Tip Sheet for Medicare Providers on First Level of Appeals (Redeterminations)

If you disagree with Medicare’s claim determination, you may Appeal. However, please follow these important tips before you submit a first level of appeal (Redetermination) with your MAC, National Government Services about appeals and levels of appeals

Appeal Tips

• Be timely and valid in submission – Submit redetermination requests on time, within 120 days of the initial claim determination date on your RA. Verify claim messaging on the RA has appeal rights, certain claim denial reasons do not. Review:
  • Request a Redetermination
  • Appeals Timeline Calculator
• Be appropriate in Submission – Submit in writing (mail to applicable address) or electronically, NGSConnex, or esMD. Review:
  • Part A Redetermination Request Form – Level 1
  • Part B Redetermination Request Form - Level 1
  • Get Help Submitting an Appeal Hard Copy
  • Submit an Appeal Electronically with NGSConnex
  • Providers Using NGSConnex for Appeals and Supporting Documentation
  • Submit an Appeal Electronically via esMD
• Be patient – The Appeals Department has 60 days to process all requests; please do not send duplicate requests within this timeframe. Review:
  • How to Prevent Duplicate Appeal Requests in NGSConnex
• Be forthcoming for future contact – Include with your redetermination request a POC for your provider/facility so we may contact you with any questions.
• Be prompt – If you receive a request for documentation, respond by the date provided.
• Be thorough – Submit relevant supporting documents that were not provided with the original claim submission. Review:
  • What Documents are Needed
  • Providers Using NGSConnex for Appeals and Supporting Documentation
  • Also, if applicable:
    • Include a copy of the demand letter(s) when appealing an overpayment determination.
    • Include a copy of the Appointment of Representative form if the requestor is outside your facility or agency and is representing the appellant.

Related Content

• MLN Booklet®: Medicare Parts A & B Appeals Process
• MLN Fact Sheet: Medicare Overpayments