Providers and beneficiaries have the right to appeal claim determinations made by National Government Services. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by NGS are governed by CMS.
First Level of Appeal (Redetermination) Processing Timeline
Per the CMS IOM Publication, Medicare Claims Processing Manual, Chapter 29 – Appeals of Claims Decisions, Section 310.5:
310.5 - The Redetermination Decision
(Rev. 3549, Issued: 06-24-16, Effective: 07-26-16, Implementation: 07-26-16)
A. Redetermination Decision Letters
The law requires contractors to conclude and mail and/or otherwise transmit the redetermination decision within 60 days of receipt of the appellant's request, as indicated in Section 310.4. For unfavorable redeterminations, the contractor mails the decision letter to the appellant, and mails copies to each party to the initial determination (or the party’s authorized representative and/or appointed representative, if applicable).
Because of the 60-day decision turnaround time allowed, NGS asks for your patience in waiting up to 60 days for an appeal decision to be made. Submitting duplicate appeal requests, either via paper or NGSConnex in an effort to speed up this process causes administrative delays and may slow down the processing of your appeal.
Please keep in mind the 60-day turnaround NGS has to process your appeal. We appreciate your patience as we work diligently to process your Redeterminations.
- To correct minor errors or omissions on a rejected claim, providers should initiate an adjustment to the claim to correct the error or omission. Errors or omissions can also be addressed through the reopening process.
- For full denials resulting from more complex issues, you must request a redetermination.
Reopening vs. Redetermination
- Minor clerical errors
- Transposing numbers
- Entering the incorrect number of units
- Failing to include all pertinent medical diagnoses
- Coverage/medical necessity of furnished items and service
- Whether the deductible has been met and/or the computation of the coinsurance amount
- The number of days used for inpatient hospital, psychiatric hospital, or post-hospital extended care
- Physician certification requirement
- Beginning and ending of a benefit period
- Determination with respect to the limitation of liability provision
- Issue(s) affecting the amount of benefits payable (including over/underpayments)
- Prepay/postpay probes, including CERT, UPIC, SMRC, RAC and QIO
Please share your thoughts about your experience with our redetermination process.