Last Modified: 10/25/2024
Location: FL, PR, USVI
Business: Part A, Part B
1. Have you checked claims status via SPOT or the IVR?
2. Do you have a SPOT account? If not,
get one.
4. Have you reviewed the remittance advice to find out why the claim was not paid, or not paid in full?
5. Is there an opportunity to do a clerical reopening?
Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
You may not appeal
a claim returned as unprocessable.
Filing an appeal on an unprocessable claim only delays payment and could result in a timely-filing denial if not re-filed with the correct information within the timely-filing period.Before you file for a claim redetermination, the first level of the appeal process, check to see if there was a clerical error caused your claim to be denied or amount reduced. Common mistakes such as transposed procedure or diagnosis codes, inaccurate data entry, misapplication of fee schedule information, or incorrect data items such as provider number, modifier, and date of service affect a large percentage of denied claims.
Four options for conducting a clerical reopening of a claim:
1. Correct your claim through First Coast’s portal,
SPOT. SPOT offers account holders the time-saving advantage of viewing claim data online, and the option of correcting clerical errors in their eligible Part B claims quickly, easily, and securely. Part A providers may use SPOT’s appeals form submission via the secure messaging feature to request a clerical claim reopening.
2. Use the
Reopening Gateway to electronically reopen your part B claim. This interactive tool requires no registration or enrollment and offers a quick and easy way to make Part B claim corrections directly on the First Coast website.
3. Correct your claim on the telephone with the
interactive voice response (IVR). The IVR allows providers/customers to request telephone reopenings on certain claims. For the IVR touch-tone converter,
click here.
First Coast offers multiple ways of submitting your claim appeal. The most efficient way to do so is through First Coast’s portal, SPOT. SPOT offers account holders the ability to submit
claim redetermination forms and supporting documentation under the Appeals menu. SPOT also enables Part A providers to submit level two (reconsideration) forms. Once appeals are submitted, SPOT users may track the status and view the outcome of appeals. SPOT is free to Medicare providers. To establish your SPOT account, follow
this step-by-step process.
Electronic submission
Learn how to electronically submit your appeals, medical records, and other correspondence.
When you wish to dispute the determination on a claim, Medicare offers five levels in the Part A and Part B appeals process.
After you have reviewed your claim and determined that the claim 1) was not eligible for a clerical reopening; or 2) returned to you as
unprocessable, and you still wish to appeal, then follow these steps:
A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.
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CMS redetermination form
A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. 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 a reconsideration.
CMS reconsideration form
If at least $190 (requests made on or after January 1, 2025; $180 before) remains in controversy (monetary threshold) following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA). By
clicking here you will find information on the OMHA website.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.
ALJ forms
If a party to an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy (monetary threshold*). The request for Medicare Appeals Council review 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. By
clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.
Departmental Appeals Board form for filing an appeal with the Medicare Appeals Council:
If at least $1,900 (requests made on or after January 1, 2025, $1,840 before) or more remains in controversy (monetary threshold) following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.
• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.
*Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.
Within the First Coast and CMS websites you will find information related to the five levels in the Part A and Part B appeals process.
First Coast links
CMS links
CMS resource materials available for download
CMS internet-only manuals: Publication 100-04
• Chapter 34 – Reopening and revision of claim determinations and decisions
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.