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.
- Claims denied as return reject (MA130). Note: Do not send an appeal; a new claim must be submitted with the corrected information.
- Do not submit an appeal post the 120 days redetermination (remittance advice) date, unless the reason for good cause qualifies per CMS guidelines.
- If submitting an 2nd level appeal, do not send to CGS. Note: Send your second level appeal (Reconsideration) to the address noted on the letter for the Qualified Independent Contractor (QIC)
NOTE: Claims submitted with a GA modifier: must submit a valid signed ABN Advance Beneficiary Notice of Noncoverage (ABN) Form Instructions Tool and ABN Form Instructions
The above list is not an all-inclusive list of when to submit an appeal.
Updated: 02.19.24