New provider roadmap: Appeals

An appeal is a new and independent review of an initial determination of a claim.

Step 1: Determine whether you are submitting a redetermination or clerical error reopening / claim correction. 

For information and examples, refer to Part A or Part B.

Clerical error reopening / claim corrections must be submitted within one year from the initial claim determination for:

• Minor errors or omissions on claims
  

• Mathematical or computational mistakes
  

• Inaccurate data entry
  

A redetermination (first level of appeal) is a new and independent review of an initial determination of a claim. A redetermination must be submitted within 120 days from the receipt of the determination notice for:

• Dissatisfaction with initial claim determination
  

• Disagreement with claim reimbursement
  

• Medical review denials
  

• Denials requiring documentation to support the services
  

Step 2: Choose method of submission

There are multiple methods of submitting clerical error reopening / claim corrections:

• FISS(Part A)
  

• SPOT
  

• Reopening Gateway (Part B)
  

• Interactive Voice Response (IVR) system
  

• Redetermination and clerical error reopening request form:
  
  • Part A
    

  • Part B 
    

The options for submitting a redetermination:

• SPOT
  

• Redetermination and clerical error reopening request form:
  
  • Part A
    

  • Part B
    

• Fax:
  
  • Part A - 904-361-0593
    

  • Part B - 904-361-0595
    

• Mail:
  • Part A/B

Step 3: Submit the request

Clerical error reopening:

• Submit within one calendar year from initial determination date, except for reporting an overpayment.
  

• Completed within 60 days of receipt of the reopening request.
  

Redetermination requests:

• File within 120 days after the date of receipt of the determination.
  

• Completed within 60 days of receipt of the request unless additional documentation is submitted by the provider / supplier and received prior to issuance of the dismissal and / or decision notice.
  

Step 4: Check status

• Appeal Status Inquiry Tool
  

• SPOT
  

Resources

On demand training for appeals and claim correction:

• We provide a wide array of On-demand Learning resources that allows you to learn at your own pace
  
  • Online training courses
    

  • Training videos
    

  • Webinar recordings
    

Appeals center

• Submit an appeal - Appeals news (forms and tutorials)
  

• Submit claim corrections & reopenings
  

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