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When to File Appeal

To appeal a claim, the claim must be denied (FISS status/location D B9997) or partially denied (P B9997). Generally, rejected claims (R B9997) cannot be appealed. However, there are limited exceptions, such as a claim rejected for an untimely hospice notice of election (NOE). Follow the steps below to determine if a rejected claim can be appealed.

Examples of denied claims/services that can be appealed:

  • Items or services were not covered or ordered; or
  • The physician was not eligible to order/refer, or of a specialty type that was eligible to order or refer the items and services covered by Medicare (home health only) (NOTE: CGS utilizes the Reopening process for this type of denial.);
  • Items or services were not reasonable and necessary;
  • Services were not intermittent (home health only);
  • Services constituted custodial care;
  • The patient was not homebound (home health only); or
  • If the party disputes the liability of the denied or noncovered items or services

Posted: 06.09.17

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