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Last Modified: 7/26/2018 Location: FL, PR, USVI Business: Part A, Part B

Before you file an appeal:

Many providers often appeal claims that have only been returned to them as an unprocessable claim, information was missing or another reason. Review these steps before you appeal a claim.
1. Have you checked claims status via SPOT or the IVR?
2. Do you have a SPOT account? If not, get one.
3. Was your claim returned as unprocessable? Here’s how to correct it.
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?

How to appeal a claim

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.

Correct a claim through a clerical reopening

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.
Three options for conducting a clerical reopening of a claim:
Correct your claim online with the "SPOT." The "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 -- online. Part A providers may use SPOT’s secure messaging feature to request a clerical claim reopening.
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 reopening request help sheet, click here pdf file.
Correct your claim by writing in, using the first level of appeal (redetermination) form. Sending in a paper request form may take as many as 45 days to process your request.

Better ways to appeal a claim

First Coast Service Options Inc. (First Coast) offers multiple ways of submitting your claim appeal. The most efficient way to do so is through First Coast’s Secure Provider Online Tool (SPOT). SPOT offers account holders secure messaging features which allow you to submit claim redetermination forms along with supporting documentation. SPOT is free to Medicare providers. To establish your SPOT account, follow this step-by-step process.
The timing of your appeal request is critical for its success. First Coast offers this timeline calculator to assist you in tracking your appeal.

Beginning the process

When you wish to dispute the determination on a claim, Medicare offers five levels in the Part A and Part B appeals process.
First level of appeal: Redetermination
Second level of appeal: Reconsideration
Third level of appeal: Hearing by an administrative law judge (ALJ)
Fourth level of appeal: Review by the Medicare Appeals Council
Fifth level of appeal: Judicial review
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:

First level of appeal: Redetermination

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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First Coast Service Options (First Coast) redetermination forms for Part A
First Coast redetermination forms for Part B
Centers for Medicare & Medicaid Services (CMS) redetermination form

Second level of appeal: Reconsideration

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.
First Coast reconsideration forms for Part A
First Coast reconsideration forms for Part B
CMS reconsideration form

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $150 (requests made January 1, 2015-December 31, 2016; $160 thereafter) 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 external link 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

Fourth level of appeal: Review by the Medicare Appeals Council

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 external link 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:
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Fifth level of appeal: Judicial review

If $1,500 (requests made January 1, 2016-December 31, 2016; $1,560 January 1, 2017-December 31, 2017; $1,600 thereafter) or more is still 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.

Additional resources

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 29 external pdf file – Appeals of claims decisions
Chapter 34 external pdf file – 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.