An Original Medicare appeal checklist for billing teams

Confirm which appeal process applies

This checklist concerns Original Medicare fee-for-service claims. A first-level appeal is called a redetermination: the Medicare Administrative Contractor (MAC) reviews the claim using personnel who were not involved in the initial determination. Medicare Advantage and commercial plans have separate procedures; do not apply the Original Medicare process to them.

First confirm the notice is an appealable initial determination, rather than an unprocessable claim requiring correction. Use the notice and the responsible MAC's instructions to identify the filing deadline, recipient and submission method. CMS publishes the applicable timing requirements; confirm those directly instead of relying on a generic calculator or an AI-generated date.

Build an evidence-based request

CMS permits Form CMS-20027 or a written request containing the required information. Follow the current instructions, identify the services in dispute and explain why the determination should change. A tailored explanation should connect the denial rationale to the coverage rule and the supporting record—not simply state that the claim should be paid.

Real submissions require beneficiary information and may require clinical records. Prepare and transmit those only through your office's approved secure processes. ClaimDesk's AI Appeal Assistant can help organize a non-PHI outline or draft with placeholders; it is not a substitute for the required identifiers, documentation or professional review.

• Verify the payer, appeal level and current contractor instructions.
• Save the notice and document the applicable filing deadline.
• Match each disputed service to the reason for disagreement.
• Gather the relevant coverage policy and supporting records securely.
• Review the completed request for accuracy and required information.
• Retain proof of submission and schedule a follow-up.

Track the outcome without losing the trail

Mark the appeal Submitted only after it is actually sent. Retain the submission receipt in your approved document system and track its non-PHI reference in ClaimDesk. When a decision arrives, record the decision date and outcome, then reconcile any revised payment before recording the recovered amount.

If the decision is unfavorable, read the new notice for the next available appeal level and its requirements. Do not reuse the first-level instructions automatically; later levels have different rules. No checklist or draft guarantees coverage or payment.