When Not to File Appeal

  • Ambulance Denials. Note: Run sheets/tickets, Certification of Medical Necessity (CMN) and Physician Certification Statement (PCS) should be included to support each trip.
  • Charges denied as Part A because the patient was seen in the office prior to admission in the hospital. Note: Documentation should be included to support the office service.
  • Shared care denied for global service already on file. Note: Documentation of the shared care should be included to support the service billed.
  • Claim denied as not medically necessary and the provider has supporting documentation to support the medical necessity.
  • Procedures denied for exceeding Medically Unlikely Edits. Note: Documentation supporting medically reasonable and necessary units of service should be included with the request.
  • If appealing a recoupment claim, send to the Redetermination Department with the supporting documentation. Note: If correcting a recoupment claim for a clerical reopening send to Overpayment Recovery Department.
  • CMS Reductions are not handled at the contractor level.  Providers should contact CMS directly.

The above list is not an all inclusive list of when to submit an appeal.

Updated: 01.16.20

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