10/13/2022

Healthfirst Appeals Denied as Duplicates

When we submit an appeal to HealthFirst they tend to still deny all appeals as duplicates. Online, we get denied via a letter which states nothing, then submit a level II appeal and a denial is forthcoming on the our regular EOP. When we appeal and submit on paper, they deny: HICF form can not be written on in Box 19 ( additional claim info) or Box 22 (Ref # or Resubmission code). It constitutes a void, which equals a denial. We submit the HICF form with clinical notes, a letter stating Medicare's NCCI rule regarding modifier 59 on 11721 and debridement of skin at different anatomical sites and on same date of service. E&M code with modifier 25 and global surgical rates. We send notes, letter justifying and as well as stating Medicare Guidelines. We most recently submitted a claim, #3, the third claim they deemed correct, but denied anyway as an EXACT duplicate of a closed claim (we called to follow-up) they said we needed to appeal! Why, the claim was correct. How does one appeal a correct claim. It is within the filing period. The Association could have a meeting with Healthfirst to resolve these issues. Manpower is at a premium, these appeals which are invariably denied takes away from other office functions. The HF reps are "good-for-nothing". HF has hired an Organization to review and deny until Timely Filing becomes an issue. If they are hard up for revenue, a suggestion might be to charge the same Specialist copay as other Insurers instead of cutting the Podiatry copay to $25.00 and denying services. They're really managing risk! Your assistance is greatly appreciated.

If a corrected claim is being resubmitted to Healthfirst to correct coding or other information on a previously processed claim, it should be resubmitted electronically within 180 days from the DOS. When submitting a corrected claim electronically, it should have the following (the billing software vendor should be able to clarify if you are unsure about how to input the information):

• Loop 2300, segment CLM05-3 must be noted with a value of “7” (replacement of a prior claim)
• Loop 2300, segment REF02 must have the claim number from the Healthfirst EOB of the denied claim that is being corrected

If there is a disagreement on how a claim was processed after it was corrected, a claim reconsideration can be submitted through the insurance portal or on paper to the following PO Box within 90 days of the initial denial of the claim:

Healthfirst Correspondence Unit

P.O. Box 958438

Lake Mary, FL 32795-8438

When requesting a reconsideration of a claim, the following should be included:

• a copy of the EOB,
• claim form,
• supporting documentation, and
• a written statement explaining why you disagree with Healthfirst’s determination as to the amount or denial of payment

If there is a disagreement on the reconsideration, an appeal can be submitted within 60 days of the decision from the reconsideration on paper to the following PO Box:

Healthfirst Provider Claim Appeals

P.O. Box 958431

Lake Mary, FL 32795-8431

Providers should provide a written statement explaining why they disagree with Healthfirst’s decision regarding the review and reconsideration, a copy of that determination, and, if the provider submitted the request for review and reconsideration via the Healthfirst provider website, the specific Healthfirst tracking number. Providers should also specify the name, address, and telephone number of an individual who may be contacted regarding the appeal and include any additional relevant documentation to support the provider’s position (see above for examples of documentation). Healthfirst will not accept claims appeals from providers that are not made in writing and that fail to address the reason for the appeal.