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HAP Appeal Timeframes and New Coding Validation Process with Modifier Review Effective September 1st

Appeal within 60 days!

Effective September 1, 2022, HAP will require claims appeals to be submitted within 60 days from the date of denial. This date can be found on the remittance advice. This timeframe does not apply to claims that are in an audit or medical record review and provider received a letter with appropriate timeframes.

Effective September 5, 2022, HAP is implementing a new code validation process to ensure specific modifiers have been used correctly. Diagnosis codes and modifiers should be appropriately appended so they follow the national guidelines. Reported services should be supported in the patient’s medical record.

HAP will review the following modifiers:
Modifier 25:  Indicates a significant, separately identifiable evaluation and management (E/M) service was performed by the same physician or other qualified healthcare professional on the same day of a procedure or other services.

Modifier 59:  Distinct procedural service. Used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

Modifier XE:  Separate Encounter, a service that is distinct because it occurred during a separate encounter. Only use XE to describe separate encounters on the same date of service.

Modifier XS:  Separate Structure, a service that is distinct because it was performed on a separate organ/structure.

Modifier XP:  Separate Practitioner, a service that is distinct because it was performed by a different practitioner.

Modifier XU:  Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

Prepayment review
Claims submitted with the above modifiers on or after September 5, 2022 , will pend for a prepayment review. Registered nurses with coding credentials will use nationally sourced guidelines to review information on the claim and the patient’s claim history.

Review outcome
After the review is completed, claims will either process for payment or deny. Physicians can appeal a denial decision. Please refer to the Appeals Process section in HAP’s Billing Manual.

A nurse will review medical records and supporting documentation to determine if the denial was appropriate or if it should be overturned and processed for payment.

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