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Appeals

Welcome to the WPS Medicare Appeals web page.

The Medicare program offers to physicians, suppliers, and beneficiaries the right to appeal claim determinations made by the carrier. The purpose of the appeals process is to ensure the correct adjudication of claims. The appeals activities conducted by carriers are governed by instructions from the Centers for Medicare & Medicaid Services (CMS).

Redetermination - First level of appeal. An appeal of a claim is performed when a claim denied or reduced and no clerical error was made. The request for appeal must clearly state why you are in disagreement with the reduction or denial decision that was made on the initial claim.
Clerical Error Reopening - A reopening is performed to make a minor change or correction to a previously processed claim, if the original claim has been denied or reduced. For example, you omitted or incorrectly keyed the diagnosis code or a modifier which resulted in a claim denial.
The Centers for Medicare & Medicaid Services (CMS) provide the instructions for reopening activities conducted by MACs. Section 937 of the Medicare Modernization Act (MMA) required CMS to establish a process whereby providers, physicians, and suppliers could correct minor error or omissions outside of the appeals process.
How to Request a Clerical Error Reopening

Appeals Overview

Medicare allows beneficiaries, providers, and suppliers the right to appeal Medicare coverage and payment decisions. There are five levels of Appeal.

  1. Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).
  2. Reconsideration by a Qualified Independent Contractor (QIC)
  3. Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
  4. Departmental Appeals Board (DAB)/Appeals Council
  5. Judicial Review in Federal District Court

Appeals Information

Unprocessable Claim Rejections Do Not Have Appeal Rights:
Claims rejected with Remittance Advice Remark Code (RARC) of MA130 do not have appeal rights. These claims must be corrected and resubmitted. Please refer to the information provided on Unprocessable Claim Rejections And Correction.
Change to CMS Secure Net Access Portal Reopening Feature
Does Your Appeal Request Require Documentation?
Duplicate Appeal Requests
How to Appeal a Claim Determination
How to Submit Your Appeal Request by Fax
Medicare Appeals - The Importance of Getting It to the Right Place at the Right Time!
Overpayment Redeterminations and Recoupment

CMS Resources

CMS Appeals HomepageLink to external site
CMS Appeals Tri-Fold Brochure

Calculators/Tools

Appeals Navigator
Redetermination Calculator

Forms

Find forms for each level of appeal (redetermination and reconsideration requests) as well as state-specific fax cover sheets, Reopening Request forms, and the Appointment of Representative form (CMS-1696) on the Appeals Forms page.

Frequently Asked Questions (FAQs)

Find FAQs concerning the appeals process on the Appeals FAQs page.

Page Last Updated: Wednesday, 15-Oct-2014 11:16:44 CDT