When to File or Not File an 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.
- Claims adjusted causing an overpayment may be appealed with the supporting documentation.
The above list is not an all inclusive list of when to submit an appeal.
Updated: 12.14.20