When a Medicare beneficiary or a provider is dissatisfied with a claim determination, the appeals process may be requested. This would include claims that have partially paid or denied for the following reasons:
- Coverage of furnished items and service
- Medical necessity claim denials
- Determination on limitation of liability provision
- Overpayment determinations
Appeal requests shall include documentation to substantiate the services for NGS to review. You are responsible for providing all of the information needed to support payment of your claims. See What Documents are Needed? to assist you with the appeals process, and more specifically, provide clarification regarding the appropriate information to submit with appeal requests. There are instances that will require your office to submit supporting documentation at the time of your initial appeal request. Only you can decide which documentation best supports your claim. Please provide all relevant information and documentation at the time the initial appeal is requested.
You will have appeals steps to follow that include:
- Level One – Redetermination
Time Limit for Filing a Redetermination is 120 days from date of receipt of the initial determination notice and no minimum of amount in controversy.
- Level Two – Reconsideration (QIC)
Time Limit for Filing a Reconsideration is 180 days from date of receipt of the redetermination decision and no minimum of amount in controversy.
- Level Three – Administrative Law Judge (ALJ)
Time Limit for Filing an ALJ - 60 days from the date of receipt of the reconsideration (QIC decision) and the amount in controversy for 2022 and 2023 requests filed is $180.
- Level Four – Medicare Appeals Council (MAC)
Time Limit for Filing with the Medicare Appeals Council is 60 days from date of receipt of the ALJ decision and no minimum of amount in controversy.
- Level Five – Federal Court Review
Time Limit for Filing for a Federal Court Review is 60 days from date of receipt of the MAC decision. For calendar year 2022, the amount in controversy is $1,760. For calendar year 2023, the amount in controversy is $1,850.
The information is located in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29 – Appeals of Claims Decisions
Submitting appeals via NGSConnex is the best method. If you are submitting paper via regular USPS mail, follow these steps.
- Access our website
- Select Claims and Appeals
- Select About Appeals
Visit Get Help Submitting an Appeal Hard Copy. The redetermination (appeal) form is available on this page. When you select Appeal Forms, it will take you to all the appeal forms. The first level of an appeal is a redetermination. The NGS form is labeled: Part B Redetermination Request Form – Level 1.
Yes, within the appeals section of our website, view Reopening versus Redetermination. Scroll down to redeterminations.
A redetermination shall be submitted within 120 days from the claim determination or 120 days from the date of the demand letter.
No, MA130 are claims that have rejected for missing, incomplete or invalid information contained on your claim. You will be required to submit a new claim with the corrected information.
The most common reasons a claim may be denied:
- Service was performed multiple times on the same day, but submitted on separate claims or separate line items, and did not include appropriate modifiers 76 or 77.
Medical necessity for policy related topics:
Medically unlikely edits and correct coding initiatives:
Modifier KX for use with physical therapy:
- KX Modifier Threshold
- KX appropriate when patient qualifies above the threshold under the exception regulations. These should not be reopenings. Providers are required to pre-calculate up to the therapy cap and submit claims with the KX modifier.
No. It is the providers’ responsibility to determine if Medicare is primary or secondary payer. To avoid this denial, check to see if your patient is enrolled in another plan before you submit your claim. Research NGSConnex or the IVR for eligibility facts. Make sure that you are looking at the validity indicator within NGSConnex, effective date and termination date. If your date of service falls between those dates you should submit your claim to the other insurance first.
When submitting claims to NGS as the secondary payer, submit all required loops and segments by using the Electronic Data Interchange: Medicare Secondary Payer ANSI Specifications for 837P guide.
In addition to basic claim information, NPPs (specialty as Spec. 50 [NP] or Spec. 97 [PA]) should enter additional information, identifying the provider sub-specialty in which the service was provided. This sub-specialty information is entered on the electronic claim in the Loop 2300/2400 NTE Segment or in Box 19 of a paper claim. For example, an NPP seeing a patient within the cardiology sub-specialty area would enter Spec. 06 in the Loop 2300/2400, while an NPP seeing that same patient the same day in the psychiatry sub-specialty area would enter Spec. 26.
Review the CPT/HCPCS codes billed and see if there is a NCD, LCD or MUE that has been established for the procedure code(s). If there is a policy in place review if the procedure meets an exception. If a medical appropriate exception exists, bill the service with an appropriate modifier and/or documentation to support the service. Review the CPT/HCPCS code descriptions to make sure its definition allows for how you are attempting to bill. Some questions to consider: Can the procedure be done multiple times? Is the code definition appropriate for multiple body areas/procedures?