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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 guidelinesExternal PDF.
  • 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)External Website

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 InstructionsExternal PDF

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

Updated: 02.19.24


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