Celtic Consulting

Top 10 Appeals Questions and Answers

Posted Thursday, March 27, 2014

  1. How long do I have to submit my appeal request?

    Answer:
    You have 120 days from the date of the original Medicare remittance advice to submit an appeal. Multiple resubmissions of a claim will not extend the 120-day time limit. The time limit begins with the original denied/processed claim.

  2. Can an appeal be filed past the 120-day limit?

    Answer:
    The time limit may be extended if good cause for late filing is shown. If good cause is not found, the request for appeal will be dismissed. The issue of good cause for the provider and beneficiary is addressed in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240. (982 KB)

  3. Must a redetermination request have a signature, and what type of signature is needed?

    Answer:
    Yes, it must be a full signature (first and last name) on the redetermination request form in order for it to be a valid request.

  4. How can I follow up on claims that are already in the appeal process?

    Answer:
    Please visit http://www.NGSConnex.com or call our IVR system at 877-908-9499. Both of these self-service tools allow providers/suppliers to obtain the status of all redetermination/reopening requests. Remember, the contractor has 60 days from the date the appeal was received to make a determination.

  5. I have made corrections to my denied claim. Should I rebill?

    Answer:
    A claim should only be rebilled if the claim was rejected with message MA130. If the claim denies for any other reason, do not rebill as it could result in a duplicate claim or cause delay of payment.

  6. What is a reopening?

    Answer:
    A reopening is an alternative to the appeals process where minor errors or omissions in filing claims have occurred. For more information regarding the appeals process, visit the Review Process > Appeals section on our Web site.

  7. How do you determine whether you need to submit a first level appeal request (the redetermination) or a second level appeal request (the reconsideration)?

    Answer:
    An initial claim submission will show the MA01 remark code, which states you have 120 days to appeal and request a redetermination. If you see this remark code on your claim, you need to request a redetermination from us.

    Adjustments resulting from a redetermination decision can be identified by the remark code of MA02, “If you do not agree with this determination, you have the right to appeal. You must file a written request for appeal within 180 days of the date you receive this notice.”

    Please note the difference in the amount of time to request a second level appeal, also known as the reconsideration. The MA02 message gives you appeal rights for the second level appeal or the reconsideration. If you wish to appeal claim adjustments with the MA02 remark code, you must file a reconsideration request to the Qualified Independent Contractor.

  8. Do redetermination requests have to be made in writing?

    Answer:
    Yes, they have to be made in writing or sent electronically through the http://www.NGSConnex.com portal.

  9. Where can I find the redetermination form?

    Answer:
    The National Government Services Medicare Redetermination Request form, along with additional information, is located under Quick Links > Forms.

    Related Content: Medicare Redetermination Request Form - First Level of Appeal (CMS-20027)

  10. Can I request a redetermination for all services in question on a specific claim at one time, or must I submit a separate redetermination form for each service in question?

    Answer:
    No, you do not have to submit a separate form for each service on the claim. In fact, we encourage you to request a redetermination for all services in question on the claim at one time. This ensures a faster response since any adjustments that need to be performed on your claim can be done at one time. This will also cut down on the number of letters and remittances you receive from us.

 

These questions and answers have been added to our frequently asked question (FAQ) database. Our FAQs cover a variety of topics and are a great resource for answering your questions, please visit our Web site at http://www.NGSMedicare.com, choose your Jurisdiction and Business and click on the FAQ tab.