ZPIC, ADR, RAC and Appeals Processing
Appeals specialist and Clinical consultants will organize copies of the clinical record for each episode requested and determine if addition items are required or if items need to be removed that are not required under the Medicare program, for ADR submission. Appeals specialist and Clinical consultants will conduct a clinical record review to determine if a discussion period will be appropriate for each episode denied by the Recovery Audit Contractor (RAC)*. Each clinical record review may or may not have a documented summary by Consult staff, at the discretion of clinical appeals specialists. Appeals Specialists will complete a summary/filing status for each level of appeal and submit to the client for review and signature by an authorized principle of the client. Appeals specialist will assist with and/or present the clinical finding to support reimbursement under the Medicare program, on behalf of the client at the Administrative Law Judge level.