Appeals Decision Tree

Is this a minor clerical error or omission?

   

The Reopening process allows suppliers to correct clerical errors or omissions without having to request a formal appeal. A reopening request can be initiated online via the Noridian Medicare Portal (NMP), telephone, or in writing.

Do you want to appeal the Medicare decision?

   

Are you a proper party to the initial determination?
(A person and/or entity normally understood to have standing to appeal an initial determination and/or a subsequent administrative appeal determination or decision such as assigned providers, beneficiaries, or billing clerks acting on behalf of the assigned provider etc.).

   

No appeal is necessary if you agree with the initial claim determination.

Is the line you are trying to appeal rejected with reason code MA130?

   

Are you an appointed representative appealing on behalf of the provider or beneficiary?

   

Include a completed Appointment of Representative (AOR).

Is the line you are trying to appeal rejected with one of the following reason codes MA130 or N704?

   

This claim is not appealable.

This line is not appealable. Correct the coding and resubmit claim.

Does this claim relate to issues involving Medicare Secondary Payer?

   

See MSP for further information.

Has a redetermination decision been issued for this claim?

Do not submit multiple submissions. Noridian utilizes the date from the initial submission to determine if the claim has been filed timely. More than one submission for the same claim will not grant more days to file.

   

A redetermination has already been completed on this claim. A reconsideration is the next step in the appeal process.

Does this claim meet the 120-day timeliness guidelines to appeal? The Appeals Timeliness Calculator can assist in determining timeliness.

   

This claim is appealable. Submit your appeal request though the Noridian Medicare Portal or on a redetermination request form.

This claim does not have appeal rights unless good cause can be shown to waive the late file.

 

Last Updated Feb 08, 2018