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.
The Appeals Calculator is a helpful tool used to determine the date your appeal request must be received to meet timeliness guidelines.
Medicare regulations allow providers and beneficiaries who are dissatisfied with Medicare’s determination to request that the determination be reconsidered. Through the process, Medicare seeks to ensure that the correct payment is made or a clear and adequate explanation is given supporting nonpayment.
A physician or supplier providing items and services payable under Medicare Part B may appeal an initial determination if he or she:
- Accepted assignment;
- Did not accept assignment on the claim that denied and the claim was denied as not reasonable and necessary;
- The beneficiary did not know or could not have been expected to know that the service would not be covered, requiring the provider/supplier to refund the beneficiary any payment received for the services; OR,
- Did not accept assignment, but is acting as the authorized representative of the beneficiary, and indicates this in the appeal. (Attaching a copy of the beneficiary’s Medicare Summary Notice [MSN] indicates the provider/supplier is authorized to act on the beneficiary’s behalf.)
Please note: Claims submitted with incomplete or invalid information will not be afforded appeal rights. These claims will be Returned as Unprocessable (RUC). The provider then has to submit an entirely new claim (electronic or paper) with complete valid information.
Types of Appeal Actions
|Type of Appeal||Criteria Necessary||Time Limits|
|Written Redetermination||Requests must be made in writing and must be signed.||Redeterminations must be requested within four months of the initial determination.|
|Reconsideration||Requests need to be sent to the Qualified Independent Contractor (QIC) if the party is dissatisfied with the redetermination decision. The request form is at the end of the redetermination letter.||A written reconsideration request must be filed within 180 days of the redetermination. The request must clearly explain why the redetermination was unsatisfactory. The request, a copy of the MRN, and any other useful documentation should be sent to the QIC presiding over the case. Providers may also choose to complete the Form CMS-20033, to request a reconsideration. Instructions for contacting the QIC will be included in the provider’s notice of redetermination decision.|
|Administrative Law Judge||Filed if the provider is dissatisfied with the reconsideration made by the QIC (Qualified Independent Contractor). May request a hearing before an Administrative Law Judge (ALJ). Effective January 1, 2013 the Amount In Controversy (AIC) must be at least $140.00. You may attend this hearing in person, send a representative, or have the ALJ review the record. More than one beneficiary’s claim can be used to meet the $140.00 amount in controversy.||Must be in writing to the Qualified Independent Contractor (QIC) or can be sent directly to the Administrative Law Judge within 60 days of the date of the reconsideration decision.|
|Review by the Medicare Appeals Council within the Departmental Appeals Board (DAB), (hereinafter “the Appeals Council”)||Filed if the provider is dissatisfied with the ALJ’s decision. There are no requirements regarding the amount of money in controversy. The Appeals Council will issue a decision within 90 days of receipt of a request for review (that timeframe may be extended for various reason, including but not limited to, the case being escalated from an ALJ hearing).||Must be submitted in writing within 60 days of receipt of the ALJ’s decision, and must specify the issues and findings that are being contested.|
|Federal Judicial Review||Requested if the provider is still dissatisfied with the determination of the Appeals Council Decision DAB.Effective January 1, 2013, the amount in controversy for requests must be $1,400.00.||The appeal must be submitted in writing within 60 days from date of receipt of the DAB decision notice.|
Written Medicare Part B Redeterminations
The following information is being shared with the provider community to clarify the Centers for Medicare & Medicaid Services (CMS) policy on redeterminations submitted by providers, suppliers, or Medicaid state agencies, or the party authorized to act on behalf of the Medicaid state agency. Effective March 1, 2001, any implied request for redetermination that does not meet the following requirements will be returned.
For Part B appeals, the Medicare regulation at 42 CFR 405.807 states that any party who is dissatisfied with the initial determination may request the Medicare contractor review such determination. A request for a Redetermination must be filed within four months after the date of the notice of the initial determination. Medicare cannot accept a Redetermination for which no initial determination has been made. Again, the request for a Redetermination must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of a Redetermination request outlined below.
- To initiate a redetermination, you may either access the Medicare Redetermination Request Form – CMS-20027, at the following link on the CMS Website or the Cahaba GBA Medicare B Redetermination Request form. You may also submit a written request, http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf.
- A request for a Redetermination must be a signed written statement from the provider or supplier expressing disagreement with the initial determination or indicating that the redetermination or a reexamination should be made;
- A request for a Redetermination may be filed on the provider’s or supplier’s letterhead;
- The Redetermination request must include the following information:
- Beneficiary name;
- Medicare Health Insurance Claim Number (HICN);
- Date(s) of service for which the initial determination was issued (dates must be reported in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form); and
- Which item(s), if any, and/or service(s) are at issue in the appeal.
- The printed name and signature or the person filing the redetermination request.
Note: Electronic appeals with electronic signatures are only acceptable when transmitted to the Medicare contractor via a CMS-approved secure Internet portal/application. Since Cahaba GBA does not offer a CMS-approved portal/application for this purpose, all appeals must be submitted hardcopy and include a written signature.
Medicare will not accept implied requests for Redeterminations from providers, suppliers, states, or any party authorized to act on behalf of the Medicaid State Agency. Any Provider Remittance Advice, listings, or computer printouts that are not signed and/or do not express a disagreement with a specified initial determination will be returned to the sender. Providers and suppliers are responsible for submitting documentation, if any, that supports the reason for the Redetermination. This documentation may be supplied with the Redetermination request or at the request of the Medicare contractor. Failure to submit documentation in a timely manner may result in processing delays. Do not include Post-IT notes when requesting a Redetermination, as they may become dislodged and result in your redetermination being returned for further information. Do not submit a Redetermination request and then submit another CMS-1500 form to the processing area or another electronically submitted claim, as this results in an excessive amount of duplicate claims in the system and unnecessary expense to the Medicare program.
Written Redetermination Addresses
Alabama Part B Redeterminations
PO Box 1921
Birmingham, AL 35201-1921
Georgia Part B Redeterminations
PO Box 12967
Birmingham, AL 35202
Tennessee Part B Redeterminations
PO Box 12724
Birmingham, AL 35202-6724
If you have any questions concerning Medicare Redeterminations, please contact your Provider Contact Center.
Medicare Secondary Payer Redetermination Request
Requests for reconsideration of denials or secondary allowances when Medicare is secondary payer should be referred to the Medicare Secondary Payer (MSP) Department. Do not resubmit the claim. Your request should include the beneficiary’s Medicare number (Health Insurance Claim Number (HICN)), the claim control number (or copy of the PRN) and any other documentation which supports your request. Address your request to:
Alabama Part B Medicare Secondary Payer
P O Box 12647
Birmingham, AL 35202-6647
Georgia Part B Medicare Secondary Payer
PO Box 12967
Birmingham, AL 35202
Tennessee Part B Medicare Secondary Payer
PO Box 12724
Birmingham, AL 35202-6724
- Appeals – Fee-For-Service
- Appeals Brochure
- Appeals Quick Reference Chart
- Appeals Process vs. the Clerical Error Reopenings Process
- Clerical Error Reopenings Process
- Reopening and Revision of Claim Determinations and Decisions
Page last updated: February 13, 2013