How to Avoid Common Appeals Mistakes Appeals Newsletter Part 13

The Appeals team has seen an increase in two common mistakes that we would like to help your office avoid.

  1. Adding lines that were not submitted on the original claim through an appeal
    • If your office forgot to bill a claim line (procedure code), a new claim needs to be submitted. This cannot be added in reopenings or redeterminations.
    • Whether paper or electronic form is used, make sure that the appeal provides specific details in the comment section.
  2. Timeliness for appeal levels
    There is very little room for waiving late file on an appeal. There needs to be good cause shown as the reason the appeal couldn’t be submitted in the 120 days allowed. Some of those good cause reasons include:
    • Provider recoupment
    • Natural disaster
    • Administrative delay by the contractor
    • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources

Use the timely filing tool to determine the last day for Noridian to receive your appeal. This page has timeliness calculators for all stages through the Administrative Law Judge (ALJ) Hearing level.

Resource: CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 310.2

Last Updated Oct 16 , 2024