Filing an Appeal

This module provides an overview of the appeals process and explains how to file an appeal.

This updated article outlines the available appeal levels, amount in controversy thresholds and the time limits for filing an appeal.

Amount in controversy requirements for the ALJ and Federal District Court Appeals changes are shown in this updated article.

While the majority of MUEs are publicly available on the CMS website, CMS will not publish all MUE values.

If you are dissatisfied with an initial claim determination, you have the right to request an appeal. There are several appeal levels, and each level must be processed before proceeding to the next level.

On October 14, 2021, Palmetto GBA identified incorrect fax numbers on the Jurisdiction J (JJ) and Jurisdiction M (JM) Part A Redetermination (first level appeals) form. These forms have been updated to reflect the correct fax numbers.

This article explains when and when not to file an appeal.

If you are receiving Medically Unlikely Edits (MUE) denials, determine if you are billing the appropriate number of units. The MUE limits for drugs are likely based on the manufacturer’s package insert for recommended dosage amount.

To meet standards set by CMS, MACs must complete first-level appeals (redeterminations) within 60 days from the date of receipt. Palmetto GBA is dedicated to meeting or exceeding this government standard.