New Provider Roadmap

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Home ► New Provider Roadmap - Appeals

Last Modified: 3/20/2024 Location: FL, PR, USVI Business: Part A, Part B

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 pdf.gif (Part A)

• SPOT

• Reopening Gateway (Part B)

• Interactive Voice Response (IVR) system

• Redetermination and clerical error reopening request form:

• Part A pdf.gif

• Part B pdf.gif

The options for submitting a redetermination:

• SPOT

• Redetermination and clerical error reopening request form:

• Part A pdf.gif

• Part B pdf.gif

• 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

• Back to New Provider Roadmap

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.