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Last Modified: 2/7/2018 Location: FL, PR, USVI Business: Part A, Part B

How to save time and track your claim appeal request

Tips on appealing a claim

1. Use SPOT’s secure messaging to submit redetermination requests and other critical correspondence. Do you have a SPOT account? If not, get one.
2. Make sure you are using the correct redetermination form. Overpayments resulting from billing errors, Medicare secondary payer/other payer involvement should be reported on the overpayment refund form.
3. After 15 days of filing your claim appeal, you can check the status by confirming First Coast has received it. Search on the first claim listed on your request for redetermination. There will not be a separate listing for each claim on the redetermination.
4. Use First Coast's appeals timeline calculator to help you track your claim appeal through the entire five step process.

What is a claim redetermination?

A redetermination is the first step in the claim appeals process. With a redetermination, First Coast staff review your redetermination form along with any medical documentation submitted with the request.
Providers have 120 days from the date of receipt of the initial claim determination to file an appeal. All redetermination requests must be made in writing. First Coast provides the online forms you need to file a claim redetermination. Please note that overpayments resulting from billing errors, Medicare secondary payer/other payer involvement should be reported on the overpayment refund form.

Initiating the appeals process with a request for redetermination

Providers may submit appeal requests through the mail or through First Coast’s Secure Provider Online Tool. This process of submitting redeterminations can take up to 60 days for a full review of a claim once it is received and booked into First Coast’s system.
If you choose to use paper applications and mail them to First Coast, you can confirm its receipt through the First Coast website using your provider transaction access number (PTAN). Using the appeals confirmation tool to track appeals can help prevent the filing of duplicate redetermination requests. This confirmation may take up to 15 days before it is available using paper request forms submitted through the mail. Providers using SPOT may confirm receipt using the appeal status tool 72 hours after submission.

SPOT’s secure messaging feature may be a more efficient option

In addition, SPOT offers other benefits over paper applications and the mail. SPOT represents a more efficient option for handling redetermination requests.
SPOT’s secure messaging feature allows providers to select and submit appeal requests, overpayment forms, and additional development responses (ADR) directly to First Coast’s e-documentation system. It also allows providers to upload support documentation.
Many providers have found using SPOT to handle appeal correspondence saves time and money compared to printing and mailing these documents.
“I spent 30-45 minutes a day logging appeals in a spreadsheet to track where we were in the process. We handle 20-30 appeals each day. This adds up to a lot of time for me and for my team handling appeals,” said Kristin Sierens, Supervisor for the Medicare/Tricare billing team at University of Florida/Shands Hospital physician group practice. “Being able to handle the appeals online is great. With secure messaging it is reassuring. We know when we get the email confirmation from SPOT, our appeals have been received by First Coast and they are in the system.”
Another provider who uses SPOT to submit redetermination requests said their office saves significant amounts of money using the secure messaging feature. “We would spend $8 every time we mailed a request. I love SPOT. This is saving us a lot of money using it to send correspondence,” said Laura Anderson.

Check the status of your appeal

Once your redetermination request has been finalized, you may use SPOT to check the status of your claim. Be sure to use the new internal control number (ICN) number you received when you submitted your request. You may also use the Interactive Voice Response (IVR) system to check the status of your claim once your appeal has been finalized.
If a claim appeal has been finalized, it will not display in the appeal status search tool. Providers will receive correspondence within 15 days notifying them of the results of their appeal.

Claim reconsideration

If a provider is not satisfied with First Coast’s redetermination decision, they may take the claim to the second level of appeal: reconsideration. A qualified independent contractor (QIC) conducts all claim reconsideration requests. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request reconsideration. First Coast offers online forms for providers to contact the QIC to review their reconsideration request.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.