FAQs: Medicare Part B Appeals

» View Medicare Part B Reimbursement Appeals Process

  1. We made an error or omission on our claim form and, as a result, the claim has been denied coverage. Do we have to file an appeal to get this claim reconsidered? Click For Answer
    • No. The provider can correct many errors or omissions on a claim form and the claim can be refiled with the contractor; the corrected claim will usually be considered for payment without prejudice. The “Corrected Claim” flag should be set to “Yes,” or as required for the claim format that is used.1
  2. Our claim was filed correctly, but our Medicare contractor denied coverage and we need to begin the appeals process. How do we start? Click For Answer
    • The Medicare Summary Notice (MSN) or other notice that you received from the Medicare contractor provides instructions for requesting a Level 1 appeal (a redetermination) and the address where the appeal packet should be sent. As each level of appeal is completed, the contractor will provide instructions for proceeding to the next level, if appropriate.1
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  3. What should be included in the appeal packet when a redetermination is requested? Click For Answer
    • At minimum, an appeal packet should include:1
      • A Medicare Redetermination Request Form (Form CMS-20027) or a letter that provides all of the information requested on Form CMS-20027
      • An optional Appointment of Representative Form (Form CMS-1696) if you wish to have someone represent you in the appeals process
      • Other documentation to support your reasons for appealing the claim
        • For example, if the contractor has denied your claim as “not reasonable and necessary,” you should include a Letter of Medical Necessity, which explains why the treatment that was claimed meets Medicare's definition of “reasonable and necessary.” You may also want to include copies of peer-reviewed clinical journal articles that provide clinical support for the treatment that was claimed.
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  4. If a Medicare Part B claim is denied coverage, should the treating physician or the patient file an appeal? Click For Answer
    • The treating physician typically files the appeal, although either the treating physician or the patient can do so. In most instances, if a patient initiates the appeal, the treating physician will need to help the patient prepare the appeal packet by providing a Letter of Medical Necessity and other supporting documentation.1
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  5. Can the treating physician or the patient appoint someone to represent them in the appeals process? Click For Answer
    • Yes. A representative can be appointed at any time during the appeals process. Medicare provides an Appointment of Representative Form (Form CMS-1696) for the physician or patient to use. This form must be signed and dated by either the physician or the patient who is appointing the representative. The appointed representative must also sign and date the form.1
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  6. We requested a Level 1 appeal, and it has been denied. We have new information that should have been included with the Level 1 appeal, and its absence may have affected the Level 1 reviewer's decision. Can we ask the Medicare contractor to reopen the Level 1 appeal? Click For Answer
    • No. You may, however, proceed to a Level 2 appeal and include the new information with your appeal packet.
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  7. We would like to take our appeal directly to an administrative law judge. Can we skip the Level 1 and Level 2 appeals and go immediately to Level 3? Click For Answer
    • No. Each level of appeal must be completed before you can move on to the next Level. An administrative law judge will not grant a hearing if the Level 1 and Level 2 appeals are incomplete.1
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.
  8. If we receive a positive decision following an appeal, will future claims affected by the same issue be routinely paid? Click For Answer
    • An appeal decision is specific to the claim for which the appeal was filed and the outcome will not necessarily affect your Medicare contractor's decision on future claims.
    • Destination Access is available to help you. Call 1-800-861-0048 to speak to an appeals specialist.

References:

  1. Centers for Medicare & Medicaid Services. Medicare claims processing manual. Available at: http://www.cms.hhs.gov. Accessed March 17, 2010.

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