Appeal Form Completion (appeal form) - Medi-Cal - mc 0216 medi cal renewal form

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appeal form
1
Appeal Form Completion
Page updated: September 2020
This section describes the instructions for completing an Appeal Form (90-1). An appeal is
the final step in the administrative process and a method for Medi-Cal providers with a
dispute to resolve problems related to their claims.
Appeal Form (90-1)
An appeal may be submitted using the Appeal Form (90-1). A sample completed Appeal
Form (see Figure 1) and detailed instructions are on a following page.
Note: Do not submit an appeal if a claim is still in suspense.
Supporting Documentation for Appeals
Necessary documentation, such as those listed below, should be submitted with each
appeal to help appeals examiners perform a thorough review of the case. All supporting
documentation must be legible. A copy of any of the following attachments is acceptable:
? Claim, corrected if necessary
? All Remittance Advice Details (RADs)
? Explanation of Medicare Benefits (EOMB) or Medicare Remittance Notice (MRN)
? Other Health Coverage (OHC) payments or denials
? All Claims Inquiry Forms (CIFs), Claims Inquiry Acknowledgments, CIF Response
Letters or other dated correspondence to and from the California MMIS Fiscal
Intermediary (FI) to document timely follow-up.
? Treatment Authorization Request (TAR)
? Service authorization request (SAR)
? Manufacturer's invoice or catalog page
? Report for "By Report" procedures
? Completed sterilization Consent Form (Form PM 330)
Appeals with CMS-1500 claim form attached:
Use the new CMS-1500 (02/12) version and complete the ICD indicator field.
Part 2 - Appeal Form Completion
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Page updated: October 2022
Appeals with UB-04 or 25-1 claim forms attached:
Insert the ICD indicator in the appropriate area of the diagnosis field and refer to the
appropriate claim completion sections of the provider manual, to complete this requirement.
Supplemental Claims Payment Information (SCPI) electronic transmissions are intended for
the purpose of an automated reconciliation of computer media records and are not
acceptable forms of documentation for timeliness in appeals. Although the transmissions are
from the state, the methods of creating paper facsimiles vary according to provider software
and are not standard.
Over-One-Year Dates of Service
Appeals submitted for claims billing services rendered more than 13 months prior to the
appeal date should include one of the following, if available, to show proof of recipient
eligibility:
? Copy of the Internet eligibility response or state-approved vendor software screen
print, with an Eligibility Verification Confirmation (EVC) number
? RAD showing payment for same recipient for the same month of service billed
?
? Copy of the original county-generated Notification of Eligibility for Letter of
Authorization.
Requesting Claim Adjustments
When requesting a claim adjustment, submit a copy of the RAD on which the claim line was
paid and all other pertinent attachments, including timeliness documentation.
Part 2 - Appeal Form Completion
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Page updated: October 2022
Timeliness: 90-Day Deadline
Providers must submit an appeal in writing within 90 days of the action/inaction precipitating
the complaint. Failure to submit an appeal within this 90-day time period will result in the
appeal being denied. (See California Code of Regulations, Title 22, Section 51015.)
Timeliness Verification
The only acceptable documentation to verify timely submission of a claim is a copy of a
RAD, Claims Inquiry Response Letter, Claims Inquiry Acknowledgment, or any dated
correspondence from the California MMIS Fiscal Intermediary containing a Claims Control
Number (CCN) or Correspondence Reference Number (CRN) with a Julian date falling
within the six-month billing limit for the claim submission. A copy of the CIF without its
accompanying Claims Inquiry Acknowledgment does not prove timely follow-up and may
cause an appeal to be denied.
Part 2 - Appeal Form Completion


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