Appeals <7>

When the Appeals option is selected, the IVR will request and collect the following elements:

Provider authentication elements:

• NPI
• PTAN
• TIN
  • Note: If NPI, PTAN, TIN was already provided for another option on the same call, you will not be prompted for this information again.

Beneficiary authentication elements:

• HICN or MBI
  • Refer to the Phonetic Alphabet for assistance with speaking alpha characters
• Beneficiary name
• Beneficiary date of birth
  • Note: If the beneficiary’s HICN or MBI, name and date of birth were already provided from a previous transaction, the system will not prompt you to repeat this information.

Claim information:

• Claim number for which the Appeal was submitted for.
• CCN (optional)
  • Note: If you do not have the CCN for your appeal, simply say “I don’t know it.”

Once the authentication elements have been verified, the IVR will supply the following:

• CCN
• Date appeal request was received
• Status of appeal: The description in bold will be played back for appeals in a final or pending status, the description that follows will not be read on the IVR but is provided for additional clarification:
  • Final
    • Additional Payment – Redetermination: This message indicates your Appeal was favorable and will result in an additional payment being made.
    • Affirmation and/or Overpayment: This message indicates your Appeal was unfavorable and a refund for the previously made payment should be sent to Medicare.
    • Additional Payment – Reopening: This message indicates your Appeal was favorable and will result in an additional payment being made.
    • Dismissal due to timeliness or incomplete: This message indicates your Appeal was dismissed due to being outside of the 120-day appeals timeframe or due to being incomplete. Your dismissal letter will provide additional information.
    • Dismissal by Appeals – For additional information, please contact the Provider Contact Center: This message indicates your Appeal was dismissed. There can be many factors, please contact us or review your dismissal letter for additional information.
    • History Correction – Reopening: This message indicates a favorable outcome on your appeal, however no additional payment was made.
    • Overpayment – Reopening:  This message indicates your Appeal was unfavorable and a refund for the previously made payment should be sent to Medicare.
    • Delete – For additional information, please contact the Provider Contact Center: This message indicates your Appeal was deleted. There can be many factors that would result in your Appeal being deleted, please contact us for additional information.
  • Pending
    • Pending: Review can take up to 60 days to complete.
  • Appeals resolution date: This date represents the date the case was closed. A date will only be played back for cases in a Final status.
  • Claim number
  • Adjustment claim number: Will only be played back if your appeal results in an adjusted claim.

Appeals Navigation