Appeals Decision Correspondence

Decision Type of Correspondence
Full Reversal (Fully Favorable) A new Remittance Advice (RA) and payment is issued
Partial Reversal (Partially Favorable) A new RA and partial payment will be issued. A letter is sent detailing the adjustment and why additional services are not allowed
Affirmation (Unfavorable) A letter will be sent explaining why services are not allowed

 

Invalid Appeal Requests Treated as Inquiries

If the appeal request is found to be invalid, the below items will be handled as a written inquiry. A letter will be sent to the requestor.

  • Missing required element(s) from the appeal request, including:
    • Beneficiary Name
    • Beneficiary Medicare number
    • Dates of Service
    • HCPCs/Procedure Codes
    • Handwritten or digitized signature of requestor
  • Appealed code not found on claim
  • Line item is rejected and not denied
  • Claim is rejected with no appeal rights
  • Cancelled or Returned to Provider (RTP) claims
  • Already reviewed and initial determination provided
  • Missing Appointment of Representative form
  • Claim adjusted and fully paid before appeal is submitted
  • Received appeal before claim finalized
  • Adding charges or making changes that do not require an appeal request

 

Last Updated Apr 10, 2019