Medicare Part B 101 Manual

Medicare Part B 101 Manual

Appeals/Reopenings

Table of contents

Reopenings for Minor Errors and Omissions

Providers should be aware:

  1. There is no need to request a redetermination if the supplier has made a minor error or omission in filing the claim, which, in turn, caused the claim to be denied.
  2. Clerical error reopenings are used to change the information on the claim or claim line(s) or to initiate an overpayment on claim line(s). Clerical errors do not include omissions or failure to bill items or services.
  3. You cannot add a claim line that was not previously included on the claim.
  4. Third party payer errors do not constitute clerical errors.
  5. If a claim or claim line(s) has been submitted and paid, submitting a new or corrected diagnosis does not qualify as a reopening. If the diagnosis on the paid claim needs to be corrected, or an additional diagnosis needs to be added then you would make a notation in the medical record of the issue and the diagnosis so it can be part of the record. The claim will not be corrected with a new remittance advice issued.

In the case where a minor error is involved, the provider can request Medicare to reopen the claim so the error can be corrected, rather than having to go through the appeal process. Providers can request a reopening for minor errors by telephone or in writing or online via NGSConnex. View Reopening versus Redetermination for complete details.

In situations where a provider, supplier or beneficiary requests a redetermination and the issue involves a minor error, irrespective of the request for a redetermination, the Part B MAC will treat the request as a request for a reopening.

Because some issues are more complicated than others, and may require more research or consulting medical staff, the Part B MAC reserves the right to decline the telephone reopening and request the provider submit a written reopening request. Providers can request a reopening either by telephone, in writing, or online via NGSConnex. Always refer to Reopening versus Redetermination to determine what your next steps would be for a denied claim.

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Telephone Reopening Unit

Contacting the Telephone Reopening Unit

TRU representatives are available Monday‒Friday from 8:00 a.m.‒4:00 p.m. We are closed for training on the 2nd and 4th Friday of the month from 12:00 p.m.‒4:00 p.m. ET/11:00 a.m.‒3:00 p.m. CT.

View the chart within the Telephone Reopening Unit section of Reopening versus Redetermination for scenarios that cannot be initiated via NGSConnex, but can be initiated via the Telephone Reopening Unit or by using the Part B Reopening Request Form.

Jurisdiction K Telephone Reopening Contact Number
New York 888-812-8905, press 1
Connecticut 888-812-8905, press 2
Maine 888-812-8905, press 3
New Hampshire 888-812-8905, press 4
Vermont 888-812-8905, press 5
Rhode Island 888-812-8905, press 6
Massachusetts 888-812-8905, press 7

 

Jurisdiction 6 Telephone Reopening Contact Number
Illinois 877-867-3418 Press 1
Minnesota 877-867-3418 Press 2
Wisconsin 877-867-3418 Press 3


Please note that telephone reopenings are randomly monitored for quality assurance purposes.

  1. Wait to call the telephone reopening line until you receive your Medicare remittance notice; no action can be taken until a final claim determination is issued.
  2. Providers should consult the Medicare Part B publications and any applicable medical policies before calling. Failure to have appropriate information available when you call the telephone reopening line may result in an unfavorable decision.
  3. Questions about the status of a claim, Medicare Secondary Payer issues, or general Medicare payment and coding questions, should not be directed through the telephone reopening line. Providers can obtain a claim status report through the IVR system or by using the NGSConnex online web application.
  4. Providers must have the following information on hand before placing the call for a telephone reopening:
  • Provider's full name, PTAN
  • Medicare claim control number, item or service in question, reason for denial
  • Beneficiary name and Medicare MBI number
  • Any additional information to support why you believe the decision is not correct (this includes having the correct procedure code[s], modifier[s], diagnoses, units of service, etc.)

All medical information provided to the Part B MAC must be documented in the patient’s file and available should an audit be required.

If a previous reopening decision has been issued, a redetermination must be made in writing. If a previous redetermination decision has been issued, a reconsideration must be filed.

To effectively service all callers, each call is limited to three claim issues.

Written Reopening Requests

You can submit a written request by completing and mailing a Part B Reopening Request Form.

Jurisdiction K providers should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 7111
Indianapolis, IN 46207-7111

Jurisdiction 6 providers should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Be sure to include the following information with your reopening request:

  • The beneficiary’s name
  • The Medicare MBI number of the beneficiary
  • The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
  • The name and signature of the person filing the request

Reopening requests for issues requiring documentation such as adding modifier 22 and redetermination of overpayments are not permitted. These must be submitted as a written redetermination request.

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Appeals

The Medicare Program offers providers and beneficiaries the right to appeal claim determinations made by the carrier. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by MACs are governed by instructions from the CMS.

Providers who provide services to Medicare Part B beneficiaries may appeal an initial claim determination. Beneficiaries have the right to appeal any claim determination.

The Medicare law consists of five possible levels of appeal. The appellant must begin at the first level after receiving an initial determination. Each level, after the initial determination, has procedural steps that must be taken before an appeal may be taken to the next level. The following table lists the types of appeal, the order in which appeals must be followed and the filing requirements for each.

Appeal Level Time Limit for Filing Request Where to File an Appeal Monetary Threshold
Redetermination 120 days from the date of receipt of the initial redetermination Medicare Administrative Contractor None
Reconsideration 180 days from the date of receipt of the notice of the redetermination QIC None
ALJ Hearing 60 days after the date of receipt of the reconsideration notice HHS OMHA field office For requests filed on or after 1/1/2024, at least $180 remains in controversy.

For requests filed on or before 1/1/2023, at least $180 remains in controversy.
MAC/DAB Review 60 days from the date of receipt of the ALJ decision/dismissal MAC/DAB or ALJ Hearing office None
Federal Court (Judicial) Review 60 days from the date of receipt of DAB decision or declination of review by DAB Federal court For requests filed on or after 1/1/2024, at least $1,840 remains in controversy.

For requests filed on or after 1/1/2023, at least $1,850 remains in controversy.


Note: When filing an appeal, a separate request is not required for each service/procedure code on the claim. All requests for a specific beneficiary or MBI number can be combined on one request.

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Time Limit for Filing

The time limits for filing appeals vary according to the type of appeal. The previous table indicates the time limits for filing appeal requests for each level of appeal. The time limits for filing a request for redetermination may be extended in certain situations if good cause for late filing is shown. Some conditions that establish good cause are:

  • Unavoidable circumstances that prevented the individual from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the individual’s control, such as major floods, fires, tornados and other natural catastrophes.

For more details on time limits for filing appeals and good cause for extension of the time limit for filing appeals see CMS' Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 29 – Appeals of Claims Decisions 240.1 – Good cause

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Appointment of Representative

A person/supplier/physician who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative. To act as the beneficiary’s representative, a person/supplier/physician must submit a properly executed appointment of representative. The following information must be included on an appointment of representative form or written statement:

  • The name, address and phone number of the individual.
  • The individual’s Medicare number when the party making the appointment is the beneficiary.
  • A specific individual must be named as the representative. An organization or entity may not be named as the representative, but rather a specific member of that organization or entity must be named. The representative must sign and date the form and list his/her name, address and phone number. A statement that he/she accepts the appointment needs to be included.
  • Representatives must sign the appointment within 30 calendar days of the party’s signature.
  • A statement that the party authorizes the representative to act on her or his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative.
  • Signature of the party making the appointment and the date signed.

The appointment of representative is valid for one year from either:

  1. the date signed by the party making the appointment; or
  2. the date the appointment is accepted by the representative—whichever is later.

The appointment remains valid for any subsequent levels of appeal on the claim/service in question unless the beneficiary specifically withdraws the representative’s authority. However, if during an appeal the appointment of representative expires, a new form is necessary.

For more details on appointment of representative see CMS’ Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 29 – Appeals of Claim Decisions, 207- Appointment of Representative.

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Redeterminations

The first level appeal is referred to as a redetermination. All redeterminations must be submitted within 120 days of receipt of the initial claim determination.

A party dissatisfied with an initial claim determination may request a redetermination. A redetermination is a second look at the claim and supporting documentation. If an initial determination on a claim has not been made, there are no appeal rights on that claim. Providers should wait to file a redetermination until they receive the Medicare remittance notice that provides the claim determination. A redetermination is a new, independent and critical reexamination of a claim. It is conducted by reexamining the information in the file and any additional documentation submitted with the request for a redetermination.

To request your first level of an appeal (redetermination), you may submit a fully completed Medicare Part B Redetermination electronically (NGSConnex) or via paper (Medicare Part B Redetermination Request Form). If the NGS forms are not used, your request must contain all the following information:

  • The beneficiary’s name
  • The Medicare MBI number of the beneficiary
  • The specific services(s) and/or item(s) for which the redetermination is being requested and the specific date(s) of service, and
  • The name and signature of the person filing the request

Incomplete requests will be dismissed with an explanation of the missing information. Providers will be instructed to resubmit the request with all of the missing information.

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Acceptable Signature

Printed Signature

  • An actual signature
  • First initial and last name
  • First and last name
  • A legible signature

Unacceptable Signature

  • Initials
  • First name and a last initial
  • Signature on the CMS-1500 form
  • Rubber stamped signature
  • Electronic signature
  • Typed signature by supplier or physician

In situations where a provider, supplier or beneficiary requests a redetermination and the issue involves a minor error or omission, irrespective of the request for a redetermination, the Part B MAC will treat the request as a request for a reopening.

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Reconsideration

The second level of appeal is known as a reconsideration request. Section 1869 of the Social Security Act (the Act) entitles any individual dissatisfied with the contractor’s redetermination to file a request, within 180 days of receipt of the redetermination, for reconsideration. In accordance with section1869(c), reconsiderations are to be processed within 60 days by entities called QIC. When a claim is denied on the basis of section 1862(a)(1)(A) of the Act, the QIC reconsideration will consist of a panel of physicians and other health professionals. When the panel reviews services or items rendered by a physician or ordered by a physician, the panel will consist of at least one physician.

The date of filing for requests filed in writing is defined as the date received by the QIC in their corporate mailroom. If the party has filed the request in person with the QIC, the filing date is the date of filing at such office, as evidenced by the receiving office’s date stamp on the request. If the party has mailed the request for reconsideration to CMS, SSA, Railroad Retirement Board office or another government agency in good faith within the time limit, and the request did not reach the appropriate QIC until after the time frame to file a request expired, the QIC considers good cause for late filing. (Refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Section 240, Chapter 29 (604 KB) for more information on good cause.) Likewise, if the request is filed with CMS, SSA, Railroad Retirement Board office or another government agency in person, the QIC considers good cause for late filing.

Jurisdiction 6 and Jurisdiction K providers should submit completed reconsideration requests to:

C2C Solutions, Inc.
QIC Part B North
P.O. Box 45208
Jacksonville, FL 32232-5208

The QIC may extend the period for filing if it finds the appellant had good cause for not requesting the reconsideration timely. Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Section 240, Chapter 29, [604 KB] for a discussion of good cause. In order for good cause to be considered, the appeal request must be in writing. If the QIC finds that the appellant did not have good cause for not requesting reconsideration on time, it may, at its discretion, consider reopening.

Note: There is no monetary threshold to be met when filing a reconsideration request to the QIC.

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Administrative Law Judge Hearing

The third level of appeal is an ALJ. A hearing before an ALJ of the SSA may be requested if the appellant is not satisfied with the QIC determination. The ALJ hearing must be requested in writing within 60 days from the date of the QIC’s decision. The request must specifically state that an ALJ hearing is desired and the request must be signed. 

For appeals related to Medicare Part A or Part B, you may file your appeal request online. Visit the OMHA e-Appeal Portal and register for an account. Through the portal, you may directly upload Form OMHA-100 or use the guided tutorial to create and upload your request.

Jurisdiction 6 and Jurisdiction K providers should submit completed ALJ requests to:

OMHA Central Operations
1001 Lakeside Ave. Suite 930
Cleveland, Ohio 44114-1158

Note: There must be at least $180 in controversy to request an ALJ hearing for requests filed on or after 1/1/2023. The amount in controversy for CY 2024 remains at $180.

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Medicare Appeals Council/Departmental Appeals Board Review

If an appellant is dissatisfied with the ALJ decision, the appellant may contact CMS directly for a MAC (also referred to as the Departmental Appeals Board) review. The MAC review must be requested within 60 days of the date of the ALJ decision.

Providers should submit review requests to:

Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, SW
Cohen Building, Room G-644
Washington, DC 20201

Phone:

  • Toll free: 866-365-8204
  • Local: 202-565-0100

Fax:

  • 202-565-0227

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Federal Court Review

If an appellant is still dissatisfied with the appeal decision made by the Medicare Appeals Council/Departmental Appeals Board, they may request a Federal Court Review within 60 days after receiving notice of the Council’s action in the case.

Note: The amount in controversy must exceed $1,840 for CY 2024. The amount in controversy must exceed $1,850 for CY 2023.

Providers should submit Federal Court Review requests to:

Department of Health and Human Services
Departmental Appeals Board, MS 6127
General Counsel
330 Independence Avenue, S.W.
Cohen Building, Room G-644
Washington, DC 20201

Phone:

  • Toll free: 866-365-8204
  • Local: 202-565-0100

Fax:

  • 202-565-0227

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Documentation in the Appeals Process

The following clarifications are designed to assist providers who wish to appeal original claim denials through the appeals process. Often original claim denials are upheld at the redetermination or reconsideration level of appeal due to the lack of documentation supporting the medical necessity of services rendered.

Before requesting a redetermination or reconsideration, consult the Medicare Part B publications and provider bulletins, all applicable medical policy and documentation guidelines for each service you appeal. Failure to include all appropriate documentation with the appeal may result in an unfavorable decision.

The appellant has the responsibility to provide information and/or documentation for provider submitted appeals. Decisions at these levels are based exclusively on the information and/or documentation submitted with the case.

The following lists common types of claim denials/reductions that may be submitted for appeal as well as the documentation required for each.

Type of Denial/Reduction Documentation Required
Concurrent care Narrative documentation to support that the physician is of a different specialty or subspecialty and treating a different body system.

Medical documentation that supports the need for services, e.g., office records, progress notes, etc.
Concurrent care - Nonphysician Practitioner

CMS permits one E/M service per beneficiary, per day, per provider specialty type.

Since PAs and NPs often provide specialty care (e.g., family practice, psychiatry, orthopedics), multiple E/M services on the same DOS may be permissible, when each episode of care is addressing a different clinical condition in a different sub-specialty area.

To avoid claim denials, providers may submit all claims with the sub-specialty of the NPP services performed by the same group, to the same beneficiary, on the same day.

When a NPP (PA-97 or NP-50) adds the NPP specialty information to the LOOP 2300/2400 NTE Segment of each claim, this allows National Government Services to compare the previously paid visit claim with the currently pending visit. If the specialties on the two claims are different (e.g., orthopedics vs. psychiatry) then the second visit may be allowed. See Medicare Provider/Supplier Specialty Codes.
Overutilization Medical documentation to clearly show why the patient required more than the standard number of services during the specified time period.

Please include a copy of the waiver of liability statement (i.e., ABN) signed by the patient, if one was obtained.
Service not medically necessary based on policy guidelines Specific ICD-10-CM diagnosis code or narrative documentation outlining why the services are medically necessary.
Routine screening ICD-10-CM code or narrative symptom, complaint, service. (If patient is noncovered.)
Surgery within postoperative period of another surgery Along with the request for a redetermination, documentation to support that a modifier 58 (Staged procedure) or modifier 78 (Related procedure global period) or modifier 79 (Unrelated during a global period) was appropriate and should have been sent on the initial claim.
Visit on same day or within postoperative period of surgery If the visit was performed on the same day as the surgical procedure and the visit was a significant, separately identifiable service from the surgery, send documentation to support that a modifier 25 was appropriate and should have been sent on the initial claim.

If the visit was rendered during the postoperative period and it was unrelated to the procedure, send documentation to support the need for the visit and that modifier 24 was appropriate and should have sent on the initial claim.


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Revised 1/25/2024

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