Appealing new patient denials

Appeal requests submitted for Evaluation and Management (E / M) services denials, because the new patient qualifications were not met, need to include specific information. Documentation for the specialty and sub-specialty of both the provider in question and any non-physician practitioner (NPP) seen by the same patient within the group practice is needed to consider a favorable determination.

According to CMS Internet Only Manual (IOM), Publication 100-4, Chapter 12, Section 30.6.7 a new patient is defined as a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

Please ensure you verify the following information prior to submitting an appeal on a new patient denial:

• Patient is new to your group practice for the provider specialty billed
• Physicians and NPPs are trained as a different specialty or sub-specialty than the providers within your group practice that have previously treated the patient
• Patient’s medical records have been reviewed to verify the specialties of previously billed E / M services within the group practice

An established patient is a patient who has had a professional face-to-face service from the practitioner or from a practitioner of the same specialty in the group within three previous years. If you determine the patient does not meet the new patient guidelines, you can complete a claim correction by using the SPOT, the Claim Corrections IVR, or submit a Clerical Error Reopening Request to change the E / M procedure code.

Once you determine you would like to appeal the new patient denial, provide the specialty information for individuals within the group practice, including NPPs. The NPP is designated by their primary licensure (Nurse Practitioner, Physician Assistant, Clinical Social Worker, etc.). The details specific to specialty and sub-specialty will be considered during our review of the new patient visit.

Include the following details for the providers within the multi-specialty group practice with your appeal request:

• Provider first and last name
• National Provider Identifier (NPI)
• Provider specialty and subspecialty (if applicable)
• Specialty Code (optional)

Note: Please only use Medicare approved specialties. For a complete listing of physician and non-physician specialties, refer to the CMS Internet Only Manual (IOM) 100-04 Chapter 26 Completing and Processing Form CMS-1500 Data Set section 10.8 

Example: