General

1. What information is required for submitting an appeal request?
2. Is there a form that can be used for a redetermination request?
3. What documentation should be submitted with the redetermination request?
4. What are the appropriate addresses for submitting redetermination and clerical error reopening requests?
5. What is a clerical error reopening?

1. What information is required for submitting an appeal request?

   The first level of appeal is called a redetermination.  Your request for a redetermination must be submitted in writing and filed within 120 days from the date on your Remittance Advice (RA) or Medicare Summary Notice (MSN) and it must include the following information:

   • The beneficiary name;
   • The beneficiary health insurance claim number;
   • The specific service(s) and/or item(s) for which the redetermination is being requested;
   • The specific date(s) of service; and
   • The printed name and signature of the person making the request.

   Your appeal request may be dismissed if any of the above information is not included with the request (Claims Processing Manual, Chapter 29, Section 310.1 B2). 

    

   Date Posted: 10/31/2006, Date Reviewed/Revised: 09/23/2008

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2. Is there a form that can be used for a redetermination request?

   In order to expedite your redetermination requests and to ensure that all required information is provided, the Medicare Part A Redetermination Request Form has been developed by Highmark Medicare Services for your use.  Providers are encouraged to utilize this form when requesting a redetermination.  The form may be downloaded.

   Date Posted: 10/31/2006, Date Reviewed/Revised: 09/23/2008

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3. What documentation should be submitted with the redetermination request?

   It is your responsibility to submit with your request all evidence that supports the coverage of the service(s) being appealed.  Note:   If the denial of the items/services resulted from the failure to respond timely to an additional documentation request (ADR), all the information requested in the ADR must be submitted with the appeal request.

   Date Posted: 10/31/2006, Date Reviewed/Revised: 09/23/2008

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4. What are the appropriate addresses for submitting redetermination and clerical error reopening requests?

   Redetermination and clerical error reopening requests should be submitted as follows:

   Pennsylvania Part A:
   
   Highmark Medicare Services
   Attn:  Part A Appeals Department
   P.O. Box 890385
   Camp Hill,  PA 17089-0385

   
   Maryland/DC Part A:
   
   Highmark Medicare Services
   Attn:  Part A Appeals Department
   P.O. Box 890386
   Camp Hill, PA 17089-0386

    New Jersey Part A

   Highmark Medicare Services
   Attn:  Part A Appeals Department
   P.O. Box 890420
   Camp Hill, PA 17089-0420

   Date Posted: 10/31/2006, Date Reviewed/Revised: 09/23/2008

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5. What is a clerical error reopening?

   The Centers for Medicare & Medicaid Services (CMS) has established a process, separate from appeals, whereby providers could correct minor errors or omissions. CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the party or the contractor, such as:

   • Mathematical or computational mistakes;
   • Transposed procedure or diagnostic codes;
   • Inaccurate data entry;
   • Misapplication of a fee schedule;
   • Computer errors; or
   • Incorrect data items, such as provider number, use of a modifier or date of services. 

   See the MLN Article MM4147 for additional information.  Requesting a reopening does not toll the timeframe to request an appeal.

   In order to expedite your clerical error reopening requests, the Medicare Part B of A Outpatient Clerical Error Reopening Request Form has been developed for your use. 

   The form may be downloaded.

   Note:  The clerical error reopening process does not replace the submission of an adjustment or corrected claim via Direct Data Entry (DDE) in FISS.  However, you should not submit both an adjustment via DDE and submit a clerical error reopening request for the same claim.  This could cause a delay in the processing of your clerical error reopening request.  The DDE adjustment should be submitted whenever possible.  The clerical error reopening request form should only be used for those situations where you are unable to do the DDE adjustment.

    

   Date Posted: 11/28/2006, Date Reviewed/Revised: 09/23/2008

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