MEDICARE A CMS Medicare Administrative Contractor http://www.NGSMedicare.com Jurisdiction B Supplier Manual: Chapter 20 September 2014 Update Reopenings and Appeals Overview of the Appeals Process If there is disagreement with a decision, a person or entity with a right to may request an appeal. An appeal is a review performed by people independent of those who have reviewed the claim so far. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeal activities conducted by Medicare contractors are governed by CMS. Who May File an Appeal An appeal request must be submitted by someone who is considered a party to the appeal. The appeal will be dismissed if the person requesting is not a proper party. Any of the following are considered proper parties to an appeal: • • • • • • • A beneficiary or a beneficiary’s legal representative; A participating supplier; A nonparticipating supplier accepting assignment for a specific item or service; A nonparticipating supplier of DMEPOS potentially responsible for refunding a beneficiary under Section 1834(a)(18) of the Social Security Act; A DMEPOS supplier who does not accept assignment and is responsible for refunding a beneficiary under Section 1834(j)(4) of the Social Security Act; A Medicaid state agency or party authorized to act on behalf of the state; or Any individual whose rights may be affected by the claim being reviewed Appointment of Representative A beneficiary or supplier can appoint any individual to act as his/her representative in requesting an appeal. A representative may be appointed at any time in the appeals process. The appointment of representative is valid for one year from either of the following: • • The date signed by the beneficiary or supplier making the appointment, or The date the appointment is accepted by the representative, whichever is later The appointment can be made by completing an appointment of representative form; however, an appointment of representative form is not necessary. A written statement containing all the required elements is also acceptable as a valid appointment of representative. The required elements for a written statement are: • • • • • Name, address, phone number of the beneficiary or supplier; Medicare HICN if the party is the beneficiary; Medicare supplier number if the party is the supplier; Name, address, phone number of the individual being appointed as representative; A statement that the party (beneficiary or supplier) is authorizing the representative to act on their behalf for the claims at issue and a statement authorizing disclosure of individually identifiable information to the representative; 132_0314 Supplier Manual Update • • Signature of the party (beneficiary or supplier) making the appointment and the date signed; Signature of the individual being appointed as representative, accompanied by a statement that they accept the appointment and the date signed; A supplier that furnished services to a beneficiary may represent them on their claim or appeal involving those services. However the supplier may not charge the beneficiary a fee for representation. Further, the supplier being appointed as representative may acknowledge that they will not charge the beneficiary a fee for such representation. The supplier does this by including a statement to this effect on the form or written statement, and signs and dates it. Related Content • • • Appeals Timeliness Calculator CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 29 CMS-1696 Appointment of Representative Form Levels of Appeals and Time Limits for Filing Appeal The Medicare law consists of five possible appeal levels. The appellant must begin at the first level upon receipt of an initial determination. Each level of appeal, after the initial determination, has procedural steps that must be taken before the appeal can move to the next level. The following table summarizes the types of appeal, the order in which appeals must occur, and the filing requirements for each. Type of Appeals Redetermination Level One Reconsideration (QIC) Level Two ALJ Level Three MAC Level Four Federal Court Review Level Five Time Limit for Filing Appeal 120 days from date of receipt of the initial determination notice No minimum (none) 180 days from date of receipt of the redetermination decision No minimum (none) 60 days from the date of receipt of the reconsideration (QIC decision) For requests filed on or before December 31, 2013, at least $140 remains in controversy. 60 days from date of receipt of the ALJ decision 60 days from date of receipt of the MAC decision No minimum (none) For requests filed on or before December 31, 2013, at least $1,400 remains in controversy. Amount in Controversy (monetary threshold to be met) For requests filed on or after 01/01/2014, at least $140 remains in controversy For requests filed on or after 01/01/2014, at least $1,430 remains in controversy Redeterminations—The First Level of Appeal The first level in the appeal process is referred to as a redetermination. A party dissatisfied with an initial claim determination may request a redetermination. A redetermination is a new, independent, and critical examination of a claim. It is conducted by reexamining the information in the file and any additional documentation submitted with the request, by someone who did not participate in the original decision. The denial on a duplicate claim submission is not a denial of service. There are no appeal rights on the duplicate claim submission. Appeal requests on duplicate claim denials will be treated as inquiries – not as appeals. You must request an appeal on the original claim denial (i.e., the first claim submitted). Time Limit for Filing a Redetermination The redetermination must be requested within 120 days of the initial determination date. The initial determination date is the date on the Medicare Remittance Notice or the beneficiary’s MSN. When the filing deadline for a redetermination ends on a Saturday, Sunday, legal holiday or any other nonwork day, the contractor shall apply a National Government Services, Inc. Page 2 of 12 rollover period that extends the filing deadline to the first working day after the Saturday, Sunday, legal holiday or other nonwork day. Good Cause The time limit for filing a request for redetermination may be extended in certain situations. Generally, you are expected to file appeal requests on a timely basis. A request from a supplier to extend the period for filing the request for redetermination will not be routinely granted and such requests warrant careful examination. If an appeal request is filed late, the time limit for late filing may be extended if good cause is shown. If good cause exists for late filing of the redetermination request, this does not mean that the party is then excused from the timely filing rules for the reconsideration. Good cause may be found when the record clearly shows, or the supplier alleges and the record does not negate, that the delay in filing was due to one of the following: • • Incorrect or incomplete information about the subject claim and/or appeal was furnished by official sources (CMS, the contractor, or the Social Security Administration) to the supplier; or Unavoidable circumstances that prevented the supplier from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the supplier’s control, such as major floods, fires, tornados and other natural catastrophes. Note: Failure of a billing company or other consultant (that the supplier has retained) to timely submit appeals or other information is not grounds for finding good cause for late filing. The contractor does not find good cause where the supplier claims that lack of business office management skills or expertise caused the late filing. Filing a Redetermination Request A request for redetermination must be filed with the contractor in writing. The supplier may submit a fully completed Medicare DME Redetermination Request Form when requesting a redetermination. If this form is not used, the request must contain at a minimum all of the following information. • • • • • Beneficiary’s name; Medicare HICN; The specific service(s) and/or item(s) for which the redetermination is being requested; The specific date(s) of the service; and The name and signature of the party or the representative of the party requesting the redetermination. Incomplete requests will be dismissed with an explanation of the missing information. You will be instructed to resubmit the request with all of the missing information. Incomplete requests that are resubmitted for appeal must be submitted within the 120 day timely filing limit. Incomplete requests that are resubmitted past the 120 day timely filing limit will be dismissed. When filing an appeal, a separate request is not required for each procedure code on the claim. All requests for a specific beneficiary or claim number can be combined on one request. Submission Methods for Redeterminations Requests for Redetermination via Secure Internet Portal (NGSConnex) You may submit redetermination requests via NGSConnex, a secure Internet portal. You must register to use NGSConnex; however, access to NGSConnex is free and only requires users to have the Internet and an email address. To sign-up for NGSConnex, go to the NGSConnex application. Faxed Requests for Redetermination Faxed requests will be accepted Monday through Friday during the hours of 8:00 a.m.–4:00 p.m. ET, any request received after 4:00 p.m. or on a Saturday, Sunday, federal nonworkday, or legal holiday will be counted in the next business day’s workload. Suppliers should complete the Medicare DME Redetermination Request Form. National Government Services, Inc. Page 3 of 12 Fax the redetermination request to 317-595-4737. Reminders: • • • • • You should not fax a request for redetermination if the request was previously submitted (via fax, mail or NGSConnex) You should not fax routine correspondence Requests should be separated and transmitted with a separate fax cover based on the following: o The type of request (reopening or redetermination). The request must clearly identify whether it is a redetermination or reopening request. o Different supplier number (PTAN, NPI) o Different reason for request o Different type of equipment/supply Include only one reopening/redetermination request per fax transmission. Do not include multiple redetermination or reopening requests under one fax cover. If documentation is submitted with a single request affecting multiple beneficiaries, the documentation should be in the same order as the listing of the beneficiaries. Mailed Requests for Redetermination Suppliers should complete the Medicare DME Redetermination Request Form. Submit redetermination requests to the following address: National Government Services, Inc. Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036 Checking the Status of a Redetermination Request Suppliers who submit redetermination to National Government Services can use one of the following self-service tools to obtain the status of their requests: • • The NGSConnex Web application The IVR system These self-service tools provide you with the status of your reopening or redetermination requests (first level of appeal only). NGSConnex NGSConnex displays the status of a redetermination request in both a pending or finalized status and includes all redetermination requests regardless of how they were originally initiated, (i.e., written, fax, telephone, or Connex). To check the status of a redetermination via NGSConnex follow the steps below: • • • Select the My Claims. Enter the following data elements: o Beneficiary Medicare number o Beneficiary last name o Beneficiary first name (minimum first initial) o Beneficiary date of birth (MM/DD/YYYY) o Claim control number (CCN) or o Document control number (DCN) Select Load Redetermination/Reopening Status. NGSConnex will search for any redetermination that has been received for the CCN or DCN entered, and display the status of the redetermination found, if a match is found. When the redetermination has been completed, the National Government Services, Inc. Page 4 of 12 system will display a ‘finalized’ status and provide a ‘status’ description. When the review is still being conducted the status will display as ‘pending’. The redetermination can take up to 60 days to complete. IVR System To check the status of an appeal (i.e., redetermination/reopening) follow these steps: • • • Select Option 4 of the IVR Enter the following data elements: o NPI o PTAN (ten-digit supplier number) o Last five digits of the TIN o Beneficiary Medicare number o Beneficiary first and last name (last name and first initial if using touch-tone) o Beneficiary date of birth o CCN Once the authentication elements have been verified, the IVR will supply the following, if applicable: o DCN o All associated CCNs o Appeal status o Received date o Dates of service o Appeal decision Redetermination Decision The contractor must complete and mail a redetermination notice for all requests for redetermination within 60 days of receipt of the request. For unfavorable redeterminations, the contractor mails the decision letter to the appellant, and mails copies to each party to the initial determination (or the party’s authorized representative and/or appointed representative, if applicable). For partially favorable redeterminations, the contractor mails and/or otherwise transmits the decision letter, and an adjusted MSN or RA to the appellant. For fully favorable redeterminations, the contractor mails or otherwise transmits an MSN or RA reflecting the adjustment action to each party (or the party’s authorized representative, if applicable) on the next scheduled release. Note: Do not file a redetermination request if a previous redetermination decision has been issued. Instead, proceed to the second level of appeal, the reconsideration. Reconsideration—The Second Level of Appeal The second level in the appeals process is reconsideration. If a previous redetermination decision has been issued which resulted in an unfavorable decision for the supplier (i.e., the initial denial was upheld), a reconsideration request must be filed to the QIC if the supplier chooses to continue to pursue the appeal. There is no monetary threshold to be met when filing a reconsideration request to the QIC. The reconsideration is conducted by the QIC. A redetermination must be issued on the claim in dispute before requesting reconsideration. The reconsideration process provides a complete reexamination of the information contained in the redetermination case file. Any new information or medical evidence should be submitted with the request for reconsideration and prior to the reconsideration decision being issued. If all evidence is not submitted prior to the issuance of the reconsideration decision, the supplier will not be able to submit any new evidence to the ALJ for further appeal unless they can demonstrate good cause for withholding the evidence from the QIC. Time Limit for Filing a Reconsideration The reconsideration request must be requested within 180 days of receiving the redetermination decision letter. Submission Methods for Reconsiderations Mailed Requests for Reconsideration National Government Services, Inc. Page 5 of 12 You should complete the reconsideration request form included with the redetermination letter or complete the CMS-20033 Medicare Reconsideration Request form. However, it is not required that either one of these forms be used to submit the Reconsideration Request form. If neither form is used you may submit a written request containing all of the following information: • • • • • The beneficiary’s name; The beneficiary’s Medicare HICN; The specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service; The name and signature of the party, or representative of the party requesting the reconsideration; The name of the contractor that made the redetermination Submit reconsideration requests to the following address: C2C Solutions, Inc. Attn: DME QIC P.O. Box 44013 Jacksonville, FL 32231-4013 Reconsideration Decision If a supplier receives a favorable reconsideration decision from the QIC, they should receive a remittance advice within 60 days from the date of the reconsideration from the Jurisdiction B DME MAC. If the remittance advice is not received within 60 days, the supplier should contact the QIC and request to have them refax the decision to the Jurisdiction B DME MAC. Note: For questions about a reconsideration, you may contact C2C Solutions, Inc. – QIC DME at 904-224-7433. Administrative Law Judge Hearing—The Third Level of Appeal The third level in the appeals process is an ALJ hearing. If there is dissatisfaction with the reconsideration decision and the amount remaining in controversy meets the required threshold (may be an aggregate of multiple claims), the appellant is entitled to an in-person (which includes teleconference or video-teleconference) or an on the-record hearing before an ALJ. Time Limit for Filing an ALJ Hearing The ALJ Hearing request must be requested in writing within 60 days following the date of receipt of the reconsideration decision. Submission Methods for ALJ Hearing Mailed Requests for ALJ Hearings The ALJ hearing must be requested in writing by submitting the CMS-20034 A/B form located on the CMS website or by submitting a written request. The request must specifically state that an ALJ hearing is desired and the request must be signed. Send written requests for ALJ hearings to the office specified in the reconsideration determination. In most instances, the reconsideration will direct you to submit your written request to the Division of Centralized Docketing at the following address: HHS OMHA Centralized Docketing 200 Public Square, Suite 1260 Cleveland, OH 44114-2316 However, always defer to the address specified in the reconsideration or reconsideration determination. Failure to do so will delay the processing of the request. For complete details on the content required for a request for a hearing, refer to the federal regulations and the OMHA website. National Government Services, Inc. Page 6 of 12 ALJ Hearing Decision When the ALJ has rendered the decision, a copy of the decision letter will be sent to the appellant and the Administrative QIC. Favorable or partially favorable decisions will be adjusted for payment within 30 days of receiving the case file from the Administrative QIC office. Note: The DME MAC cannot effectuate payment, until the formal effectuation notice has been received from the Administrative QIC. Any questions regarding the status of a case must be directed to the OMHA Office at the address listed above or, you may contact the OMHA at 855-556-8475. Departmental Appeals Board Review – Appeals Council—The Fourth Level of Appeal The fourth level in the appeals process is the Appeals Council. This is the level of administrative review available to parties after the ALJ hearing decision or dismissal order has been issued, but before judicial review is available. Time Limit for Filing a Departmental Appeals Board Review – Appeals Council Review A party to the ALJ hearing may request review by the Appeals Council within 60 days after receipt of the notice of the ALJ’s hearing decision or dismissal. Note: There is no monetary threshold to be met when filing a departmental appeals board review. Federal Court Review—The Fifth Level of Appeal If an appellant is dissatisfied with the Departmental Appeals Board – Appeals Council decision, they may request a federal court review. The federal court review must be requested within 60 days from the date of receipt of the DAB decision or declination of review by the DAB. Note: Current amount in controversy requirements can be found on the CMS website. Documentation in the Appeals Process The following clarifications are designed to assist suppliers who wish to appeal original claim denials through the appeals process. Original claim denials are often upheld at the redetermination or reconsideration level of appeal due to the lack of documentation supporting the medical necessity of services rendered. Before requesting a redetermination or reconsideration, consult the JB Supplier Manual, supplier bulletins and all applicable medical policy and documentation guidelines for each piece of equipment/supply being appealed. Failure to include all appropriate documentation with the appeal may result in an unfavorable decision. The appellant has the responsibility to provide information and/or documentation for supplier submitted appeals. Decisions at these levels are based exclusively on the information and/or documentation submitted with the case. The following examples describe common denial situations presented through the appeals process. • Medical necessity of DMEPOS items. Medical necessity is established by copies of medical records that address the condition of the patient and how the item in question fits into the treatment plan of the patient. Depending on the item in question, some examples of documentation may include: o The diagnosis relating to the limitations and or relating to the need for the equipment/supply o Complicating medical conditions o Functional abilities (e.g., ability to ambulate or transfer, the distance that the patient can walk independently and/or with the assistance of a walker or other ambulatory aid, or abilities of the upper and lower extremities [including tone, range of motion limitations, etc.]) o Amount of time in bed, chair, or wheelchair o Frequency and type of activities outside the home o Functional limitation o Rehabilitation potential (including recent prior functional level) o Duration of the condition o Description of and response to prior treatment experience with other equipment prognosis National Government Services, Inc. Page 7 of 12 • • o Physical examination findings, test results, etc. o CMN or DIF if required Many suppliers create forms that are not approved by CMS which they send to physicians to complete. Even if the physician completes the supplier-generated form and puts it in the patient’s medical records, it is not a substitute for maintaining comprehensive medical records. Pursuant to Section 1833(e) of the Social Security Act, it is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other health care professionals, and test reports. Individual consideration pricing determinations. o If it is an item, the brand name and model name/number should be given and copies of the invoice and/or catalogue with prices should be included. o If it is a custom made item, include a detailed description and/or photograph. o If it is a service (e.g., repair, custom item), list the labor time, the major materials used, and their cost. In addition to the documentation types described above, copies of the doctor’s orders or narrative explanations by the supplier/physician may assist in clarifying the medical necessity of items/services provided. Handwritten documentation must be legible to be effective in the appeal process. Appealing an Overpayment If the supplier disagrees with an overpayment request, then an appeal request may be initiated through the first level of the appeals process, the redetermination. However, if the overpayment was initiated as a result of a redetermination, then the supplier must request a reconsideration to be conducted by the QIC which is the second level of the appeals process. When an overpayment demand letter is received by the supplier and the letter is requesting a refund, the supplier should immediately refund the amount requested and then file an appeal, if necessary. This will help the supplier avoid an offset with interest charges from accruing. The overpayment letter will have detailed instructions on how to file for an appeal. When possible suppliers should include a copy of the overpayment recovery letter when appealing a refund request. Related Content • • • • • • • • • • • • Appeals Timeliness Calculator C2C Solutions, QIC Website Fifth Level of Appeal: Judicial Review in Federal District Court, Amount in Controversy Medical Policy Center Medicare DME Redetermination Request Form Medicare DME Redetermination Request Form Completion Guide (565 KB) Medicare DME Reopening Request Form Medicare DME Reopening Request Form Checklist (571 KB) Medicare DME Reopening Request Form Completion Guide (571 KB) NGSConnex Website OMHA Website Request for Part B Medicare Hearing by an Administrative Law Judge (CMS-20034) Reopenings for Minor Errors and Omissions If a supplier has made a minor error or omission in filing the claim, which in turn causes the claim to be either denied or incorrectly paid, there is no need to request a redetermination. In the case where a minor error or omission is involved, the supplier can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. Suppliers must wait to submit a reopening request until a final claim determination has been made, and they have received their Medicare remittance notice. No action can be taken until a final claim determination is issued. National Government Services, Inc. Page 8 of 12 Examples of minor error or omissions include: • • • • • • • mathematical or computational mistakes; transposed procedure or diagnostic codes; inaccurate data entry, misapplication of a fee schedule; computer errors; or, denial of claims as duplicates which the party believes were incorrectly identified as a duplicate; incorrect data items, such as provider number, use of a modifier or date of service. Issues That Cannot Be Handled As A Reopening • • • • Untimely filing issues Claims returned as unprocessable cannot be corrected through reopenings. For example, a majority of the LCDs require suppliers to append either the KX, GA, GZ or GY modifier, and if one of these modifiers is omitted the claim line will be returned as unprocessable. The claim must be corrected and resubmitted. MSP issues Any claim denied as the result of an audit Note: You should consult the JB Supplier Manual and applicable medical policy guidelines before requesting a reopening. Failure to understand the reason for denial and Medicare requirements before submitting a reopening request may result in an unfavorable decision. Time Limit for Filing a Reopening for a Minor Error or Omission A party may request a contractor reopen and revise the initial claim determination or redetermination under the following conditions: • • • Within one year from the date of the initial determination or redetermination for any reason; or Within four years from the date of the initial determination or redetermination for good cause; or At any time if the initial determination is unfavorable, in whole or part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based. A third party payer error does not constitute a clerical error. Submission Methods for Reopenings for Minor Errors or Omissions Telephone Requests for Reopenings You must have the following information available before place the call for a telephone reopening: • • • • • • • • Supplier’s name NPI PTAN Last five digits of TIN Medicare CCN Beneficiary Name Beneficiary Medicare HICN Any additional information to support why the initial determination is not correct, and needs to be reopened. This includes having the correct procedure code(s), modifier(s), diagnosis, units of service, etc. The following issues cannot be handled by telephone reopenings: • • Interruptions in a period of continuous use issues (i.e., BIN or BIB) BIN issues, CMN/DIF issues or changes are not permitted. These types of requests usually require a supplier to submit copies of CMNs/DIFs, delivery and pick-up information and other documentation before a final determination can be made. Limitation on liability issues (inquiries regarding a missing GA, GY or GZ modifier) National Government Services, Inc. Page 9 of 12 • Inquiries on the status of a claim(s) Questions about the status of a claim or general Medicare payment and coding questions should not be directed through the telephone reopening line. Claim status and eligibility can be verified through NGSConnex, or the IVR. General payment and coding questions should be directed to the Jurisdiction B DME MAC Provider Contact Center. • • 866-590-6727: Provider contact center representatives are available Monday–Friday, 8:30 a.m.–5:30 p.m. ET 877-299-7900: IVR is available Monday–Friday, 7:00 a.m.–6:00 p.m. ET, and Saturdays 7:00 a.m.–3:00 p.m. ET All medical information provided to the DME MAC must be documented in the patient’s file and available upon request. Note: The DME MAC TRU is closed on Friday from 2:30 p.m.–4:00 p.m. ET for training purposes. Mailed Requests for Reopening You may submit a fully completed Medicare DME Request for Reopening Form when requesting a reopening. If the Medicare DME Request for Reopening form is not used, your request must contain the following information: • • • • The beneficiary’s name The beneficiary’s Medicare HICN The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and The name and signature of the person filing the request Mail reopening requests to: National Government Services, Inc. Jurisdiction B DME MAC Reopenings P.O. Box 6036 Indianapolis, IN 46206-6036 If several claims require a reopening, but for various reasons (i.e., date of service change, units of services correction, modifier correction/addition, etc.), a separate Medicare DME Request for Reopening form should be completed for each type of request. If all claims do not fit onto one form, attach an itemized spreadsheet. Faxed Requests for Reopenings Faxed requests will be accepted Monday through Friday during the hours of 8:00 a.m.–4:00 p.m. ET, any request received after 4:00 p.m. or on a Saturday, Sunday, federal nonworkday or legal holiday will be counted in the next business day’s workload. You should complete the Medicare DME Request for Reopening Form. If the Medicare DME Request for Reopening form is not used, the supplier’s request must contain all the following information: • • • • The beneficiary’s name The beneficiary’s Medicare HICN The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and The name and signature of the person filing the request Fax the reopening request to 317-595-4737. Reminders National Government Services, Inc. Page 10 of 12 • • You should not fax a request for reopening if the request was previously mailed or submitted via the Internet portal, NGSConnex. You should not fax routine correspondence or a response to an additional documentation request to the reopening fax line. If several claims require a reopening, but for various reasons (i.e., date of service change, units of services correction, modifier correction/addition, etc.), a separate Medicare DME Request for Reopening form should be completed for each type of request. If all claims do not fit onto one form, attach an itemized spreadsheet. Requests for Reopening Via Internet Portal (NGSConnex) Suppliers may submit reopening requests via our secure Internet portal, NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, log into the NGSConnex application. Checking the Status of a Reopening Request Suppliers who submit reopening requests to National Government Services can use one of the following selfservice tools to obtain the status of their requests: • • The NGSConnex web application The IVR system These self-service tools provide you with the status of your reopening requests. Follow the instructions below when using either NGSConnex or the IVR system. NGSConnex NGSConnex displays the status of a reopening request in both a pending or finalized status and includes all reopenings requests regardless of how they were originally initiated, (i.e., written, fax, telephone or NGSConnex). To check the status of a reopening via NGSConnex follow the steps below: • • • Select the My Claims. Enter the following data elements: o Beneficiary Medicare number o Beneficiary last name o Beneficiary first name (minimum first initial) o Beneficiary date of birth (MM/DD/YYYY) o CCN or o DCN Select Load Redetermination/Reopening Status. NGSConnex will search for any reopening that has been received for the CCN or DCN entered, display the status of the reopening found if a match is found. When the reopening has been completed the system will display a ‘finalized’ status and provide a ‘status’ description. When the reopening is still being conducted the status will display as ‘pending’. The reopening can take up to 60 days to complete. IVR System To check the status of an appeal (i.e., redetermination/reopening) follow these steps: • Select Option 4 of the IVR o Enter the following data elements: o NPI o PTAN (ten-digit supplier number) o Last five digits of the TIN o Beneficiary Medicare number o Beneficiary first and last name (last name and first initial if using touch-tone) National Government Services, Inc. Page 11 of 12 • o Beneficiary date of birth o CCN Once the authentication elements have been verified, the IVR will supply the following, if applicable: o DCN o All associated CCNs o Appeal status o Received date o Dates of service o Appeal decision Related Content • • • • • Medical Policy Center Medicare DME Reopening Request Form Medicare DME Reopening Request Form Checklist (571 KB) Medicare DME Reopening Request Form Completion Guide (571 KB) NGSConnex Website National Government Services, Inc. Page 12 of 12
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