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When to File Appeal

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)

Updated: 12.21.18

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