KMAP BULLETIN: Clean Claims and Provider Reconsiderations, Appeals, External Independent Third-Party Reviews, and Fair Hearings

Date: 07/13/21

KMAP GENERAL BULLETIN 21137 (PDF)

The Centers for Medicare and Medicaid Services (CMS) recently changed a federal regulation that defines payment denials. The effect of the change in definition was to narrow the types of claim denials eligible for Reconsiderations, Appeals, External Independent Third-Party Reviews, and Fair Hearings.

Currently, providers may submit requests for Reconsiderations, Appeals, External Independent Third-Party Reviews, and Fair Hearings for denials of payment involving clean and non-clean claims. CMS' definition change limits those requests to denials of payment involving clean claims only. Providers may submit requests for Reconsiderations, Appeals, External Independent Third-Party Reviews, and Fair Hearings once the denied claim qualifies as a clean claim.

Definition of a clean claim: A claim that can be processed without obtaining additional information from the provider of the service or a third party. This includes claims with errors originating in the State’s claims system and does not include a claim from a provider under investigation for fraud or abuse or is under review for medical necessity.

Effective with claims processed on or after July 1, 2021, denials of payment involving non-clean claims will not be eligible for appeal rights with Aetna, Sunflower, or United Healthcare. This change affects only appeal rights for providers and does not change any claim processes Aetna, Sunflower, or United Healthcare currently have.