Corporate

Determining Appropriate Appeal Requests

What services can be appealed?

  • You disagree with the amount paid
  • The service was denied as statutorily non-covered
  • The service was denied as not reasonable and necessary
  • The service was denied for failure to meet coverage criteria
  • The service was denied as a contractual obligation (provider is responsible) and you believe the provider is NOT liable for the non-covered or denied services.
  • The service was rejected or denied based on a review by the:
    • Medicare Administrative Contractor (MAC)
    • Recovery Auditor (RA)
    • Comprehensive Error Rate Testing (CERT)contractor
    • Supplemental Medical Review Contractor (SMRC)
    • Unified Program Integrity Contractor (UPIC)
    • Quality Improvement Organization (QIO)
    • Office of Inspector General (OIG)

What are examples of claims or services that cannot be appealed?

  • Return to¬† Provider (RTP) claims (S/LOC T B9997), including claims returned for timely filing (reason code 39011)
  • Paid claims¬† (S/LOC P B9997) that do not include a denied line item
  • Claims that were never submitted to Medicare
  • Claims in a suspended status/location (S XXXXX, where the Xs represent various numbers and/or letters).

When a claim has completed processing (paid, denied or rejected), a 5-digit reason code is applied by FISS, which explains the processing outcome. Each reason code has a Remittance Advice Remark Code (RARC) associated with it. The RARC provides additional information about how CGS processed each claim and whether or not appeal rights apply. These remark codes are available in Direct Data entry (DDE) and on your RA.

Follow these instructions for accessing reason and remark codes to determine whether your claim may be appealed:

  1. Determine the 5-digit reason code that was applied to the claim. This can be done using DDE Option 12 (Claims) and entering the beneficiary’s Health Insurance Claim (HIC) number and the From and To date of the claim. Review the REAS (reason code) field. You may appeal a claim or claim line that receives a full or partial medical denial with a reason code starting with either “5” or “7”.

    Appeals

    To look up the reason code, select the claim and press F1. Press the F8 key to review the "Appeals (A)" and "Appeals (B)" field.  If code MA01 is present, you may appeal the claim. Other codes, such as 'N211', indicate the claim cannot be appealed. For a complete list of all RARCs, refer to the RARC Code ListExternal Website on the Washington Publishing Company websiteExternal Website.

    Appeals

  2. Reviewing the RARC on your Remittance Advice (RA). The 'Remark Codes' section of the Single Claim (SC) Screen [No Longer Available] on your Electronic Remittance Advice (ERA) will show the Remittance Advice Remark Codes (RARCs) that were applied to the claim. MA01 indicates there are appeal rights associated with the service. Other codes, such as 'N211', indicate the claim cannot be appealed. For a complete list of all RARCs, refer to the RARC Code ListExternal Website on Washington Publishing Company websiteExternal Website.

    On the Standard Paper Remittance Advice (SPR), RARC codes appear on the AC page in the "REM" field. MA01 indicates there are appeal rights associated with the service. For a complete list of all RARCs, refer to the RARC Code ListExternal Website on Washington Publishing Company websiteExternal Website.

    Appeals

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