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Appealing a Denied Claim

At times, providers submit a claim that ends up being denied; the denial may include appeal rights. Providers can appeal all of their overpayment claims on one request for redetermination, which is the first level of an appeal. There are five levels of appeals: 

  1. Redetermination
  2. Reconsideration
  3. Administrative Law Judge
  4. Medicare Appeals Council
  5. Federal Court Review

When submitting a redetermination, you are required to submit all necessary medical documentation to support the services billed on your claim, you must submit a complete medical record when requesting an appeal. However, if documentation was previously submitted to the Medical Review Department or another contractor, such as the RA, CERT or UPIC, those medical records are included in the file reviewed by the Appeals department and you do not have to resend those records to us.  The supporting documentation can either be submitted through the NGSConnex portal or through the postal service. Please note: If submitting an appeal request in NGSConnex, only one claim can be appealed at a time. We will only review the claim indicated on the NGSConnex form.

In the event the provider’s redetermination request is denied and the decision is made to submit a reconsideration to the QIC, the supporting documentation already submitted does not need to be included again.  If any new documentation is available, just that new documentation should be included in the request for a reconsideration. The previously submitted documentation will be forwarded to the QIC when the appeal moves to the next level. This is also true when an appeal move on to the next appeal level.  

Posted 3/22/2023