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Last Modified: 9/14/2018 Location: FL, PR, USVI Business: Part A

Important things to know about Part A Appeals

General information about appeals

Q1: I have a claim that was returned-to-provider (RTP) and it is in 'T' status. What does that mean?
A1: When a claim is submitted, it processes through a series of edits in the Fiscal Intermediary Shared System (FISS), to ensure the information submitted is complete and correct. If the claim has incomplete, incorrect or missing information, it will be sent to your RTP file.
For example, if an invalid procedure code is submitted, the claim will be moved to the RTP file in status/location T B9997 for you to correct.
Q2: Can I submit an appeal on a claim that was returned (RTP) and is in 'T' status?
A2: 'T' status claims have not finalized and are not able to be appealed. Electronic providers can access claims in the RTP file using FISS and make the necessary corrections to the claim. The claim will remain in the RTP status/location T B9997 for up to 36 months. A new receipt date is assigned to a claim when it is moved out of the RTP file. Therefore, it is important to ensure your billing transactions are corrected from RTP status/location (T B9997) prior to the timely filing deadline, which is one year from the date of service.
Q3: Can a rejected claim be appealed?
A3: Claims that have been rejected due to billing errors may be adjusted by the provider through the normal claim submission process. Providers should submit adjustments to correct billing errors rather than requesting redeterminations.
Q4: Is an appeal and a redetermination the same thing?
A4: An appeal is the process used when a beneficiary, provider, or supplier disagrees with a decision to deny or stop payment for health care items or services, or a decision denying an individual's enrollment in the Medicare program. A redetermination is an independent re-examination of an initial claim determination; a request to review a claim when there is dissatisfaction with the original determination.
There are five levels in the claims appeals process under Medicare:
Level 1: Redetermination
Level 2: Reconsideration
Level 3: Administrative Law Judge (ALJ)
Level 4: Appeals Council
Level 5: Judicial Review
Q5: Do I have to submit an appeal using the redetermination form on the website?
A5: For Part A, the website provides a redetermination/reopening form.
First level: Request for redetermination of a Part A claim
However, the redetermination request does not have to be submitted on the form, but must contain the following:
Beneficiary name
Medicare ID number of the patient
Specific service(s) and/or item(s) for which the redetermination is being requested
Specific date(s) of the service
Dates must be reported in a manner consistent 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.
Name and address of the provider/supplier of service
Signature of the provider/party to the appeal (or the representative of the party)
Source: The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Pub. 100-04, Chapter 29, Section 310.1 external pdf file
Q6: I submitted a redetermination on my claim and have not heard anything yet. Should I submit a new claim?
A6: The Interactive Voice Response (IVR) system can give you the status of your appeal. The IVR is available 24 hours a day, seven days a week except for regularly scheduled maintenance. However, specific claim and/or eligibility information is available during the following times with the exception of holidays:
Monday-Friday 7 a.m. to 7 p.m., ET
Saturday 6 a.m. to 3 p.m., ET
If your appeal is on file, please do not submit a new claim. This could result in the dismissal of your redetermination request.
Q7: How long should I wait before I hear something on my appeal?
A7: CMS allows contactors 60 calendar days from the date of appeal receipt to make a decision on a redetermination.
Q8: My claim had multiple services that were denied under the same Document Control Number (DCN). Should I submit separate requests for each service?
A8: If all of the services were denied under the same DCN, you can submit them all in one redetermination request. However, if the services were processed under multiple DCNs, they should be submitted in separate requests.

Overpayment appeals

Q9: What is a Medicare overpayment?
A9: A Medicare overpayment is a payment that you received in excess of amounts properly payable under Medicare statutes and regulations. When Medicare discovers an overpayment of $10 or more, the Medicare administrative contractor (MAC) initiates the overpayment recovery process by sending an initial demand letter requesting repayment. The second and third demand letters are mailed 30 days after the most recent demand letter.
Q10: I have received an overpayment letter and I want to submit an appeal. What should I do?
A10: Requesting a redetermination to appeal the overpayment is one of several options for responding to the initial demand letter. If you disagree with an overpayment decision, you can file an appeal with your MAC to conduct an independent review of the decision. For Medicare Part A, First Coast Service Options (First Coast) provides an option for overpayment appeals on the Request for Redetermination/Reopening form.
Florida pdf file
Q11: Do I have to submit the payment with my overpayment appeal?
A11: Refunds and overpayment appeals are not processed within the same department. To prevent delay of either, you should not submit them together.
Q12: My letter says that the overpayment will be automatically recouped if payment is not received within 40 days but I am submitting an appeal. Will the recoupment still take place?
A12: When a valid overpayment appeal is received, Medicare will not begin overpayment collection of debts (or will cease collections that have started) in the following circumstances:
If limitation of recoupment provisions apply, or
When Medicare receives notice the provider has requested a Medicare contractor redetermination (first level of appeal) or a reconsideration by a Qualified Independent Contractor (QIC)
Source: MLNŽ Matters article MM6183 external pdf file
Q13: If my overpayment appeal involves multiple claims and/or beneficiaries, should I submit them separately, or all together?
A13: If you are appealing all of the claims included in one overpayment letter, you should submit one redetermination request and indicate the letter number in your appeal. If your claims are included in separate letters, then you should group them together by the letter and submit them that way.

Reopenings

Q14: What is the difference between a reopening and an appeal?
A14: An appeal is the process used when a beneficiary, provider, or supplier disagrees with a decision to deny or stop payment for health care items or services, or a decision denying an individual's enrollment in the Medicare program.
Section 937 of the Medicare Modernization Act required CMS to establish a reopening process, distinct from the appeals process, whereby providers, physicians and suppliers could correct minor errors or omissions. Clerical errors or minor errors are limited to errors in form and content, and that omissions do not include failure to bill for certain items or services. A contractor shall not grant a reopening to add items or services that were not previously billed, with the exception of a few limited items that cannot be filed on a claim alone (e.g., G0369, G0370, G0371 and G0374). Reopenings are only allowed after normal timely filing period has expired. A reopening will not be granted if an appeal decision is pending or in process.
Q15: How do I request a reopening?
A15: Reopening requests should be submitted through Direct Data Entry (DDE) or your electronic system.
Overall source: CMS IOM Pub. 100-04, Chapter 29 external pdf file

Secure Provider Online Tool (SPOT)

Q16: What options are available for using the SPOT?
A16: SPOT has the functionality for providers to submit the following appeals form through secure messaging:
Part A Claim redetermination request -- Level 1 appeal request with supporting documentation
Once the appeal is submitted, they will receive a confirmation number. They may use 'Check Status' under Secure Messaging to determine if their appeal was successfully uploaded. They may also use the Confirmation of appeals requests tool to confirm First Coast has received the appeal.
Here are some links to supporting documents and FAQs about SPOT for your reference:
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.