Appeals Redetermination Level Successful Submission

A provider must determine if they would need to appeal to get their claim paid. Is it paid correctly? If not, check your Remittance Advice before appealing. Know what the reductions are. If this is an MSP issue, utilize the website to send to the correct team. If you are replying to ADR, verify where the documentation should be sent.

A service can only be reviewed once. If proper documentation was not submitted the first time you must go to the next level of appeal, reconsideration, and submit your documentation at that time. Noridian does not reopen decisions when a second appeal is submitted with documentation, and you are risking your timeliness to submit your next level of appeal.

Duplicate appeal submissions slow down the processing of appeals overall. Noridian has 60 days to complete an appeal from the date it is received. If it has not been 60 days, utilize the portal to check the status of your appeal. Do not submit another appeal stating you filed an appeal. The NMP can be used to make sure your appeal was received, duplicate submission by different methods is unacceptable.

If you are appealing, include all the documentation needed to do a review of the code and denial and be clear about what you would like reviewed.

Noridian’s website has a timeliness calculator for determining your timeline for an appeal. If you are filing after 120 days, you must include good cause to avoid an appeal dismissal.

Noridian needs your help in reducing the number of duplicate appeals submitted to Noridian.

  • The Appeals team dismisses hundreds of unnecessary appeals daily
    • Correct documentation not provided
    • Appealing duplicate denials instead of reopening with a correction
  • Clear reason for the appeal not provided
    • Documentation to support your appeal
  • Wrong form being submitted
  • Multiple submissions of the same appeal
  • Appeals to pay higher than the Medicare Fee Schedules
  • Diagnosis pointer goes to the wrong diagnosis code

How can the provider help?

  • Make sure you are aware of what, and how many, your billing service is appealing
  • Complete the Action Request and Comments (paper), or Details and Explanation on the portal form, with what or why you are appealing
  • Check to see if your issue is something that can be done through a reopening
  • Verify your diagnosis pointer in Box 24E, or the electronic equivalent, refers to the correct primary diagnosis code in Box 21
    • Review NCD or LCD for medically necessary diagnosis codes

Noridian Medicare Redetermination/Reopening Form

            Last Updated Tue, 15 Nov 2022 18:33:23 +0000