Level V: Federal district court. Providers have 60 days from
the Medicare Appeals Council decision to file an appeal to the
federal district court. The overpayment must be paid at the
administrative law judge hearing and the federal district court
stages.
Navigating the Appeals Process
Providers should take the following steps before submitting
any claim to the appeals process:
x Validate that all available documentation has been
submitted.
x Review the content of the documentation related to the
denial and determine if additional documentation or
clarification is needed (e.g., queries, updates, missing
documentation).
x Include documentation (e.g., physician letter) from
experts immediately involved in the case to provide
additional clarification or insight.
x Review regulatory guidance (e.g., Coding Clinic, ICD-
9-CM Official Guidelines for Coding and Reporting,
local and national coverage determinations, fiscal
intermediary/CMS billing guidance) with regard to the
date of the account in question.
x Determine whether there were any changes in regulatory
guidance that would support or deny an appeal on the
case in question. If there is, note the guidance changes
and decide if next steps are needed from an appeals
standpoint. If it is fewer than 15 days from the receipt of
denial, call the RAC for a discussion period review. If it is
more than 15 days, appeal the denial. If no other cause
for appeal is found, consider accepting the denial and
allowing recoupment.
After following these steps, organizations may need to
move to the first level of appeals. The RAC should forward the
record to the fiscal intermediary for the first level of appeal.
The fiscal intermediary may prefer to receive the record with
the redetermination form to ensure the record is detailed in a
format that is logical and easy to follow. Organizations should
communicate with their fiscal intermediary to determine
what it needs and its capabilities to receive electronic records.
It is up to the provider to ensure all deadlines are met and
the proper forms are submitted in a timely fashion for each
appeal level. Keep in mind, level II is the last level that allows
organizations to enter new evidentiary support. Organizations
should put their best foot for ward at this level.
It is possible to aggregate denials and present them in groups
that have related denial reasons for appeal decisions. Writing
appeal letters can be time consuming and take internal staff
away from their primary duties. Providers should identify the
key staff who will participate in the appeals process. In some
situations, it may be necessary or more beneficial to enlist the
help of an external contractor to manage the appeals process.
Regardless of whether appeals are managed internally
Automated Denials versus Complex Denials
BEFORE MOVING FORWARD with the appeals process,
organizations should understand the difference between
automated and complex denials.
Automated denials offer a limited opportunity to appeal
and are based off very specific guidelines, most often related
to a billing guideline, coding rule, or other regulation (e.g.,
CPT description). These denials are often related to a rule or
guideline change.
Complex denials offer increased opportunity to appeal and
may require more legal expertise and increased physician
involvement.
or externally, providers should follow these steps when
navigating the appeals process:
x Include all related components specific to the denial (e.g.,
request form, medical record, supporting documentation).
x Complete all necessary forms required for each level of
appeal.
x Adhere to the time frames for each level, including the
time frames for recoupment.
x Confer with the attending physician to obtain any addi-
tional insight on the case. The physician can be involved
in helping ensure the letter accurately reflects the points
of the case and as a witness in a hearing such as the ad-
ministrative law judge hearing.
x Use terminology associated with the denial in the ap-
peal letter (e.g., “Coding Clinic, first quarter, 2003, pg. 6,
states…”).
x Include clinical support from the health record in the ap-
peal letter.
x Add appropriate interdisciplinary team notes for addi-
tional documentation support in the letter.
x Include references to medications as well as ancillary
tests in the letter.
x Appropriately summarize the case, including documen-
tation extracts in the letter.
x Provide a chronological sequence of events and add clini-
cal justification as appropriate in the letter.
x Validate all evidence-based references or those related to
anatomy, physiology, or the disease process.
x Include formal references to supporting materials in the
letter (e.g., Coding Clinic, CPT Assistant, and Federal Reg-
ister).
Providers can consider the following sample language when
writing appeal letters:
As stated in the Uniform Hospital Discharge Data Set
(UHDDS) rules for coding and reporting of diagnoses,
conditions that are documented by the physician that
are clinically evaluated, diagnostically tested, and/or
