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The purpose of the appeals process is to ensure the correct adjudication of claims. Physicians, suppliers, and beneficiaries have the right to appeal claim determinations made by MACs.
The beneficiary or their representative may request an appeal on any service processed for them. Providers and Suppliers may appeal services for which they accepted assignment. For unassigned claims, providers/suppliers may act as the beneficiary's representative if the beneficiary signs an authorization statement (such as the CMS-1696 Appointment of Representative). In addition, providers/suppliers may request a redetermination on an unassigned claim if Medicare denied the service as not reasonable and necessary or the provider/supplier billed in excess of the Limiting Charge and the provider/supplier must refund any fees collected from the beneficiary.
Deadlines
The Medicare Summary Notice (MSN) and Provider Remittance Advice specify the date by which a beneficiary, provider, or supplier must file an appeal of a denied claim to the contractor. You can also use our Redetermination Calculator to find the deadline for submitting a redetermination request.
Levels of Appeal
There are five levels of appeals. Time limits and monetary thresholds for filing vary for each level. As a MAC, WPS Government Health Administrators handles the first level, redetermination requests.
| Redetermination |
120 days from the date of receipt of the notice of initial determination |
None |
| Reconsideration |
180 days from the date of receipt of the redetermination. NOTE: If a party requests QIC review of a contractor's dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor's dismissal notice. |
None |
| Administrative Law Judge (ALJ) Hearing |
60 days from the date of receipt of the reconsideration |
Current AIC requirements can be found on the CMS website. |
| Departmental Appeals Board (DAB) Review/Appeals Council |
60 days from the date of receipt of the ALJ hearing decision |
None |
| Federal Court Review |
60 days from date of receipt of the Appeals Council decision |
Current AIC requirements can be found on the CMS website. |
Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 1 
, Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."
How to Submit Your Redetermination Request
- WPS Government Health Administrators Portal
- Written Request
How to Submit Your Redetermination Request via the WPS Government Health Administrators Portal
To submit a redetermination request, you must use a specific claim. Once logged in, use the claim inquiry link to find the claim. After identifying the claim number to view the claim details, you will find additional actions listed under Claim Actions. Choose Request Redetermination to begin the submittal process.
You can find more specific information on how to submit a redetermination request using this method and common errors and limitations in the WPS Government Health Administrators Portal User Manual.
How to Submit Your Redetermination Request in Writing
Providers and beneficiaries can use the Redetermination Request form to express disagreement with the initial claim determination. Mail the form to the address included on the form.
If you choose not to use the form, we can process your request without further delay if you include the following information in your request:
- Beneficiary name
- Medicare ID
- Name and address of provider of service
- Date(s) of service for which the initial determination was issued (you must report dates in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and a signature of the party or representative of the party
In addition, we highly recommend you include the provider facility phone number and submit your request on the provider’s letterhead.
Note: We will only accept properly secured CD (compact disc) records if they are in addition to a hardcopy appeal request. We will not accept appeal requests submitted via CD only, even if properly secured.
Note: Providers should be aware, 1) A QIO notification is not a demand letter and 2) Providers can appeal once they receive the initial demand letter that was released due to the QIO notification.
Documentation Requirements
Providers are responsible for providing all information required to adjudicate the claim(s) at issue. We will not request additional documentation for provider initiated redetermination requests.
The provider should submit documentation related to the initial denial reason. You do not need to resubmit previously submitted documentation. This includes documentation submitted to the initial medical review contractor (Recovery Auditor (RA), Medical Review, Zone Program Integrity Contractor (ZPIC), Supplemental Medical Review Contractor (SMRC), or Comprehensive Error Rate Testing (CERT)). Documentation submitted for an appeal should include new information.
You must submit a corrected billing statement, in addition to the pertinent medical documentation, when submitting redetermination requests for Local Coverage Determination (LCD) denials.
For beneficiary initiated appeals, when necessary documentation has not been submitted, we will contact the provider via letter to request they submit the required documentation. If we do not receive the additional documentation within 14 calendar days, we will conduct the review based on the information in the file.
We encourage you to use electronic submission of medical documentation (ESMD). For information on ESMD see the CMS website.
Check the Status of Your Redetermination Request
Providers can use the WPS Government Health Administrators Portal to check the status of their redetermination request. Status information is normally available within 15 days of date we received your request. You can find more information about checking the status of a redetermination request in the WPS Government Health Administrators Portal User Manual.
Reconsideration (Second Level of Appeal)
If you disagree with the outcome of your redetermination, the next level of appeal is a reconsideration with the Qualified Independent Contractor (QIC). There is no minimum dollar amount required for requesting a reconsideration. In addition, you must submit the request for reconsideration on the Reconsideration Request Form and file the request within 180 days of the date of receipt of the notice of redetermination. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter. You can also access the Reconsideration Request Form from our website or submit your reconsideration request through the WPS Government Health Administrators Portal.
Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 1 , Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."
How to Submit Your Redetermination Request
- WPS Government Health Administrators Portal
- Written Request
How to Submit Your Redetermination Request via the WPS Government Health Administrators Portal
To submit a redetermination request, you must use a specific claim. Once logged in, use the claim inquiry link to find the claim. After identifying the claim number to view the claim details, you will find additional actions listed under Claim Actions. Choose Request Redetermination to begin the submittal process.
You can find more specific information on how to submit a redetermination request using this method and common errors and limitations in the WPS Government Health Administrators Portal User Manual.
How to Submit Your Redetermination Request in Writing
Providers and beneficiaries can use the Redetermination Request form to express disagreement with the initial claim determination. Mail the form to the address included on the form.
If you choose not to use the form, we can process your request without further delay if you include the following information in your request:
- Beneficiary name
- Medicare ID
- Name and address of provider of service
- Date(s) of service for which the initial determination was issued (you must report dates in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and a signature of the party or representative of the party
In addition, we highly recommend you include the provider facility phone number and submit your request on the provider’s letterhead.
Note: We will only accept properly secured CD (compact disc) records if they are in addition to a hardcopy appeal request. We will not accept appeal requests submitted via CD only, even if properly secured.
Note: Providers should be aware, 1) A QIO notification is not a demand letter and 2) Providers can appeal once they receive the initial demand letter that was released due to the QIO notification.
Documentation Requirements
Providers are responsible for providing all information required to adjudicate the claim(s) at issue. We will not request additional documentation for provider initiated redetermination requests.
The provider should submit documentation related to the initial denial reason. You do not need to resubmit previously submitted documentation. This includes documentation submitted to the initial medical review contractor (Recovery Auditor (RA), Medical Review, Zone Program Integrity Contractor (ZPIC), Supplemental Medical Review Contractor (SMRC), or Comprehensive Error Rate Testing (CERT)). Documentation submitted for an appeal should include new information.
You must submit a corrected billing statement, in addition to the pertinent medical documentation, when submitting redetermination requests for Local Coverage Determination (LCD) denials.
For beneficiary initiated appeals, when necessary documentation has not been submitted, we will contact the provider via letter to request they submit the required documentation. If we do not receive the additional documentation within 14 calendar days, we will conduct the review based on the information in the file.
We encourage you to use electronic submission of medical documentation (ESMD). For information on ESMD see the CMS website.
Check the Status of Your Redetermination Request
Providers can use the WPS Government Health Administrators Portal to check the status of their redetermination request. Status information is normally available within 15 days of date we received your request. You can find more information about checking the status of a redetermination request in the WPS Government Health Administrators Portal User Manual.
Reconsideration (Second Level of Appeal)
If you disagree with the outcome of your redetermination, the next level of appeal is a reconsideration with the Qualified Independent Contractor (QIC). There is no minimum dollar amount required for requesting a reconsideration. In addition, you must submit the request for reconsideration on the Reconsideration Request Form and file the request within 180 days of the date of receipt of the notice of redetermination. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter. You can also access the Reconsideration Request Form from our website or submit your reconsideration request through the WPS Government Health Administrators Portal.
Unprocessable Claim Rejections Do Not Have Appeal Rights
When Medicare rejects a claim for lack of information (unprocessable), the provider must submit a new claim with the additional information. We cannot perform a redetermination.
Unprocessable claims have a Remittance Advice Remark Code (RARC) of MA130. The RARC MA130 states, "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information." In addition to RARC MA130, the remittance advice will contain one or more additional messages detailing the specific reason for the rejection. You can find information about correcting unprocessable claims in our Rejected Claims Tool.
Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 1 , Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."
Bundled, Not Valid for Medicare Purposes, and Non-covered Services
Services with "B,” "I," or "N" status indicators on the Medicare Physician Fee Schedule database are always bundled, invalid for Medicare, or non-covered. The addition of a modifier with medical documentation will not enable Medicare to pay on an appeal. To pay, CMS would need to change the fee schedule indicator.
Likewise, adding a modifier and submitting notes for services with the NCCI indicator "0" for a particular code pair will not cause Medicare to reverse the initial determination. In this situation, CMS would need to revise the NCCI edit before Medicare could pay.
How to Submit Your Redetermination Request
- WPS Government Health Administrators Portal
- Fax
- Written Request
How to Submit Your Redetermination Request via the WPS Government Health Administrators Portal
To submit a redetermination request, you must use a specific claim. Once logged in, use the claim inquiry link to find the claim. After identifying the claim number to view the claim details, you will find additional actions listed under Claim Actions. Choose Request Redetermination to begin the submittal process.
You can find more specific information on how to submit a redetermination request using this method and common errors and limitations in the WPS Government Health Administrators Portal User Manual.
How to Submit Your Redetermination Request via Fax
WPS Government Health Administrators receives the fax request as an electronic image. The fax process eliminates possible delays caused by sorting and imaging of hard copy receipts. In addition, the fax confirmation generated by your fax machine provides you with confirmation that we received your request timely.
To submit redetermination requests by fax you must complete the Redetermination Request Form and use the appropriate fax cover sheet and fax number for your state.
To avoid potential problems with your redetermination request make sure you completely fill in each field on the form. Do not use highlight to indicate services you want us to review. We may return incomplete forms to the sender.
Please note:
- Each claim or Internal Control Number (ICN) requires a separate form. You can locate the ICN on your remittance notice.
- Submitting a fax form alone does not qualify as a valid redetermination request. The request must also include a Redetermination Request form.
How to Submit Your Redetermination Request in Writing
Providers and beneficiaries can use the Redetermination Request form to express disagreement with the initial claim determination. Mail the form to the address included on the form.
If you choose not to use the form, we can process your request without further delay if you include the following information in your request:
- Beneficiary name
- Medicare ID
- Date(s) of service for which the initial determination was issued (you must report dates in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and a signature of the party or representative of the party
Development of Requests for Provider/Supplier-Initiated Appeals
If we need additional documentation to process an appeal, the party submitting the appeal (i.e., the provider/supplier) should obtain and submit the documentation within the prescribed time period following notification of an initial determination.
Providers/suppliers and Medicaid State agencies (or the party authorized to act on behalf of the Medicaid State agency) are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. You may supply this documentation with the appeal request or at the request of the contractor. Failure to submit requested documentation in a timely manner may result in processing delays.
Tips for Submitting Documentation
WPS Government Health Administrators often receives extensive unnecessary documentation. Please be sure that we need all the documentation that you are including with your redetermination request. Many times, we receive 20 - 40 pages of documentation. Frequently, we do not need the information to process the redetermination.
If your claim denied for medical necessity, please review the denial to determine if:
- The claim denied based on the diagnosis. If there is a more appropriate code, provide that. Check the Local Coverage Determination (LCD) for covered diagnosis codes and required documentation.
- The frequency of the service
Please verify the documentation is for the date of service and the beneficiary on the denied claim.
When sending documentation, clearly indicate the section of the documentation that supports your opinion that Medicare should not have denied the claim. State this on the redetermination request form, in the section "I do not agree with the determination of my claim. My Reasons Are.”
Appeals for Glycated Hemoglobin A1C Tests, Procedure Code 83036
- When submitting appeals for A1C tests (83036) describe the patient's condition. Include documentation, such as the A1C test results, to support the medical necessity for providing this service more frequently than once every three months. National Coverage Decision (NCD) 190.21 provides the medical necessity criteria.
- Also, note that the Multi-Carrier System (MCS) begins the three-month count the day after the date of service billed. For example if the date of service is December 15, 2019, then count day one as December 16, 2019.
Providers who submit their redetermination request through the WPS Government Health Administrators Portal can also submit documentation to support their request through the portal. See “Appeal Submission” in the WPS Government Health Administrators Portal User Manual for instructions.
Check the Status of Your Redetermination Request
Providers can use the WPS Government Health Administrators Portal to check the status of their redetermination request, regardless of how they submitted the request. Status information is normally available within 15 days of date we received your request. You can find more information about checking the status of a redetermination request in the WPS Government Health Administrators Portal User Manual.
When your redetermination request is complete, we will issue an Appeal Decision which will include the following Important Information About Your Appeal Rights .
Reconsideration (Second Level of Appeal)
If you disagree with the outcome of your redetermination, the next level of appeal is a reconsideration with the Qualified Independent Contractor (QIC). There is no minimum dollar amount required for requesting a reconsideration. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter. You can also access the Reconsideration Request Form from our website.
Mail your reconsideration request to the QIC at the below address:
C2C Innovative Solutions, Inc. - QIC Part B North
P.O. Box 45208
Jacksonville, Florida 32232-5208
Unprocessable Claim Rejections Do Not Have Appeal Rights
When Medicare rejects a claim for lack of information (unprocessable), the provider must submit a new claim with the additional information. We cannot perform a redetermination.
Unprocessable claims have a Remittance Advice Remark Code (RARC) of MA130. The RARC MA130 states, "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information." In addition to RARC MA130, the remittance advice will contain one or more additional messages detailing the specific reason for the rejection. You can find information about correcting unprocessable claims in our Rejected Claims Tool.
Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights
CMS requires Medicare contractors to deny claims submitted after the timely filing limit. In addition, the CMS Internet-Only Manual (IOM), Publication 100-04, Chapter 1 , Section 70.4 states, "When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal."
Bundled, Not Valid for Medicare Purposes, and Non-covered Services
Services with "B,” "I," or "N" status indicators on the Medicare Physician Fee Schedule database are always bundled, invalid for Medicare, or non-covered. The addition of a modifier with medical documentation will not enable Medicare to pay on an appeal. To pay, CMS would need to change the fee schedule indicator.
Likewise, adding a modifier and submitting notes for services with the NCCI indicator "0" for a particular code pair will not cause Medicare to reverse the initial determination. In this situation, CMS would need to revise the NCCI edit before Medicare could pay.
How to Submit Your Redetermination Request
- WPS Government Health Administrators Portal
- Fax
- Written Request
How to Submit Your Redetermination Request via the WPS Government Health Administrators Portal
To submit a redetermination request, you must use a specific claim. Once logged in, use the claim inquiry link to find the claim. After identifying the claim number to view the claim details, you will find additional actions listed under Claim Actions. Choose Request Redetermination to begin the submittal process.
You can find more specific information on how to submit a redetermination request using this method and common errors and limitations in the WPS Government Health Administrators Portal User Manual.
How to Submit Your Redetermination Request via Fax
WPS Government Health Administrators receives the fax request as an electronic image. The fax process eliminates possible delays caused by sorting and imaging of hard copy receipts. In addition, the fax confirmation generated by your fax machine provides you with confirmation that we received your request timely.
To submit redetermination requests by fax you must complete the Redetermination Request Form and use the appropriate fax cover sheet and fax number for your state.
To avoid potential problems with your redetermination request make sure you completely fill in each field on the form. Do not use highlight to indicate services you want us to review. We may return incomplete forms to the sender.
Please note:
- Each claim or Internal Control Number (ICN) requires a separate form. You can locate the ICN on your remittance notice.
- Submitting a fax form alone does not qualify as a valid redetermination request. The request must also include a Redetermination Request form.
How to Submit Your Redetermination Request in Writing
Providers and beneficiaries can use the Redetermination Request form to express disagreement with the initial claim determination. Mail the form to the address included on the form.
If you choose not to use the form, we can process your request without further delay if you include the following information in your request:
- Beneficiary name
- Medicare ID
- Date(s) of service for which the initial determination was issued (you must report dates in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and a signature of the party or representative of the party
Development of Requests for Provider/Supplier-Initiated Appeals
If we need additional documentation to process an appeal, the party submitting the appeal (i.e., the provider/supplier) should obtain and submit the documentation within the prescribed time period following notification of an initial determination.
Providers/suppliers and Medicaid State agencies (or the party authorized to act on behalf of the Medicaid State agency) are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. You may supply this documentation with the appeal request or at the request of the contractor. Failure to submit requested documentation in a timely manner may result in processing delays.
Tips for Submitting Documentation
WPS Government Health Administrators often receives extensive unnecessary documentation. Please be sure that we need all the documentation that you are including with your redetermination request. Many times, we receive 20 - 40 pages of documentation. Frequently, we do not need the information to process the redetermination.
If your claim denied for medical necessity, please review the denial to determine if:
- The claim denied based on the diagnosis. If there is a more appropriate code, provide that. Check the Local Coverage Determination (LCD) for covered diagnosis codes and required documentation.
- The frequency of the service
Please verify the documentation is for the date of service and the beneficiary on the denied claim.
When sending documentation, clearly indicate the section of the documentation that supports your opinion that Medicare should not have denied the claim. State this on the redetermination request form, in the section "I do not agree with the determination of my claim. My Reasons Are.”
Appeals for Glycated Hemoglobin A1C Tests, Procedure Code 83036
- When submitting appeals for A1C tests (83036) describe the patient's condition. Include documentation, such as the A1C test results, to support the medical necessity for providing this service more frequently than once every three months. National Coverage Decision (NCD) 190.21 provides the medical necessity criteria.
- Also, note that the Multi-Carrier System (MCS) begins the three-month count the day after the date of service billed. For example if the date of service is December 15, 2019, then count day one as December 16, 2019.
Providers who submit their redetermination request through the WPS Government Health Administrators Portal can also submit documentation to support their request through the portal. See “Appeal Submission” in the WPS Government Health Administrators Portal User Manual for instructions.
Check the Status of Your Redetermination Request
Providers can use the WPS Government Health Administrators Portal to check the status of their redetermination request, regardless of how they submitted the request. Status information is normally available within 15 days of date we received your request. You can find more information about checking the status of a redetermination request in the WPS Government Health Administrators Portal User Manual.
When your redetermination request is complete, we will issue an Appeal Decision which will include the following Important Information About Your Appeal Rights .
Reconsideration (Second Level of Appeal)
If you disagree with the outcome of your redetermination, the next level of appeal is a reconsideration with the Qualified Independent Contractor (QIC). There is no minimum dollar amount required for requesting a reconsideration. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter. You can also access the Reconsideration Request Form from our website.
Mail your reconsideration request to the QIC at the below address:
C2C Innovative Solutions, Inc. - QIC Part B North
P.O. Box 45208
Jacksonville, Florida 32232-5208
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