
billed under Part B. Such disputes are resolved through the appeals process, which also is used to
resolve disputes over denials based on medical necessity.
Revised 11/02/2015
Page 4
Q: If I file a payment dispute with Care Improvement Plus and do not agree with the decision,
should I appeal?
A: If a payment dispute is submitted to CIP, and the provider disagrees with the CIP determination,
providers can appeal to an independent contractor, C2C.
Q: What is the timeframe for submitting Payment Disputes, Re-opening Requests and
Appeals?
A: Re-opening Requests must be submitted within 1 year of the determination, and Appeals must be
submitted within 60 days of the provider denial notice or claim decision.
Q: How many levels of Appeals do non-contracted providers have with Care Improvement
Plus?
A: As with traditional Medicare, non-contracted providers have 5 levels of appeal rights.
Resources:
Chapter 13 Medicare Managed Care Appeals – Medicare Managed Care Beneficiary Grievances,
Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and
Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans)
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c13.pdf
Chapter 3 Medicare Program Integrity Manual – Verifying Potential Errors and Taking Corrective
Actions
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf
Chapter 8 Medicare Program Integrity Manual – Administrative Actions and Statistical Sampling for
Overpayment Estimates
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c08.pdf
Revised 11/02/2015
Page 5