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Appeals FAQs

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  1. What's a reopening and when are they used?

    • Reopenings are conducted at the discretion of the Medicare Administrative Contractor (MAC), and are used to correct claims with clerical errors, which include minor errors and omissions; however, providers typically submit claim adjustments in these situations. CGS may grant a reopening when an appeal request (redetermination) is received for an inpatient or outpatient claim that was fully denied with reason code 56900, indicating the Additional Development Request (ADR) documentation was not received timely. Providers may still request a redetermination (first-level appeal) if they are dissatisfied with the claim adjudication resulting from the completed reopening. Refer to the "Reopenings" web page on the CGS website for additional information.

      Updated: 12.19.14

  2. Our redetermination request was dismissed because it was untimely. What is considered a timely redetermination request?

    • A request for a redetermination must be submitted within 120 days of the date the initial claim denial was processed to be considered timely. Providers can use the PD DT field on the Claims Summary Inquiry screen (FISS Inquiry Option 12) or the date on your Remittance Advice (RA), or Electronic Remittance Advice (ERA) to determine the date of the claim denial. Refer to the "Appeals Timeliness Calculator" Web page for assistance in determining the date your appeal request must be received to meet the timeliness guidelines.

      Reviewed: 12.19.14

  3. Will my Remittance Advice tell me if a processed claim can be appealed if I'm disputing the denial?

    • Yes. The Medicare Remittance Advice contain reason codes and/or remarks codes when a claim has been fully or partially denied and is, therefore, appropriate to appeal. The "Claim Adjustment Reason Code" field (RC) and "Remittance Advice Reason Code" field (Rem) are available on the "All Claims" page of the Standard Paper Remittance Advice (SPR) and the "Single Claim" page of the Electronic Remittance Advice (ERA). A "Single Claim" page is available for each claim listed on the ERA. The codes found in the "RC" and "Rem" fields can be researched using the WPC websiteExternal Website to determine if appeal rights are available for the initial claim determination.

      Reviewed: 12.19.14

  4. Where can we find more information about the Medicare Appeals process?
  5. Can all Medicare claim determinations be appealed?

    • Medicare claim determinations can only be appealed when a claim has been denied by Medicare and the beneficiary or provider is disputing the denial. Full denials appear in the Fiscal Intermediary Standard System (FISS) status/location (S/LOC) D B9997. Partial denials will appear in FISS S/LOC P B9997, with the noncovered revenue code lines available for viewing by accessing FISS Page 02 and pressing the F2 key to display MAP 171D. Use the F6 key to scroll through and locate the noncovered revenue code lines and associated denial reason codes.

      As a reminder, it is never appropriate to submit appeal requests in the following situations:

      • The claim was paid in full (FISS S/LOC P B9997)
      • The claim was never submitted to Medicare
      • The claim is in a suspended status/location (S XXXXX where the Xs are various numbers and/or letters)

      Reviewed: 12.19.14

  6. How long will it be before I receive a decision letter on a redetermination request?

    • CGS Administrators, LLC is required to mail a decision letter (i.e., redetermination notice) within 60 days of receipt of the redetermination request. In cases where the decision letter is not mailed until the 60th day, please allow a 5-day period for mail delivery.

      Reviewed: 12.19.14

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