Appeals for Inpatient Psychiatric Denials
Hospitals have the right to reconsideration of inpatient psychiatric precertification, retroactive admission and post-payment review denials. There are two different types of denials; medical necessity and technical.
Medical Necessity Denials are the result of a Permedion physician reviewer determining that the patient’s psychiatric admission did not meet an inpatient level of care.
Technical Denials, known also as administrative denials, are the result of a provider not following the precertification, retroactive admission, and post-payment review processes. The most common reasons for technical denials are:
- Retroactive admission requests where a patient was not Medicaid-eligible upon admission and Permedion was not provided with date-stamped proof that eligibility was checked, e.g., MITS screenshot, within the precertification time frame.
- Precertification requests that were submitted late to Permedion for patients who were Medicaid eligible upon admission. Providers have two (2) business days from a patient’s psychiatric admission date to submit the Inpatient Psychiatric Precertification form. On requests made prior to April 30, 2015, providers had only one (1) business day to submit.
For all denials, both First and Second Level Appeal processes are available to providers.
A First Level Appeal request is that which a provider can make following an initial denial. The request is reviewed and an outcome determined by a Permedion physician reviewer.
A Second Level Appeal request is that which a provider can make following the denial of a First Level Appeal. Although this request should always be sent directly to Permedion, it is reviewed and an outcome is determined by an Ohio Mental Health and Addiction Services (OMHAS) physician reviewer.
The appeal processes for medical necessity and technical denials differ. The following will clarify the processes, thus supporting hospital efforts to manage appeals both effectively and on a timely basis.
How to Submit Medical Necessity Appeals
Both First and Second Level Medical Necessity Appeal requests must be received within 60 calendar days of the date on the last denial letter. Any request for appeal that is postmarked after the 60-day deadline is considered late and, as a result, a technical denial will be issued.
The request for reconsideration must include:
- A cover letter requesting the appeal and explaining why the initial determination should be reconsidered.
- A copy of the last denial letter.
- A copy of the entire medical record.
- Any additional information supporting medical necessity.
Send all requests for First and Second Level Appeal requests to:
Permedion/Ohio Mental Health Reconsideration
350 Worthington Road, Suite H
Westerville, Ohio 43082
Medical Necessity Appeal requests are reviewed within 30 business days from the day they are received by Permedion.
How to Submit Technical (Administrative) Appeals
Technical Appeals are also known as Administrative Appeals. Technical Appeals must be received within 30 calendar days of the date on the denial letter. Any request for appeal that is postmarked after the 30-day deadline is considered late and, as a result, a technical/ administrative denial will be issued.
The request for reconsideration of a technical denial must include:
- A cover letter requesting the appeal and explaining why the initial determination should be reconsidered
- A copy of the denial letter
- Any additional information supporting the hospital’s position.
Technical appeal reviews do not require the entire medical record and in compliance with HIPAA should NOT be submitted with the appeal requests.
Protected Health Information
It is important to remember that technical appeals should not include the entire medical record. Personal health information (PHI) is protected by law in order to support patient privacy. Permedion and providers should work together to ensure that unnecessary records not be shared.
A central aspect of the privacy rule is the principle of “minimum necessary use” and disclosure. A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of PHI needed to accomplish the intended purpose. A covered entity must develop and implement policies and procedures to reasonably limit uses and disclosures to the minimum necessary. When the minimum necessary standard applies, a covered entity may not use, disclose or request the entire medical record unless it can be specifically justified.
Taking the Privacy Rule into account, Permedion does not request providers to send medical records for technical appeals.
Change of Contact
As needed, hospitals should contact Permedion with any primary contact changes. Permedion’s experience has been that sometimes the proper hospital personnel do not receive correspondence on a timely basis because it was delivered to the incorrect person.
In order to update a hospital primary contact with Permedion, complete the Change of Contact form.