ALJ appeal

Unknown

For those of you that have escalated to the ALJ level of appeal would you please let me know your experience (good or bad)with the process and your definition or take on what constitutes the phrase "good cause". Can "good cause" be as simple as a process inadvertently not followed d/t unfamiliarity with the process. (not sending the necessary documentation needed for an appeal)

Thanks for any suggestions,

Chris

Chris Lamboley, RN, BSN
Utilization Review Supervisor

Illinois Valley Community Hospital
925 West Street
Peru, IL. 61354
O: 815.780.3294
F: 815.780.3640
Chris.lamboley@ivch.org
"Try not to become a man of success but a man of value"
-Albert Einstein

kburger@chsbuffalo.org

Hi Chris,
I have been working closely with our System HIM Manager to address our Denials at the 2nd Level and the ALJ. We have had success, particularly with our local insurers. It has generally been DRG reassignments involving Sepsis and Acute Renal Failure. We have been able to enlist our Chairs of Medicine to review the record, decide if it is defendable. Then one of us completes the letter and the physician signs it. The timeframes are tight but sometimes have been able to request an extension from the local insurer. Right now we have 30 days for our 1st and 2nd levels and trying to negotiate that to 45 at this time. Our process right now is the 1st level denials are completed by the coder, the HIM manager and I decide on the 2nd level and complete the letter with the MD support. So we update the letter if it needs to go to the ALJ. It is always gratifying to receive that favorable decision. Makes all work worthwhile.We have two Appeal nurses who do LOC denials. Any questions feel free to contact me.
Karen Burger RN, BSN, CCM, CCDS
CDEI Educator
Catholic Health - Nazareth Campus
291 North St.
Buffalo, NY 14220
Cell:(716)359-6926
Fax: (716)923-4896