Document 6545203

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:
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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:
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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:
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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
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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
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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
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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:
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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.
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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.
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Fax the redetermination request to 317-595-4737.
Reminders:
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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:
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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:
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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
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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:
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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
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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:
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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.
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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.
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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
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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
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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.
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Examples of minor error or omissions include:
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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
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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:
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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:
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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:
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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)
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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.
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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:
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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:
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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
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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:
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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:
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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)
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•
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
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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
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