About Appeals
Providers 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 NGS are governed by CMS. The appeals process is completely independent of the medical review process.
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. 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, via either paper or NGSConnex in an effort to speed up this process causes administrative delays and slows down the processing of your appeal.
When submitting your appeal, please verify that you have included the documentation that Medical Review stated was missing and/or documentation that supports payment of the denied services.
Who Reviews an Appeal?
The first level of appeal is carried out by the affiliated contractor/Medicare Administrative Contractor.
- Time limit to initiate = 120 days from date of receipt of the initial determination notice
- Time limit to complete the review = 60 days
- Amount in controversy = no minimum amount
How Do I Submit an Appeal?
- NGSConnex is the safest, cheapest and fastest way to submit an appeal. You can learn more about NGSConnex with step-by-step instructions on submitting an appeal on using the NGSConnex User Guide, which can found on our website under Provider Resources, then click on NGSConnex and then the NGSConnex User Guide.
- If an appeal is mailed, complete and return the Level 1 Redetermination Form
Where Can I Find More Information About Appeals?
On our website, choose the CLAIMS & APPEALS tab, then choose About Appeals and you will find information about appeals such as:
- Who May File an Appeal
- Levels of Appeals and Time Limits for Filing
- Reopening’s for Minor Errors and Omissions
- What Documents are Needed
- Submitting an Appeal Electronically with NGSConnex
- Appeals Forms
Posted 3/22/2021