Common Definitions for Claim Submission Types
Appeals
An appeal is an independent review of the initial or revised determination. Proceeding with an appeal is the responsibility of the provider. Overall there are five levels of appeal the first being a redetermination. For more information see the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29.
Postpayment Review
After receiving payment for rendered service(s), providers may be asked to submit supporting documentation for postpayment review. This may result in recoupment or adjustment of payment. For more information see CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.5.
Prepayment Review
Once a service has been rendered, providers under prepayment review will submit documentation for review before receiving payment. This will result in an initial determination. For more information see CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.
Prior Authorization
To receive prior authorization, the provider must submit documentation for approval of a proposed service before it’s rendered. Failure to comply will result in non-affirmation of the service. Once a service has been performed, existing claim review processes and responses as summarized in this document would apply. For more information see CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.10.
Reopenings
Reopenings are separate and distinct from the appeals process and at the discretion of the MAC. MACs may revise an initial determination. Examples include clerical errors or omissions. If a provider submits a request for a reopening, it will not impact or alter the timeframe for an appeal. For more information see CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 34.
Reopening for No Response Denials
A reopening will be performed on a claim that denied for no response, meaning no documentation was returned upon MAC request. The decision rendered on a reopening for no response will be the initial determination. For more information see CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.9
Posted 11/6/2023