Appeals FAQs

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All FAQs are current as of the date noted next to the question.

  1. What is a reopening? (09/06/12)
  2. Where can I find the redetermination form? (09/06/12)
  3. I recently received a denial from WPS Medicare for services I provided to a Medicare beneficiary. Subsequently, I filed a Medicare Redetermination Request form with WPS Medicare appealing the denial. Could you please tell me how long WPS Medicare has to respond to our appeal? (09/06/12)
  4. Does Medicare Part B have an Offset Request Form that providers can use to initiate a request for immediate offset of an overpayment? (09/06/12)
  5. I have submitted a redetermination request and I do not agree with the outcome of the decision. What would be the next step I take to receive payment for the services I provided to the beneficiary? (09/06/12)
  6. I have recently received notification from the insurance company that they should not have been paying primary. They are requesting their money back and telling me to file with Medicare for primary payment. How far back can I request an appeal of these claims for primary payment? (09/06/12)
  7. When can you expect to hear from WPS once you have filed a Redetermination? (09/06/12)
  8. How will you know when WPS has completed your redetermination request? (09/06/12)
  9. How do you determine whether you need to submit a first level appeal request, the REDETERMINATION, or a second level appeal request, the RECONSIDERATION? (09/06/12)
  10. What do you do if you have not heard from us? (09/06/12)

  1. What is a reopening?

    A reopening is an alternative to the appeals process where minor errors or omissions in filing claims have occurred. For more information regarding the appeals process, visit our website at:
    http://www.wpsmedicare.com/part_b/departments/appeals/

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  2. Where can I find the redetermination form?

    The redetermination form, along with additional information, is located on WPS' site at:
    http://www.wpsmedicare.com/part_b/forms/

    CMS also has this form available at:
    http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf

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  3. I recently received a denial from WPS Medicare for services I provided to a Medicare beneficiary. Subsequently, I filed a Medicare Redetermination Request form with WPS Medicare appealing the denial. Could you please tell me how long WPS Medicare has to respond to our appeal?

    The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, Publication 100-4, Chapter 29, Section 310.4, explains that the contractor must complete and mail a redetermination notice for all requests for redeterminations within 60 days of receipt of the request. The date of receipt for purposes of this standard is defined as the date the request for redetermination is received in the corporate mailroom.

    To view a copy of this publication, please refer to the CMS website below:
    http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c29.pdf

    Additional information on the appeals process, appropriate forms, and mailing addresses are available on the WPS Medicare website.

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  4. Does Medicare Part B have an Offset Request Form that providers can use to initiate a request for immediate offset of an overpayment?

    Yes, Medicare now offers a Immediate Offset form. Instructions for Immediate offsets can be found on the form tab.

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  5. I have submitted a redetermination request and I do not agree with the outcome of the decision. What would be the next step I take to receive payment for the services I provided to the beneficiary?

    When you are dissatisfied with the outcome on a redetermination request submitted to WPS Medicare, you would need to submit a reconsideration to the next level. The next level of appeal would be filed to the Qualified Independent Contractors (QIC). The reconsideration request must be filed within 180 days of the receipt of the notice of the redetermination. The reconsideration request must be submitted on CMS Form 20033 and can be found on the CMS website at: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20033.pdf .

    Please mail your request to the QIC at the following address:
    C2C Solutions - QIC Part B North
    P.O. Box 45208
    Jacksonville, FL 32232-5208

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  6. I have recently received notification from the insurance company that they should not have been paying primary. They are requesting their money back and telling me to file with Medicare for primary payment. How far back can I request an appeal of these claims for primary payment?

    The request for redetermination must be filed within 120 days after the date of receipt of the notice of the initial determination. The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, Publication 100-4, Chapter 29, Section 240.4, explains that failure of a billing company or other consultant 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 provider, physician, or other supplier claims that lack of business office management skills or expertise caused the late filing.

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  7. When can you expect to hear from WPS once you have filed a Redetermination?

    When you submit a redetermination request, using the correct form, providing complete information, and by mailing the form to the correct PO Box, you help us shorten the time needed to process your appeal.

    The WPS Medicare Redetermination Request Part B processing times currently result in quick response times for WPS Medicare providers. A full 99% of all pending redetermination requests are less than 30 days old from the date we received them. For most of our customers, this means you need not worry about the status of your redetermination because you will generally be hearing from us close to 30 days from the date we receive your redetermination request.

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  8. How will you know when WPS has completed your redetermination request?

    You will know WPS Medicare completed the redetermination request when you receive a corrected Remittance Advice (RA).

    1. If the redetermination decision results in a payment to you (favorable decision), you will receive a RA showing that the claim was reprocessed and Medicare allowed payment. Since WPS Medicare is making most redetermination decisions within 30 days, you will most likely see the payment resulting from a favorable redetermination decision between 35 and 45 days from the date we receive your appeal request.


      2. You will be able to tell the adjustment was because of the redetermination by the region code of the Internal Control Number (ICN).

      The first two digits of the ICN identify the region code. The WPS state region codes are follows:
      - WI 56
      - MN 66
      - IL 83
    2. You will know we completed the review when you receive a Medicare Redetermination Notice (MRN). The MRN is a letter from WPS Medicare, which provides the rational for an unfavorable redetermination decision. The MRN also includes information on how to submit a second level appeal request or a reconsideration request.
      • If your redetermination does not result in additional payment, or results in a partial payment, the decision is unfavorable. You will receive a letter from us explaining the reason(s) payment could not be allowed.
      • Since we are making most redetermination decisions within 30 days, you will most likely receive the letter from us within 35 to 40 days from the date we receive your redetermination request.

    When analyzing and posting your accounts receivable, we encourage you to continue to check your RA or the MRN for the details about your redetermination decision. In doing this, you can efficiently know the status of your redetermination.

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  9. How do you determine whether you need to submit a first level appeal request, the REDETERMINATION, or a second level appeal request, the RECONSIDERATION?

    • An initial claim submission will show the MA01 remark code which states you have 120 days to appeal and request a redetermination. If you see this remark code on your claim, you need to request a "REDETERMINATION" from WPS.
    • Adjustments resulting from a redetermination decision can be identified by the remark code of MA02, "If you do not agree with this determination, you have the right to appeal. You must file a written request for appeal within 180 days of the date you receive this notice."

    Please note the difference in the amount of time to request a second level appeal or the RECONSIDERATION. The MA02 message gives you appeal rights for the second level appeal or the reconsideration. If you wish to appeal claim adjustments with the MA02 remark code you must file a reconsideration request to the Qualified Independent Contractor (QIC).

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  10. What do you do if you have not heard from us?

    Remember you can always call the Provider Contact Center to ask us to check on the status of your Appeal. However, we recommend doing this only after you have checked the claim status within C-SNAP, checked your RAs, etc., or if the period has been long enough that you are concerned. We leave this decision up to you.

    • The Legacy States (IL, MN, WI) Provider Contact Center toll free numbers are:
      • IL Toll Free Number - (866) 234-7340
      • MN Toll Free Number - (866) 359-1598
      • WI Toll Free Number - (866) 359-1599.

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Page Last Updated: Wednesday, 17-Apr-2013 15:01:12 CDT