New provider roadmap: Appeals

An appeal is a new and independent review of an initial determination of a claim.

Step 1: Determine whether you are submitting a redetermination or clerical error reopening / claim correction. 

For information and examples, refer to Part A or Part B.

Clerical error reopening / claim corrections must be submitted within one year from the initial claim determination for:

• Minor errors or omissions on claims
• Mathematical or computational mistakes
• Inaccurate data entry

A redetermination (first level of appeal) is a new and independent review of an initial determination of a claim. A redetermination must be submitted within 120 days from the receipt of the determination notice for:

• Dissatisfaction with initial claim determination
• Disagreement with claim reimbursement
• Medical review denials
• Denials requiring documentation to support the services

Step 2: Choose method of submission

There are multiple methods of submitting clerical error reopening / claim corrections:

• FISS(Part A)
• SPOT
• Reopening Gateway (Part B)
• Interactive Voice Response (IVR) system
• Redetermination and clerical error reopening request form:
  • Part A
  • Part B 

The options for submitting a redetermination:

• SPOT
• Redetermination and clerical error reopening request form:
  • Part A
  • Part B
• Fax:
  • Part A - 904-361-0593
  • Part B - 904-361-0595
• Mail:
  • Part A
  • Part B

Step 3: Submit the request

Clerical error reopening:

• Submit within one calendar year from initial determination date, except for reporting an overpayment.
• Completed within 60 days of receipt of the reopening request.

Redetermination requests:

• File within 120 days after the date of receipt of the determination.
• Completed within 60 days of receipt of the request unless additional documentation is submitted by the provider / supplier and received prior to issuance of the dismissal and / or decision notice.

Step 4: Check status

• Appeal Status Inquiry Tool
• SPOT

Resources

On demand training for appeals and claim correction:

• We provide a wide array of On-demand Learning resources that allows you to learn at your own pace
  • Online training courses
  • Training videos
  • Webinar recordings

Appeals center

• Submit an appeal - Appeals news (forms and tutorials)
• Submit claim corrections & reopenings

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