MEDICARE APPEAL OF RAC OR MAC CLAIM DENIALS

Process

Hospital clients receive CMS Medicare claim denial notices due to audit by the Recovery Audit Contractor (RAC) or the Medicare Administrative Contractor (MAC). Within the client appeal filing date deadline, a St. Clair Physician Adviser (PA) performs a comprehensive review of the clinical record documentation and prepares/submits the written appeal , with supporting clinical rationale,  to the Fiscal Intermediary at Medicare Appeal Level 1.

If Level 1 appeal is denied, St. Clair files appeal with  Qualified Independent Contractor (QIC) at Medicare Appeal Level 2. If Level 2 is denied,  St. Clair files the Level 3 appeal request. Also, our PA consultant makes, in the telephonic hearing, the verbal presentation of our clinical appeal rationale using “simple layman” terms that are understandable to the Administrative Law Judge (ALJ).

St. Clair can assist a hospital client in preparing and presenting a Medicare fourth level appeal to the Appeals Council Review and, if denied, the fifth level appeal with the Federal District Court.

Pricing Approach

For the handling of  referred RAC or MAC claim denial appeals, St. Clair has competitive professional fees per claim appeal level.