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Appeals Process

REOPENINGS

Use the telephone reopening process to resolve clerical, minor errors or omissions as follows:

  • Errors that involve units of service
  • Service date corrections
  • HCPCS code corrections
  • Transposed diagnosis codes
  • Certain modifiers (GA, GY, GZ, KX cannot be changed/added via a Reopening)
  • Place of service correction
  • Mathematical or computational mistakes
  • Inaccurate data entry
  • Misapplication of the fee schedule
  • Claims incorrectly denied as duplicate charges

Be prepared to have the following documentation available when contacting Medicare’s Reopening Unit…

1) Beneficiary’s Medicare Number

2) Beneficiary’s Name

3) Date of Service

4) Claim Control Number  

5) NPI Number

6) Provider Transaction Access Number (PTAN)

7) Last 5 digits of Tax ID Number (TIN)

Additionally you should have the HCPC Codes for the Items  in question, dates of service of the claim, and the reason for the request.

Reopenings can be faxed using the “Medicare DME MAC Reopening Request Form” found at :  https://www.noridianmedicare.com/dme/forms/docs/nas_reopen_dme.pdf.  Note: all DME MAC regions share the same form.

 

Durable Medical Equipment Medicare Administrative Contractors (DME MACs). Medicare contractors that educate Medicare suppliers, process claims and claim reopenings, and perform first level claim appeals called redeterminations.

Key Links:

Table 1: Reopening DME MAC Contact Information

DME MAC

Hours of Availability

Telephone

Fax

Mail

Region A

Monday–Friday
7:00 – 4:00 (ET)

 

866-419-9458

5 claims per call permitted

701-277-2425

Noridian JA DME
Attn: Reopenings
PO Box 6780
Fargo, ND 58108-6780

 

Region B

 

 

Monday–Friday
8:00 – 4:00 (ET)

 

844-240-7490

5 claims per call permitted

underpayment fax 615.660.5978

overpayment fax 615.782.4508

 

CGS Administrators, LLC
PO Box 200007
Nashville, TN 37202

Region C

Monday–Friday
7:00 – 5:00 (CT)

 

866-813-7878

5 claims per call permitted

615-782-4649

 

 

 

CGS DME MAC Jurisdiction C
ATTN: Clerical Error Reopening Department
PO Box 20010
Nashville, TN 37202

 

Region D

Monday–Friday
8:00 – 6:00 (CT)

877-320-0390

5 claims per call permitted

701-277-7886

Noridian JD DME
Attn: DME Reopenings
PO Box 6727
Fargo, ND 58108-6727

 

 

Table 2: Appeal Levels and Process

 

Level 1

Redetermination

Level 2

Reconsideration

Level 3

Administrative Law Judge – ALJ

Level 4

Departmental Appeals Board – DAB

Level 5

Federal Court

Time Limit for Filing

120 days from date of receipt of the notice initial determination

180 days from date of receipt of the redetermination

60 days from the date of receipt of the reconsideration

60 days from the date of receipt of the ALJ hearing decision

60 days from the date of receipt of DAB decision or declination of review

Amount in Controversy

No minimum (none)

No minimum (none)

At least $140 remains

No minimum (none)

At least $1,300 remains

Where to File Appeal

DME MAC (mail or fax)

* See Table 3, below for Address/Fax information for the DME MACs. 

 

All 4 regions use the same form

Qualified Independent Contractor (QIC)


All DME MAC Regions mail to:

RiverTrust Solutions, Inc.
1 Cameron Hill Circle Suite 0011 Chattanooga, Tennessee 37402-0011

Health and Human Services Office of Medicare Hearings and Appeals (OMHA) field office

DAB or ALJ hearing office

 

 

The “Medicare DME MAC Redetermination Request Rorm” Note: all DME MAC regions share the same form.

Helpful guide from CGS titled Reopening vs. Redetermination Job Aid

On March 2, 2015 OMHA announced the implementation of the ALJ Appeal Status Information System (AASIS) Website.  The AASIS website provides public access to appeal status information and is accessed through the OMHA website (http://www.hhs.gov/omha) by selecting the “Appeal Status Lookup” link located on the left navigation bar.  Information on data availability, updates, and status definitions,  is also provided to assist with your search.

AASIS allows users to query level 2 and/or level 3 appeal numbers and returns appeal data such as:

  • Date appeal received
  • Appeal status
  • Field office
  • ALJ assignment and team phone number

Table 3: Redetermination DME MAC Contact Information

Region A
Region B
Region C
Region D

Noridian JA DME
Attn:DME Redeterminations
PO Box 6780
Fargo, ND 58108-6780

CGS
P.O. Box 23070
Nashville, TN 37202

CGS
P.O. Box 20009
Nashville, TN 37202

Noridian JD DME
Attn: DME Redeterminations
PO Box 6727
Fargo, ND 58108-6727

For Overnight Delivery use:

Noridian JA DME
Attn: Overpayment Redeterminations
PO Box 6728
Fargo, ND 58108-6728

 

 

 

 

 

 

 

 

 

 

For Overpayment Redeterminations

Noridian JD DME
Attn: Overpayment Redeterminations
PO Box 6728
Fargo, ND 58108-6728

 

Fax:701-277-2425Fax: 615.660.5976Fax: 615-782-4630

Fax:  701-277-7886

 

 

When a Redetermination is filed it is imperative that you review all documents prior to submission to ensure they are applicable and meet CMS guidelines.  Note that if you do not feel fully prepared for the Redetermination and you are close to the 120 day filing limit you should consider submitting the Redetermination even though you may be denied.  CMS is stringent on the filing limit so it is better to submit the documentation you have knowing that you may have to go to Reconsideration to file the additional documentation once obtained.

Redetermination requests should include the following:

  • Verbal/dispensing order that includes:  Patient Name, description of Item, prescribing physician’s name, date of order (and start date if start date is different from the date of order), suppliers signature on verbal orders or physician’s signature on written orders.
  • Detailed written order (DWO) which includes: Physician’s Name, physician’s signature and dated prior to the claim’s bill date, date of order (and start date if start date is different from the date of order), detailed description of the items ordered, dosage, route, frequency, duration, quantity to be dispenses, number of refills and length of need as applicable.  Click here for additonal details on the elements of DWOs.
  • Beneficiary or authorized representative’s attestation of the refill request. The date of the request must be prior to the date of delivery and should be documented.  The request must include a description of the items being requested and documentation that the supply is approaching exhaustion by the expected delivery date.
  • Proof of Delivery (POD) must following the regulations defined in the 3 methods of delivery.  Click here for additional information on POD or see the Supplier Manual for full details.  In general when delivered in person by the supplier the POD to a patient is the signed and dated delivery ticket (delivery slip).  If using a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the HIT/DME provider to the patient.  Proof of Delivery must be closely adhered and should follow all guidelines set by CMS.
  • Pick up slip for previous equipment (if applicable)
  • Advanced Beneficiary Notice of Noncoverage (ABN) (if applicable).  The ABN must be included if you are attempting to change a liability decision (from “CO” to “PR”) and must include all elements specified by CMS.
  • Correct diagnosis codes that are supported by documentation from the treating physician. The medical record submitted in the redetermination should support the change you are requesting to the diagnosis code.
  • Any information required for the use of specific modifiers as defined in certain DME policies.  An example of this is the KX modifier.  If this modifier is used you must have the documentation that supports the therapy.
  • Relevant medical records and related progress notes which include but not limited to physician’s office records, hospital records, nursing home records, home health agency records, records from other health care professionals and test reports.  Read though the documentation you are submitting to ensure it is applicable to your case. Submitting documentation that is not relevant may cause delays in the Redetermination decision.

In order to support the case for a specific therapy additional documentation may be necessary and may include:

 

External Infusion Pump/Covered Drugs

  • DME Information Form (DIF) (should be signed/dated prior to the date of the claim submission)
  • Medical records that contain:

    • Documentation to support the Length of Need
    • Documentation to support the Diagnosis on the DIF
    • Documentation to support reported test results (such as those on the Inotropic Data Collection Form)

Immunosuppressive Drugs

  • Date of the organ transplant
  • Documentation that the transplant was Medicare approved to have met the coverage criteria in effect at the time.
  • The patient was enrolled in Medicare Part A at the time of transplant

 

Parenteral/Enteral

  • DME Information Form (DIF) must be signed/dated prior to the claim submission date
  • Specialty formulas: Documentation supporting the need for these categories (i.e., office notes, lab reports, progress notes, etc.)
  • Nutrition provided outside of Medicare’s recommended total caloric daily intake
  • Statement from the physician as to why lower/higher calorie intake is needed
  • Documentation that supports the criteria used to qualify the patient for TPN.  The LCD & Policy Article provide specific information for each criterion.

 

Appeal Tips:

  • Use the redetermination form but also include a cover letter to point out specifics in your documentation that demonstrates coverage criteria has been met
  • Send only related documentation
  • Do not highlight because highlighted sections are often illegible after the document is scanned

Additional Documentation

The suggested documentation items listed here are just that – suggested. It is important that you read the audit and submit all documentation requested in that audit. If you feel additional documentation not requested would help support your claim then you should submit it. In an appeal situation, you should determine which pieces of documentation will best support your appeal.