Appeal type: unknown
Decision: unknown

record review, also fill out the "Waiver of Right to an Administrative Law Judge (ALJ) Hearing" and send it to
us.
Maximus Federal Services will then send your request form and the case file used to decide your appeal to the
OMHA office in your jurisdiction for review. Once this is done, any further communications regarding your
appeal will come directly from the OMHA office.
How we made our decision
1. We read all the papers in the file.
2. We checked Medicare rules.
3. We checked the contract with the Plan.
4. If required, we sent the file to a Maximus Federal Services physician reviewer.
To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked
to see if the Plan correctly followed Medicare rules and regulations.
Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan
and the member. It is usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this
contract carefully to see what the Plan is supposed to cover.
Medicare rules
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service
(POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. If the
physician bills for lab services performed in his/her office, the POS code for "Office" is shown. If the
physician bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for
"Other" is shown. If the physician bills for a lab service furnished by an independent lab, the code for
"Independent Laboratory" is used. Items 21 and 22 on the Form CMS-1500 must be completed for all
laboratory work performed outside a physician's office. If an independent lab bills, the place where the sample
was taken is shown. An independent laboratory taking a sample in its laboratory shows "81" as place of
service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a
hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on
campus-outpatient hospital (POS code 22), respectively. You can find this rule at Medicare Claims Processing
Manual Chapter 26 Section 10.6.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code
that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative
Manual, Chapter I.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. You can find this rule at 42 CFR
Section 424.5.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com