MA Appeal – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to safeguard and process the claim, as required by Federal law. Prompt reimbursement of a claim is defined under 42 CFR §422.520(a): (a) Contract between CMS and... View more
MA Appeal – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Please be advised that 42 CFR §422.566(d) states: If the MA... View more
MA Appeal – Misdirected Claims
Last Updated: May 24, 2020 | Letter Type: Appeals | Jurisdiction: MA
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Pursuant to 42 CFR §422.504(i), regardless of the relationship may... View more
MA Appeal – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse emergency services as required by Federal law. Our investigation has concluded the following: As you are aware, an MA organization is financially responsible for emergency... View more
MA Appeal – No Claim on File
Last Updated: May 23, 2020 | Letter Type: Appeals | Jurisdiction: MA
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to safeguard and process the claim, as required by Federal law. Prompt reimbursement of a claim is defined under 42 CFR §422.520(a): (a) Contract between CMS... View more
MA Appeal – No Contract Underpayment
Last Updated: November 19, 2021 | Letter Type: Appeals | Jurisdiction: MA
URGENT- IMPERATIVE ACTION Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to properly reimburse health services as required by Federal law. Our investigation has concluded the following: Pursuant to 42 CFR § 422.216(a) (3) Noncontract providers. The... View more
MA Appeal – Notice Requirements for Adverse Determinations
Last Updated: April 6, 2022 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Please be advised that 42 CFR §422.566(d) states: If the MA... View more
MA Appeal – Poststabilization Timeframe
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to provide timely authorization for medically necessary poststabilization services and care as required by Federal law. Our investigation has concluded the following: THIS CLAIM IS NOW DAYS... View more
MA Appeal – Refund Recoupment – Reducing LOC
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to properly reimburse medically necessary services as required by Federal law. Our investigation has concluded the following: Pursuant to the Medicare Managed Care Manual, Chapter 4, Section... View more
MA Appeal – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Appeals | Jurisdiction: MA
IMPERATIVE-ACTION REQUIRED Dear Director of : This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to reimburse authorized health services as required by Federal law. Our investigation has concluded the following: Pursuant to the Medicare Managed Care Manual, Chapter 4, Section 10.16:... View more