Right to Appeal

The provider, beneficiary and representative have the right to appeal any initial determination concerning a request for payment under Medicare Part A relating to:

• Coverage of furnished items and service
• Amount of the deductible
• Application of the coinsurance provision
• The number of inpatient hospital days used toward the 190-day lifetime limitation of inpatient psychiatric hospital covered days
• The number of lifetime reserve days used
• The number of skilled nursing facility (SNF) days used
• The physician certification requirement
• The request for payment requirement
• The beginning and ending of a benefit period
• The medical necessity of the services
• A determination with respect to the limitation of liability provision
• Any issue(s) affecting the amount of benefits payable (including overpayments or underpayments)
• Benefit Integrity Support Center (BISC) denials
• Comprehensive Error Rate Testing (CERT) denials
• Prepay and post pay probes