About Appeals

Providers, suppliers and beneficiaries have the right to appeal claim determinations made by National Government Services. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by National Government Services are governed by the CMS.

First Level of Appeal (Redetermination) Processing Timeline

Per the CMS IOM Publication, Medicare Claims Processing Manual, Chapter 29, Appeals of Claims Decisions, Section 310.5, The Redetermination Decision

"A. Redetermination Decision Letters

The law requires contractors to conclude and mail and/or otherwise transmit the redetermination decision within 60 days of receipt of the appellant's request, as indicated in Section 310.4. For unfavorable redeterminations, the contractor mails the decision letter to the appellant, and mails copies to each party to the initial determination (or the party’s authorized representative and/or appointed representative, if applicable)."

Because of the 60 day decision turnaround time allowed, NGS asks for your patience in waiting up to 60 days for an appeal decision to be made. Submitting duplicate appeal requests, either via paper or NGSConnex in an effort to speed up this process causes administrative delays and slow down the processing of your appeal.

Please keep in mind the 60 day turnaround NGS has to process your appeal. We appreciate your patience as we work diligently to process your Redeterminations.

To appeal determinations resulting from minor errors, you should use the reopening process.
For denials resulting from more complex issues, you must use a redetermination and the full appeals process.

Reopening Versus Redetermination

Reopenings

Mathematical or computational mistake
Transposed procedure or diagnostic codes
Inaccurate data entry
Computer errors
Incorrect data items

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Redetermination

Coverage of furnished items and service
The medical necessity of the services
A determination with respect to the limitation of liability provision
Determinations from prepay and/or postpay probe reviews
CERT and/or RAC denials

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Understanding your next steps are very important for quick reimbursement. The Reopening Versus Redetermination article will help you determine if you should submit a reopening or a redetermination

Ambulance Documentation for Appeals: Necessary Information

NGS has seen in an increase in redetermination requests for ambulance claims in which the correct documentation is not being submitted. This leads to the Appeal not being successful and will cause providers to have to go to the next level of appeal which can cost more time and money for you.

The problems that NGS has seen relates to the documentation not being specific enough regarding the transport. In many cases, the reason for the transfer is not included in the documentation. Once a claim goes to the Appeal process the documentation must be supported to show the medical necessity and reasonableness of the transport. NGS must know why the patient was being transported, what medical need caused the transport, where they were coming from and being transported to, as well as why they could not have traveled by any other means. Also, included within the documentation, providers must also make sure that if they are transporting to/from a hospital that the complete name of the hospital is indicated. Many redetermination requests have included acronyms for the name of the hospital. We cannot make an assumption on which hospital was involved; therefore, acronyms are not appropriate for the transport record.

Please share your thoughts about your experience with our redetermination process.