Appeals Decision Correspondence - JF Part A
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 Dec 09 , 2023
