Article Detail - JF Part B

Make sure your staff is aware of the time frames, and which appeal should be submitted:

Timely Filing calculator - See first link below

Submitting a Reopening, instead of a Redetermination, could cause you to miss timely filing

Not an Appeal

• Reopening - 365 days from initial determination date

Appeal Levels

• Redetermination - 120 days from initial determination
• Reconsideration - 180 days from Redetermination date
• Administrative Law Judge - 60 days from Reconsideration receipt date
• Medicare Appeals Council Review - 60 days from ALJ hearing decision receipt
• Federal Court Review - 60 days from receipt of Medicare Appeals Council Review

Example: 

• You send a Reconsideration 130 days after your remit date on a group of 20 claims for $10.000 each. 
• A list is generated monthly and sent to Noridian for providers that send Reconsideration, instead of Redetermination. 
• Then we send out education to everyone on the list (potentially 160 days past remit date now).
• On Day 170 you try to submit a Redetermination, but you are past timely filing. 
• Your appeal is denied.  There is NO late forgiveness for appeals.
• You have now lost $200,000.00

Submitting a reopening leaves your level of appeals open but always keep track of your timely filing dates

Appeals have shorter times allowed than Reopening

*Initial Determination Date - The date your claim processed the first time

• Noridian Medicare JF Part B Timeliness Calculators
• CMS Internet Only Manual (IOM) Publication 100-04 Chapter 29 Appeals of Claim Decisions ???????
• CMS Internet Only Manual (IOM) Publiaction 100-04 Chapter 34 Reopening and Revision of Claim Determinatios and Decisions