Hint: Don’t mix up reopenings with appeals. Picture this scenario: You submit a claim to Medicare Part B, but it is denied. You want to appeal the decision, but you’re not sure how to proceed. The MAC National Government Services recently held a webinar to help you demystify the five levels in the Medicare Part A and Part B appeals process. Answer the following questions to make sure you understand how each of the levels work. Question 1: How do reopenings differ from appeals? Answer 1: A reopening, also referred to as a preredetermination is not an appeal, but a request to reopen a claim, according to Shelly Dailey, MSN, BSN, RN, CPHM, Medicare home health and hospice clinical consultant at National Government Services. Reopenings are not processed through the appeals department and only occur at the discretion of the contractor, Dailey explains. If a contractor refuses to reopen a claim for a minor error, that decision is not appealable. Timeline: A reopening can be performed within one year of the claim’s finalized date, Dailey says. There are several reasons for a reopening, according to Dailey. These include the following: On the other hand, appeals are different from reopenings. You cannot file an appeal for a reopening. Appeals: Before an appeal request can be made, you first have a processed claim, according to Dailey. When Medicare has either fully or partially denied the claim, then you may submit an initial appeal for a redetermination, which is also known as a Level 1 appeal. The purpose of the appeals process is to “ensure correct adjudication of claims,” Daily explains. CMS governs all appeals activities. Additionally, all providers and beneficiaries have the right to appeal any claim determination their MAC makes. Question 2: How many levels of appeal are there? Answer 2: There are five levels of appeal. They are as follows: Don’t miss: Documentation is the key to the success of any level of appeal, Dailey says. Providers must include all pertinent information to avoid the dismissal of the case. Question 3: What are the different time limits for filing at each level of appeal? Answer 3: There are strict time limits for filing at each level of appeal, Dailey explains. They are as follows: