Overview
Providers cannot appeal pre-payment review status, but can appeal denials of claims. The appeal must be submitted within 30 days of the denial of the claim.
Claims Process While on Prepayment Review
When a provider is on pre-payment review status:
- Claims will only be paid if they comply with Georgia Medicaid guidelines.
- If a claim does not comply, it will be denied and the reason for the denial will be stated.
- A provider may resubmit a denied claim, but it will only be paid if the error is corrected.
According to Victoria, all of this information is contained within the notice of pre-payment suspension that was sent to you.
Appeals Process and Deadlines
- Filing an appeal does not guarantee payment of the denied claims.
- There will be a hearing on whether the claims were properly denied.
- If a claim was denied over 30 days ago, any relief might need to come from an appellate court, which appears to be the Georgia superior courts.
Recommendation on Legal Representation
Because there is no guarantee of being permitted to participate in an administrative hearing or a Georgia Superior Court proceeding, it is strongly recommended that you:
Retain local counsel to preserve your resources and avoid the risks associated with being represented by out-of-state counsel.
Frequently Asked Questions
Can I appeal being placed on pre-payment review status?
No, providers cannot appeal the decision to be placed on pre-payment review. However, they can appeal specific claim denials that occur while on pre-payment review status.
What happens if my claim is denied during pre-payment review?
If a claim is denied, the denial notice will include the reason. You can resubmit the claim after correcting any errors. Only claims that fully comply with Georgia Medicaid guidelines will be paid.
How long do I have to appeal a denied claim?
You must file an appeal within 30 days of the denial. Claims denied more than 30 days ago may require pursuing relief through the Georgia superior courts.
Does filing an appeal guarantee payment?
No, filing an appeal does not ensure payment. An administrative hearing will determine if the denial was appropriate based on the guidelines and submitted documentation.
Should I hire a local attorney for my case?
Yes, it is strongly recommended to retain local counsel. They are more familiar with the Georgia court system and can help avoid risks associated with using out-of-state representation.