Appeals Decision Tree

Has your claim finalized and appeared on a Remittance Advice?

An appeal or reopening cannot be requested until a final claim determination has been issued. Please wait until you have received your Medicare Remittance Advice with your initial claim determination.

Yes No

Does the Remittance Advice show the line item or claim has been afforded appeal rights (remark code MA01 or N210)?

You have no appeal rights. You must correct the claim and submit either an adjustment or a new claim.

Yes No

Did you make a clerical error that you wish to correct?

Rejected or processed claims with minor omissions/errors can be corrected without going through the appeals process. To correct the claim, submit an adjustment to the original claim in the Fiscal Intermediary Shared System (FISS) Direct Data Entry (DDE) system.

Yes No

Have you filed a redetermination on this claim previously?

Yes No

Did you already receive and disagree with the redetermination decision?

File a Reconsideration request to the Qualified Independent Contractor (QIC) if it has not been longer than 180 days from the date you received your redetermination decision.

Please allow 60 days for processing. You can verify appeal status in NGSConnex or via the IVR at 877-567-7205 (Jurisdiction K) and 877-309-4290 (Jurisdiction 6).

Yes No

Did your claim reject for untimely filing?

You have no appeal rights. If you have good cause to request an exception, submit an adjustment to your claim and add your explanation to the Remarks section of the claim. Please refer to the Claim Timely Filing Job Aid for information on Timely Filing Exceptions.

Yes No

Is Medicare the secondary payer (MSP) for this claim?

For a claim that has been rejected for no MSP information and the MSP record has been updated, submit an adjustment to the original claim.

*If the MSP record has not been updated, please have the beneficiary contact the Benefits Coordination and Recovery Contractor (BCRC) at 1-855-798-2627. Once the MSP file has been updated, submit an adjustment to the original claim.

Yes No

Is the date of the initial determination within 120 days?

Your appeal rights have expired. If you have good cause for filing a late request for a redetermination, submit a Redetermination using NGSConnex or use the Redetermination Request form. Please refer to the Medicare Claims Processing Manual, Chapter 29, Section 240.3 for conditions that may establish good cause for late filing by providers.

Yes No

Are you the appointed representative for the provider?

Submit the Appointment of Representative/CMS 1696 Form and a Redetermination using the Redetermination Request form.

Yes No

Are you an NGSConnex user?

Submit a redetermination using NGSConnex.

If you are unsure how to complete a redetermination in NGSConnex, please refer to the NGSConnex Navigation YouTube Playlist or the NGSConnex User Guide

We strongly encourage you to register now and take advantage of all of the benefits NGSConnex has to offer! You can also mail your redetermination request using the Redetermination Request form.

For additional information about NGSConnex and to learn how to get started, please refer to the NGSConnex Orientation YouTube Playlist.

Yes No