The following suggestions will help support the appeal process by clearly identifying what is being requested for review. When instructions are unclear or all lines are selected, it becomes difficult to determine the specific request.

Paper/Electronic submission

• List the HCPCS/Procedure codes you are appealing
• Paid lines should only be listed if appealing the paid amount
• Clearly state what you are requesting in the comment section
• Provide complete contact information
• Verify documentation is attached and for the correct beneficiary

Portal submission

• Only select the lines you are appealing
• Paid lines should only be selected if appealing the paid amount
• Clearly state what you are requesting in the comment section
• Verify documentation is attached and for the correct beneficiary