IMPORTANT NOTE:
Before using this template rebuttal letter, please ensure that your participation contract/agreement DOES NOT have a clause in it committing you to abide by the managed care organization’s in-house policy ONLY and not in addition to the CMS regulations and directives. If there is such a clause, then the argument below does not apply.
DRAFT – 42 CFR (OPL #46) Rebuttal Letter – Medicare Advantage Plans
I am writing with reference to your organizations adjudication of my claims submitted for ______, a service I have provided to my patient, a Medicare Advantage or managed care beneficiary.
Your organization has denied/reduced/bundled the services on the attached claims based on your contention that the service in question is _______________.
The Medicare policy, however, states that ____________________________.
Please note that the Center for Medicare & Medicaid Services (CMS) requires all Medicare Managed Care Organizations (MCOs) to abide by the directives encompassed by 42 C.F.R 422.101(a).
This regulation stipulates that MAOs (both risk and cost plans) must abide by the Centers for Medicare and Medicaid Services (CMS) regulations and/or national coverage decisions (NCDs) and they must also abide by specific written policies made by the Medicare Administrative Contractors (MACs) with jurisdiction for claims in the geographic area served by the plan under their Local Coverage Determinations (LCDs);
In addition, the Health Policy Branch of CMS has reiterated in past communications that you are required to abide by the above and follow Local Coverage Determinations and basic Medicare payment regulations.
Your denial/reduction/bundling of this service is in direct contradiction to the regulation as well as CMS’ reaffirmation as a policy exists that addresses this issue. It is outlined in the following policy/documentation:
(Insert CMS or local carrier policy reference link here).
In closing, and at the specific request of CMS’ Health Policy Branch, I am requesting that CMS initiate an investigation into this breach of the regulation by your organization.
It is respectfully requested that your office make the proper adjudication to these claims. If there are any questions, please feel free to contact me. Thank you.
Sincerely,
XXXXX
Cc: Lauren Dulay
CMS/CDHPC
Division of Policy, Analysis and Planning
Medicare Advantage Group
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244
Russell Hendel
CMS/CDHPC
Division of Policy, Analysis & Planning
Medicare Advantage Group
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244