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.

Yes No

Does the Remittance Advice show your claim has been rejected as unprocessable with MA-130?

You have no appeal rights and cannot reopen. You must correct and submit a new claim.

Yes No

Did you submit everything correctly on the claim or do you need to make major changes or supply additional documentation?

Claims with minor omissions/errors can be corrected without going through the appeals process. To correct the claim , submit a Reopening using NGSConnex or the

Reopening Request Form.

Yes No

Have you filed a redetermination on this claim previously?

Yes No

Have you already received and disagree 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. If you are unsure of the status, you can verify in NGSConnex or by contacting the IVR at 1-877-869-6504 for JK or 877-908-9499 for J6.

Yes No

Did your claim deny for untimely filing?

You have no appeal rights. Please refer to the Requesting an Exception to Timely Filing for information on Timely Filing Exceptions.

Yes No

Is Medicare the secondary payer for this claim?

For a claim denied for no MSP information or if the MSP record now shows Medicare is primary, submit a Reopening using the

Reopening Request Form.

* 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 a Reopening using the

Reopening Request Form.

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

Reopening Request Form.

Please refer to the Medicare Claims Processing Manual Section 240.3 for conditions that may establish good cause for late filing by providers.

Yes No

Are you the Appointment of Representative?

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

Reopening 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 money and time saving features NGSConnex has to offer! You can also submit 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