MEDICAL REVIEW: How do I appeal a claim that MR reviewed but went to a T status or R status because of a CWF issue after MR processed?

After MR makes their payment decision on an ADR request, the claim cycles through the edits of the CWF including a variety of checks for eligibility, other primary payers, and edits that ensure billing requirements for specific bill types have been met.  When an issue or concern is identified, the claim may reject or deny, overriding the MR decision.  In these cases, the CWF concern must be addressed and corrected (if correctable) before the MR decision can be applied to the claim and prior to giving the provider their appeal rights on the MR decision. Please call the NGS Provider Contact Center at the number listed in the Resources > Contact Us section of our website for assistance in determining the reason for rejection or denial. Upon resolution of the CWF issue, the MR decision is applied to the claim and provider appeal rights are restored.