Appeals

Appeals Decision Tree

Do you need to file an appeal on your previously submitted claim?  The Appeals Decision Tree is a tool with a series of questions designed to assist the provider in determining if an appeal needs to be filed to Cahaba GBA.

Appeals Calculator

The Appeals Calculator is a helpful tool used to determine the date your appeal request must be received to meet timeliness guidelines.

General Information

• Medicare Claims Processing Manual (Pub 100-04 Ch. 29)

A provider or beneficiary may appeal an initial claim determination when Medicare’s decision is to deny or reduce payment based on §1862(a)(1), §1834(a)(17)(B), §1834(j)(1), or §1834(a)(15).

Medicare provides five (5) possible levels of appeal in the following order:

1. Redetermination
2. Reconsideration
3. Administrative Law Judge (ALJ) Hearing
4. Appeals Council Review
5. Final Judicial Review

For additional information, refer to the following items:asdf a

• The Medicare Appeal Process Quick Reference Tool
• Adjustments or Add-ons to Appealed Claims
• Medicare Appeals Process: Five Levels to Protect Providers, Physicians, and
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Page last updated:
October 24, 2012