Appeals Decision Tree - Can My Claim be Appealed?

Q0

My claim has denied. Can it be appealed?

Is your claim in a finalized status of D BXXX7, R BXXX7, or P BXXX7?

   
DE Q0N

Please wait until the claim is in a finalized status of D BXXX7, R BXXX7, or P BXXX7 before submitting a redetermination request.

If you are unsure about the location of your claim please review the remittance advice. Any further questions, please contact the IVR for claim information.

Q1 Q0Y

Do you want to appeal the Medicare decision?

   
DE Q1N

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

Q2 Q1Y

Is the line you are trying to appeal rejected with one of the following reason codes: W7020, W7021, W7039, or W7040?

   
DE Q2Y

This line is not appealable. Please correct coding and resubmit claim.

Q3 Q2N

Does this claim relate to issues involving Medicare Secondary Payer?

   
DE Q3Y

Please see MSP for further information.

Q4 Q3N

Has a redetermination decision been issued for this claim?

   
DE Q4Y

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

Q5 Q4N

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

   
DE Q5N

This claim does not have appeal rights unless good cause can be shown for late file. More information on Good Cause for late filing can be found in the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240.

Q6 Q5Y

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

   
DE Q6Y

Include a completed Appointment of Representative (AOR).

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

DE Q6N

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

 

Last Updated Tue, 19 Jul 2022 15:16:25 +0000