Frequently Asked Questions Appeals

Our redetermination request was dismissed because it was untimely. What is considered a timely redetermination request?

A request for a redetermination must be submitted within 120 days of the date the initial claim denial was processed to be considered timely. Providers can use the date on your Remittance Advice (RA), or Electronic Remittance Advice (ERA) to determine the date of the claim denial.

(July – September 2008 FAQ - reviewed November 2008)

Can all Medicare claim determinations be appealed?

Medicare claim determinations should only be appealed when a claim has been denied by Medicare and the beneficiary or provider is disputing the denial. Full denials appear in the Fiscal Intermediary Standard System (FISS) status/location (S/LOC) D B9997. Partial denials will appear in FISS S/LOC P B9997, with the noncovered revenue code lines available for viewing by accessing FISS Claim Page 02 and pressing the F2 key to display MAP 171D. Use the F6 key to scroll through and locate the noncovered revenue code lines and associated denial reason codes.

As a reminder, it is never appropriate to submit appeal requests in the following situations:

The claim rejected (FISS S/LOC R B9997)
The claim was paid in full (FISS S/LOC P B9997)
The claim was never submitted to Medicare
The claim is in a suspended status/location (S XXXXX where the Xs are various numbers and/or letters)

(January – March 2008 FAQ - reviewed November 2008)

Will my Remittance Advice tell me if a processed claim can be appealed if I’m disputing the denial?

Yes. Medicare Remittance Advice contain reason codes and/or remarks codes when a claim has been fully or partially denied and is, therefore, appropriate to appeal. The “Claim Adjustment Reason Code” field (RC) and “Remittance Advice Reason Code” field (Rem) are available on the “All Claims” page of the Standard Paper Remittance Advice (SPR) and the “Single Claim” page of the Electronic Remittance Advice (ERA). A “Single Claim” page is available for each claim listed on the ERA.

The codes found in the “RC” and “Rem” fields can be researched using the WPC Web site to determine if appeal rights are available for the initial claim determination.

(January – March 2008 FAQ - reviewed November 2008)

Where can we find more information about the Medicare Appeals process?

The Medicare Claims Processing Manual (CMS Pub. 100-04, Ch 29)
The Cahaba Appeals Web page
The Medicare Appeal Process quick reference tool
The Medicare Appeals Process brochure

(January – March 2008 FAQ – updated November 2008)

Page last updated: December 4, 2008