Appeals

Appeals Overview

Providers, suppliers and beneficiaries may appeal claim determinations made by National Government Services. The appeals process aims to ensure the correct adjudication of claims. The CMS governs appeals activities conducted by NGS. There are different levels of appeals as well as time limits for filing an appeal at each level. For more information on filing an appeal visit our resources listed here.

Provider Tips

How Do I Appeal a Claim Denied Through the TPE Process?

The TPE process does not replace or change appeal rights.
- The educational sessions are not an appeals forum nor do the result letters or the educational sessions extend the appeal period.
- When a claim has been denied during a TPE review, and the provider wishes to appeal the decision, a formal appeal must be submitted.
- When submitting an appeal all documentation that you would like the appeals department to consider must be submitted with the appeal
- NGS has 60 days to process the appeal and you’ll be notified by mail if the appeal is denied. If the appeal is favorable, the claim will automatically be reprocessed, and you’ll be issued a unique check and remittance advice. The status of the appeal can be accessed via NGSConnex or the IVR.
Resubmitting a claim denied due to medical necessity will result in a duplicate denial.
- There are time frames for which a timely appeal can be submitted, therefore, providers must file their appeals promptly upon receiving the initial determination notice. You’re not required to wait until formal education, or the results letter is received to appeal a claim.
- NGSConnex is the preferred method for filing an appeal. Visit NGSConnex for more information.
For paper appeals
- Ensure your paper appeal is mailed to the Appeals Department and not to the Medical Review Department as this will further delay the process.
- An appeals form must accompany paper appeals.

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Reviewed 11/25/2024