Appeals Decision Tree – Home Health and Hospice
Check claim status in DDE or myCGS.
1. Has your claim finalized/appeared on a Remittance Advice?
2. Have you previously requested a Redetermination for this claim?
3. Have you received a decision?
You may request a Reconsideration from the QIC.
3. Was the claim submitted with clerical errors (including minor errors/omissions)?
4. Was the claim submitted within the claim timely filing limit (one calendar year from the "through" date of service)?
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Submit a claim adjustment (TOB XX7) in DDE or your electronic software.
Submit a Claim Reopening (TOB XXQ) in DDE or complete a Clerical Error Reopening Request Form (Part A) or a Reopening Adjustment Request Form (HHH).
4. Did the claim receive an ordering/referring denial (HHA only)?
Complete the Reopening Adjustment Request Form. Reference the Ordering/Referring Denial Reopenings information on our website.
5. Did the claim receive denial reason code 56900?
Submit a 56900 reopening request via the myCGS portal or complete the 56900 Reopening Request Form.
6. Did you receive a claim or line item denial/demand letter within the last 120 days?
7. Are you the Appointment of Representative as defined by CMS in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 29, section 270?
Submit a Redetermination Request in myCGS or use the Redetermination Request Form. Include an AOR with your Redetermination Request. Use the CMS-1696 Form or a conforming written instrument as described in the CMS Medicare Claims Processing Manual (Pub.100-04), chapter 29, section 270.1.2, subsection B.
Submit a Redetermination Request in myCGS or use the Redetermination Request Form.
Your appeal rights have expired per the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 29, section 240.
2. Is the claim in the Return to Provider (RTP) location (TB9997)??
Correct the claim in DDE or resubmit the claim with corrections.
Please wait until the claim finalizes and appears on a Remittance Advice.