skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer


This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Send a link to this page
[Multiple email addresses must be separated by a semicolon.]
Last Modified: 6/24/2024 Location: FL, PR, USVI Business: Part A, Part B

The SPOT User Guide

Section 6 – Appeals

Part A and Part B users may use the Appeals feature to submit an appeal request, and view appeals status / outcome.
This information is also accessible though the claim status feature highlighted in section five of the SPOT User Guide.
Part A:
Part B:
Appeal Request – Part A
Part A level one appeals are titled redeterminations and level two appeals are titled reconsiderations. To submit a redetermination (level one appeal) request via the Appeals feature:
Select Appeals from the top menu.
Click Appeal Request from the submenu.
peals menu
Figure 1: Part A – Appeals menu
Using the search tab on the left, complete the required fields.
Click Search.
ppeals request search results
Figure 2: Part A – Appeals request search results
Click on the view appeals summary icon under the Actions column to access the appeal summary tab on the Claim Summary screen.
Note: This appeal summary page may also be accessed when viewing claims and appeals detail in the Claim Status feature via the Claims Summary icon.
peal summary
Figure 3: Part A – Appeal summary
Depending on the status of the claim or appeal, appeal features will vary.
To submit a level one appeal (redetermination), click on the Redetermination Request button.
Additional features will be available in the Actions column (when applicable). An icon key is available on the top of the screen.
Click the icons to access action needed. Options include:
Level two appeal (reconsideration) submissions – Part A only
Additional documentation submission for reconsiderations – Part A only
Download the decision letter
Redetermination Request – Part A
After clicking the Redetermination Request button on the Appeals Summary page, the Redetermination and Clerical Error Reopening Request Form will display.
Complete/verify all required fields (indicated with a red asterisk).
determination Request 1
determination Request 2
Figure 4: Part A – Redetermination Request
Upload supporting documentation and Click Submit. Only PDF and TIFF images are acceptable. rt A – Redetermination Request Attachments
Figure 5: Part A – Redetermination Request Attachments
If your submission was successful, you will receive a message with a confirmation number for tracking.
You may use this tracking number to review status via the Appeals Status feature.
Reconsideration Request – Part A
To submit a level two appeal (reconsideration), search for the claim in the Claim Status feature.
Click the view claim summary icon in the action column.
Click the Appeal Summary tab.
Click the “Submit Reconsideration Request” icon in the action column. The Reconsideration Request form will display. A first level appeal needs to have been completed previously to have the option to submit a reconsideration request.
rt A – Reconsideration Request
rt A – Reconsideration Request 2
Figure 6: Part A – Reconsideration Request
Complete the required fields on the Reconsideration Request.
Upload supporting documentation.
If the appeal has multiple claims associated, PDF, XLS, XLSX, DOC, DOCS, and CVS files are acceptable.
If there are not multiple claims, only PDF files are acceptable.
Click Submit. If your submission was successful, you will receive a message with a confirmation number for tracking.
You may use this tracking number to review status via the Appeals Status feature.
If you need to submit additional documentation for your reconsideration request, you may return to the appeals summary and use the additional documentation feature.
rt A – Reconsideration Additional Documentation
rt A – Reconsideration Additional Documentation 2
Figure 7: Part A – Reconsideration Additional Documentation
Appeals Status – Part A
To check the status of an appeal, users may directly navigate to the appeals status feature.
Select Appeals from the top menu.
Click Appeals Status from the submenu.
peals Status Query
Figure 8: Appeals Status Query
Using the search tab on the left, complete the required fields.
Click Search to view the status of the appeal.
rt A – Appeal Status
Figure 9: Appeals Status
Click the appeals request summary icon under the Actions column to view the Appeals Summary page.
Please allow at least 60 days for appeal processing.
Appeal Request – Part B
NOTE: Appeal features are not currently available for dental providers.
Select Appeals from the top menu.
Click Appeal Request from the submenu.
art B – Appeals request
Figure 10: Part B – Appeals request
Using the search tab on the left, complete the required fields.
Click Search.
Click on the claims summary icon under the Actions column.
rt B – Appeals request search results
Figure 11: Part B – Appeals request search results
Select the line(s) you wish to appeal. Click the top check box to select all lines and appeal the full claim or select individual lines then click Next.
rt B – Claim details
Figure 12: Part B – Claim details
Complete the required fields and upload any supporting documentation. Only PDF and TIFF images are acceptable.
Click Submit.
rt B – Redetermination request form
rt B – Redetermination request form 2
rt B – Redetermination request form 3
Figure 13: Part B – Redetermination request form
Depending on the submission timeframe, and / or if you fail to include supporting documentation, a warning banner will display. Click Cancel to edit your appeal submission, if necessary, then Submit Request to proceed.
A confirmation message will display upon successful submission. You may use this confirmation number to track your submission via the Submission History feature.
Appeals Status – Part B
See Appeals Status details above. This feature is the same for Part A and Part B.
Claim Correction – Part B
A claim correction /reopening request allows a provider to submit corrections to a previously submitted claim with the goal of changing the initial determination of the claim, which may have resulted in an overpayment or an underpayment.
Although a claim reopening request may be initiated in response to an unanswered additional documentation request (ADR), the most common type of claim reopening request submitted by providers is often called a “clerical reopening” (based on the types of corrections requested). Clerical reopenings may include corrections to clerical errors, minor errors, or omissions.
The claim reopening process is not a part of the five-level appeals process and should not be confused with a claim redetermination, which is the first level of the appeals process. Submitting a claim reopening request is not the same as filing an adjustment claim, and the timely filing requirements of each differ greatly:
Claim reopenings: Must be filed within one year of the receipt of the initial determination.
Claim reopening requests may be submitted for any reason within one year of the receipt of the initial determination. However, with a showing of good cause, claim reopening requests may be submitted (in writing) up to four years from the receipt of the initial determination.
Adjustment claims: Must be filed within one year of the date of service.
Claim redetermination: Must be filed within 120 days from initial claim determination.
The submission of a claim reopening request does not guarantee its acceptance, ensure that the initial claim determination will be revised, or extend the timeframe in which to request an appeal. Granting a claim reopening request is at the discretion of the MAC, and a contractor’s refusal to reopen a claim does not initiate new appeal rights. Claim reopening requests will not be granted if an appeals decision is pending or in process. The decision to not reopen a claim determination is not an initial determination and is not appealable.
Claim reopening requests submitted after 5 p.m. ET during weekdays, at any time during a weekend, or on First Coast’s corporate holidays, will receive a receipt date that reflects the next business day.
To submit a Claim Correction (reopening request):
Select Appeals from the top menu.
Click Claim Correction from the submenu.
rt B – Claim Correction
Figure 14: Part B – Claim Correction
Using the search tab on the left, complete the required fields.
Click Search.
Click on the claims summary icon under the Actions column.
rt B: Claim Corrections action icon
Figure 15 – Part B: Claim Corrections action icon
To make a change to the header level information, click Edit.
Available edits: Referring Provider NPI, Referring Provider Name, and / or Claim Diagnosis Code
Part B: Claim correction edit
Figure 16 – Part B: Header level edit
Make the necessary changes directly in the correlating field and then click Submit.
To make a change to the line level information, click the pencil icon in the line needing changed.
Available edits: Date of Service From, Date of Service To, Place of Service, Procedure Code, Modifier Codes, Billed Amount, Quantity Billed, Line Diagnosis Code, Diagnosis Pointers (this field is required)
rt B: Claim line level edit
Figure 17 – Part B: Claim line level edit
Make the necessary changes directly in the correlating field and then click Save.
Note: Your claim correction is not submitted yet. Upon saving, you will be directed to the previous claim reopening / correction submission page.
Click Submit.
Limitations to claim reopenings on the SPOT
Multiple request types (e.g., Edit Procedure Code and Add Modifier) may not be utilized for the same eligible line item.
Line items may not be added or removed.
Certain corrections (e.g., updates to beneficiary information or status) may not be submitted.
Rendering provider’s NPI may not be changed.
Claim reopening requests submitted through SPOT must be filed within one year of the receipt of the initial determination.
Multiple modifiers, procedure codes, or diagnosis codes may not be added through SPOT.
Claim Reopening Requests submitted after 6 p.m. ET during weekdays, at any time during a weekend, or on First Coast Service Options’ corporate holidays, will receive a receipt date that reflects First Coast’s next business day.
Claim Reopening Requests: Eligibility Criteria
After the claim has been accessed, the initial eligibility of any of its line items for claim reopening will be determined automatically by SPOT. For example, line items associated with pending and adjusted claims are ineligible.
SPOT determines eligibility of a particular line item for submission of a Claim Reopening Request through SPOT based upon specific criteria at the claim or line-item level, which includes:
Claim may not be an adjustment claim.
Claim may not be a non-assigned claim. If the claim is non-assigned, SPOT will display a message that the claim cannot be reopened, and the user should refer to the reason code and/or remark code for direction on how to correct the claim.
Claim/line item may not be in pending status.
Claim may not be an adjusted claim (Note: If the claim as been adjusted, SPOT will display a message that a redetermination is possible).
Claim may not have been returned as unprocessable (RUC).
Restricted codes and modifiers that cannot be corrected through the reopening process using SPOT.
A previous claim reopening request for the ICN has not been submitted through SPOT or IVR.
The claim’s ICN must begin with one of the following two-digit combinations, which indicates whether the ICN is a claim, an adjustment, or correspondence as well as the provider’s location:
Florida: Regions 01 through 19 - Exceptions: Region 05 and Region 13
Puerto Rico: Regions 01 through 10 - Exception: Region 05
U.S. Virgin Islands: Regions 11 through 19 - Exception: Region 13
The first two digits of an ICN represent its “region,” which indicates whether the ICN is a claim, an adjustment, or a correspondence.
If the ICN does not fall within one of these regions above, or has been adjusted, SPOT will display a message saying the claim cannot be reopened.
Only one claim reopening request type per line item may be submitted; however, multiple line items may be included in the same request.
Even if a claim is potentially eligible to initiate a reopening request, some or all of its associated line items may still be ineligible:
If a line item is eligible, SPOT will display a hyperlink stating “View line items eligible for claim reopening” above that line item.
If a line item is ineligible, the hyperlink will not display above that line item.
Overpayment Correction – Part B
SPOT allows Part B users to make additional claim corrections, via the Overpayment Correction feature. Overpayment correction is also known as Billed in Error (BIE) throughout portal documentation.
To make an overpayment correction in SPOT:
Select Appeals from the top menu.
Click Overpayment Correction from the submenu.
Figure 18: Part B – Overpayment Correction
Using the search form on the left, complete the required fields and click Search.
Click the third icon in the Actions column on the claim line you wish to correct.
ctions icons
Figure 19: Actions icons
Select the line(s) you wish to appeal. Click the top check box to select all lines and appeal the full claim or select individual lines. Then click Submit.
Please allow 7-10 business days before retrieving your overpayment demand letter.
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.