When to File or Not File an Appeal
When to File an 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 Audit Contractor (RAC)
- 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)
When Not to File an Appeal
- Duplicate appeal/redetermination request. CGS has 60 days (allow additional days for mail factor for redetermination letters) to process an appeal/redetermination request.
- When no initial determination has been made. The Provider Remittance Advice must have a MA01 remarks code indicating that you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.
- Do not submit a new or corrected claim if you have a pending appeal/redetermination on file. Wait until you have received notice the appeal/redetermination is processed.
- Claim has no appeal rights
- Return/Reject claims have no appeal rights, providers must correct claim error and submit new claim
- Second Level Reconsideration request should be sent to the Qualified Independent Contractor (QIC)
- Third Level Appeal should be sent to the Administrative Law Judge (ALJ)
- Fourth Level Appeal should be sent to the Appeals Council Review
- Fifth Level Appeal should be sent to the Judicial Review in US District Court
Updated: 12.08.23