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Both Part A and Part B portal appeals begin by locating the claim in the portal using the Claim Inquiry function. Click the links below to jump to the step-by-step instructions for submitting:

• Part A appeals
• Part B appeals

Requesting a Part A Redetermination in the Portal

Before submitting a Part A appeal, review the following guidelines to ensure an appeal is available to you and is appropriate for your situation:

• Claims must be in a finalized location: PB9997, DB9997, RB9997, and MSP finalized locations with PB75XX.
• You must retrieve claims in an offline location (O9998) before you can submit an appeal. Offline retrieval takes a weekend cycle before the claim is online again.
• Appeals submitted beyond the timely filing limit (within 120 days of the initial determination) require an explanation for filing the appeal late. Please review the acceptable reasons for filing a late appeal before submitting one. 
  • NOTE: Appeals submitted after 4:30 PM CT (5:30 PM ET) are considered to be submitted the following business day.
• Timely appeals for reason codes 56900, 7RAC1, 5RACG, 5RACH, 5RACK, and 5RACL (claim or line level) will be forwarded to the Medical Review department to be complete as a claim reopening. (Submitting as an appeal first is the correct action.)
• You must bill all claim lines before submitting your appeal. You cannot add lines to a claim after it has been reviewed and adjusted due to on a medical review.
• If you have claim level denials that are also missing charges that need to be appealed, include corrected UB claim form and a clear statement of what is exactly being added within your appeal request details. The appeal statement should state what is being appealed and why, as well as provide the detail of what is being added.
• Claims or claim lines without an MR indicator that were denied due to missing information or incorrect billing can be adjusted instead of being appealed. (When available, it is to the provider’s benefit to adjust or resubmit a claim instead of appealing it.)
• If your claim was rejected (status location of RB9997) with an X in the tape-to-tape indicator, you can resubmit your claim. This should be considered when missing or incorrect billing caused the claim to reject. 

Part A Claim Situations That Cannot Be Appealed in the Portal

The following types of claims cannot be appealed through the WPS Government Health Administrators Portal or can only be appealed in limited situations:

• You cannot appeal a claim with a cancel date.
• Claims denied because they were not submitted timely (reason codes 39011 and 39012) cannot be appealed. If you meet CMS’ definition of “good cause” for filing a late claim, please work with the Claims department to have your claim processed.
• Claims denied for reason code 30801 can only be appealed to the MAC if they are an 11X bill type and related to the two-midnight rule. Any other bill type and reason must be appealed through the QIO (Quality Improvement Organization) that denied the claim.
• Claims or line level denials with reason codes 7SMR0, 7SMR1, 7SMR4, and 7SMR6 cannot be appealed to the MAC. You must complete your reopening request with the Supplemental Medical Review Contractor (SMRC) that denied the line/claim for records not being received.
• Claims with a status of T or S are not finalized claims and cannot be appealed.
  • If the claim is in status of T, make your corrections to the claim so it can continue processing. 
  • If the claim is in status of S, the MAC is working the edits internally and will continue processing the claim after working the edits.

Steps for Submitting a Part A Portal Appeal

Once you confirm an appeal is appropriate, follow the steps below to submit your Part A appeal: 

Step 1: Locate the claim you want to appeal and navigate to the Claim Actions section of the claim details. Click the Request Redetermination button to begin the appeal.

Step 2: Review the claim information to verify you are appealing the correct claim.

Step 3: Indicate whether you are appealing the entire claim or certain line items.

If you are appealing certain claim line items, place a check mark next to the lines you are appealing.

Step 4: Indicate why you disagree with Medicare’s initial claim determination. You can also provide additional information you want Medicare to consider when making the redetermination.

NOTE: If you are submitting your redetermination late (i.e., more than 120 days after the initial determination), the portal will alert you that your appeal is late. It will also provide an additional field where you can indicate your reason for filing a late appeal. You will only see this additional field if it has been more than 120 since the initial determination.

Step 5: Provide your contact information. Note that your name will be prepopulated from your portal account.

Step 6: Indicate whether you have documentation to submit with your appeal. It must be included with the redetermination request; you cannot submit it after you submit the request.

If you do have documentation to submit, click the Choose File button to upload it from your computer. The file size cannot exceed 100 MB (102,400 KB) for Part A appeals. The portal accepts the following document types:

• .docx
• .xlsx
• .pdf
• .jpg
• .jpeg
• .gif
• .tif
• .tiff
• .zip

If you have multiple documents to submit (up to 20 files), place them all in a single .zip file. Remember to disable all password protection, macros, and external links before submitting the documentation. 

Step 7: Review the disclosure statement and indicate if you agree to the terms. If you agree, click the Review button to have the portal check your appeal for missing items. You can click the Clear button to clear the information on the form or the Cancel button to exit the appeal without submitting it.

Step 8: Once portal reviews your appeal for missing items, click the Submit button to submit your redetermination, the Edit button to make changes, or the Cancel button to exit the request without submitting it. 

NOTE: You cannot make any changes to your appeal once you submit it.

Step 9: The portal will display a confirmation message along with a tracking number. You can print the information for your records or close the window. 

Once we complete our redetermination, the portal will be able to provide the appeal decision, but we will continue to mail your appeal decision letter.

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Requesting a Part B Redetermination in the Portal

The process for submitting a Part B redetermination is very similar to the Part A process of appealing a claim. 

• The claim must be finalized to request a redetermination. If a claim is approved to pay, but not yet finalized, you must wait until Medicare issues a remittance advice (i.e., the Claim Search shows a Check/EFT Number other than 000000000) to appeal any lines of service on the claim.
• If a claim is denied because requested documentation was not returned, Medicare may forward the documentation to the appropriate department for handling. Medicare will reopen the claim instead of processing a redetermination.
• You cannot appeal an unprocessable (rejected) claim. (Submit a new claim instead.)
• You cannot appeal a claim determination if you do not accept assignment on the claim.
• Claims that are W status or have been denied with EDIT 119D will either be rejected by the portal or dismissed when the appeal is worked. See How to Appeal a Claim Determination for more information on unprocessable (rejected) claims.

Steps for Submitting a Part B Portal Appeal

Step 1: Locate the claim you want to appeal and navigate to the Claim Actions section. Click the Request Redetermination button to begin the appeal.

Step 2: Review the claim information to verify you are appealing the correct claim.

Step 3: Indicate if you are appealing an overpayment decision. Section 935 of the Medicare Modernization Act (MMA) requires Medicare contractors to halt overpayment recoupment if the provider appeals the decision. Clicking Yes notifies Medicare to pause pending collection activities until the redetermination is complete.

Step 4: Select the lines of service you are appealing. The procedure codes are listed in the order they appear on your remittance advice. If your claim has repeated procedure codes, confirm you are appealing the correct lines of service.

Step 5: Indicate why you disagree with Medicare’s initial claim determination. You can also provide additional information you want Medicare to consider when making the redetermination, such as your reasons for filing a late redetermination request.

Step 6: Provide your contact information. Note that your name will be prepopulated from your portal account.

Step 7: Indicate whether you have documentation to submit with your appeal. It must be included with the redetermination request; you cannot submit it after you submit the request.

 
If you do have documentation to submit, click the Choose File button to upload it from your computer. The file size cannot exceed 100 MB (102,400 KB) for Part B redeterminations. The portal accepts the following document types:

• .docx
• .xlsx
• .pdf
• .jpg
• .jpeg
• .gif
• .tif
• .tiff
• .zip

If you have multiple documents to submit (up to 20 files), place them all in a single .zip file. Remember to disable all password protection, macros, and external links before submitting the documentation.

 
Step 8: Review the disclosure statement and indicate if you agree to the terms. If you agree, click the Review button to have the portal check your request for missing items. You can click the Clear button to clear the information on the form or the Cancel button to exit the appeal without submitting it.

 
Step 9: Once portal reviews your appeal for missing items, click the Submit button to submit your redetermination, the Edit button to make changes, or the Cancel button to exit the request without submitting it. 

NOTE: You cannot make any changes to your appeal once you submit it.

Step 10: The portal will display a confirmation message along with a tracking number. You can print the information for your records or close the window. 

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