Medicare appeal - Most commonly asked questions ?

Q: Can I resubmit or adjust a claim when an appeal is processing?

A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.

Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.

Q. Can minor errors or omissions be corrected outside of the appeals process?
A. Yes. There are two ways to correct a claim. A clerical error reopening can be initiated via the telephone or in writing; or, in many cases, the denied service(s) can simply be corrected and resubmitted. Resubmitting claims to correct minor clerical errors or omissions is the most efficient method for addressing certain denied services.*

*Resubmit the denied service(s) ONLY - resubmitting an entire claim will create a duplicate denial.

If these issues are received via written and telephone requests, it may take up to 60 days to process and finalize an adjustment, versus 14-30 days for a resubmitted claim. Ensure that you review the type of clerical error or omission you are attempting to correct and select the most efficient option available.
Note: Single-line clerical reopenings can be requested through the Part B Interactive Voice Response system (IVR). Click here for more details. If you’re registered for SPOT, you may submit Part B clerical reopening requests online. Click here for more details.
Determine if the error can be corrected and resubmitted prior to writing in or calling to request a clerical error reopening.

• Minor clerical errors or omissions that can be corrected and resubmitted:
• Change of diagnosis codes
• Add, change, or delete modifiers (e.g., 25, 50, 59, 78, 79, RT, LT)
• Incorrect place of service
• Written or telephone clerical error reopenings are appropriate only for services that were processed and received an approved amount, and could include the following types of situations:
• Number of services (NB) billed
• Submitted charge amount
• Date of service (DOS)
• Add, change or delete certain modifiers
• Procedure code; excluding codes requiring documentation on the initial submission or codes being upcoded


Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?
A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.

Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.

The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Q. What actions do providers take to request an appeal of a Medicare overpayment for an MSP claim and stop the accounts receivable offset?
A. If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.


Q: Is there a resource for providers or beneficiaries that outline what services or items can be appealed?
A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.




Q. What actions do providers take to request an appeal of a Medicare overpayment for an MSP claim and stop the accounts receivable offset?
A. If a provider receives a Medicare demand letter, refer to the appeal rights section of the demand letter for specific instruction on how to file an appeal and stop recoupment of the accounts receivable if applicable.


Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?
A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.




Q: Will First Coast’s medical review (MR) department request additional documentation from providers during the CERT process?
A. The CERT contractor will request medical records that support services rendered on randomly-selected claims. The CERT contractor reviews the medical records and determines whether the claims were billed and paid in accordance with Medicare guidelines. If CERT errors are assessed due to “insufficient documentation” or “no response to documentation request”, First Coast may attempt to procure additional documentation from the provider. First Coast will review documentation for completeness and will fax them to CERT contractor, which may result in an error being removed.


Q: During the appeal process, at what point can additional records be submitted?
A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery audit contractor (RAC) determination, the RAC will forward the medical records they received to the affiliated contractor, or First Coast Service Options Inc.


Q. What is the address for overpayment appeals?
A. The address for a Florida overpayment appeals is as follows:
First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248

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