Tools & forms: Appeals
Tools
Appeal Status 
Appeal Timeliness 
Reopening GatewayForms
Providers, participating physicians, and other suppliers have the right to appeal claim decisions. Appeals must be submitted using the following forms:
| Appeal level / form | Submission options | Instructions | ||||
|---|---|---|---|---|---|---|
|
First level: |
Fax: 904-361-0593 Fax: 904-361-0595 Mail:
|
|||||
|
Second level: |
Electronically: C2C Innovative Solutions QIC Appeals Portal Fax: 904-539-4074 Fax: 904-361-0595 Mail: |
|||||
|
Third level: |
Electronically: Office of Medicare Hearings and Appeals (OMHA) e-Appeal Portal Mail: Providers / suppliers submit to: |
|
||||
|
Fourth level: |
Electronically: DHHS Departmental Appeals Board (DAB): MOD e-File Mail: Department of Health and Human Services |
Fourth level form instructions |
Alternative submission option
Providers and suppliers may also securely submit first and second level appeal documentation through the Electronic Submission of Medical Documentation (esMD) portal – view details on this service, offered by CMS.
Overpayment refunds
Return of monies voluntary refund form
Appeal related to an overpayment?
Minor error? Request a claim reopening
Did your claim have a clerical error or other minor discrepancy? Part B claims may be corrected outside of the appeals process.
- Correct your claim online through the SPOT: SPOT offers registered users the time-saving advantage of not only viewing claim data online but also the option of correcting clerical errors in their eligible Part B claims quickly, easily, and securely -- online.
- Correct your claim using the reopening gateway: The reopening gateway offers a quick and easy way to make Part B claim corrections directly on the First Coast website.
- Correct your claim using the interactive voice response (IVR): The IVR allows providers/customers to call in to request reopenings on certain claims.
- Correct your claim by writing in, using the first level of appeal (redetermination). Writing in allows you to supply additional information you feel is necessary to correct a claim.
Exception for timely filing
There are a few exceptions which allow an extension to the 12-month timely filing period. View the following resources for additional information.
Additional resources
- Learn how an individual can become an authorized beneficiary representative for appeals -- CMS 1696: Appointment of representative
- Understand when to file an appeal and the time limits for filing requests
- Confirm First Coast has received your appeal request