We Can Now Accept Electronic Appeal Requests Using the X12 275 Version 6020 Transaction

National Government Services will now allow Medicare Part A and Part B providers to submit their claim appeal requests, including medical record documentation, through electronic transactions rather than a paper appeal form.

The purpose of the appeals process is to ensure the correct adjudication of previously processed claims. The appeal can take the form of a reopening - a reprocessing of a claim to fix minor mistakes, or a redetermination - an examination of a claim that includes analysis of documentation. To learn more about the appeals process visit About Appeals on our website.

Providers can now use the 275 electronic transaction to request a first level appeal which may include additional documentation. When a provider is requesting an appeal using the 275 transaction it is required to include:

The value of 15 in BGN01
The request for the appeal using:
- Completed Level 1 Redetermination Request Form
  - Part A Redetermination Request Form
  - Part B Redetermination Request Form

Letter that includes the following:
- Beneficiary name
- Medicare number/MBI
- Specific service/items for which the appeal is being requested
- Specific dates of service
- Name of the party or representative of the party (the provider)

Providers already enrolled to send the 275 transaction as unsolicited documentation to support the claim or as a solicited response to a request for documentation, will NOT have to enroll to send electronic appeals. The 275 enrollment includes sending documentation to support the claim and the first level appeal request.

We support up to ten separate documents sent in the 275 for one claim (up to ten iterations of the LX loop within each ST/SE).

For additional information on the 275 transaction see the NGS 275/HL7 Claim Attachment Companion guide located in the EDI Solutions section of our website.

Next Steps: You will need to contact your software vendor, system maintainer or clearinghouse to determine the process for your practice management/claim submission software.

We are excited to be able to offer this next level of automation to our provider community.

We Can Now Accept Electronic Appeal Requests Using the X12 275 Version 6020 Transaction

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