Medical Billing: How to Appeal a Rejected Medicare Claim - dummies

Medical Billing: How to Appeal a Rejected Medicare Claim

The Centers for Medicare & Medicaid Services (CMS) has a defined process for appealing a rejected medical billing claim. This process is easy to follow and quite efficient. You can find all the necessary forms at the Medicare website and individual contracted Medicare carrier websites.

The preferred method for submission is online. You can also submit additional documentation as well. The Medicare online appeal site provides a cover sheet that you can use to mail or fax the documentation to the appropriate address for consideration.

Medicare tends to see everything as black and white and makes all decisions based on the policies that were in effect on the service date. So as long as you or your software stays current with regard to Medicare policy, then appealing to this payer is quite painless.

The request for redetermination is a friendly reminder that the Medicare processing does not reflect the local fee schedule. You can find the initial request form at the Medicare website. Most Local Coverage Carriers or Medicare contractors have links to this form on their individual websites, and many allow the appeal to be submitted online with supporting documents faxed, using the assigned cover sheet.

Submit online if possible to avoid any potential timely appeal issues. According to Medicare rules, an appeal must be submitted within 90 days of the initial determination. If you submit online, you have proof of timely submission.

If the contractor doesn’t grant your request or provide solid evidence that the claim has already processed correctly, the next level of appeal is to a Qualified Independent Contractor.