Appealing a claim is an action you can take if you do not agree with a coverage or payment decision made by Medicare. An appeal is an independent review of the original claim decision. This is the only time you should use the appeals process.
A claim must be appealed within 120 days from the date on the Medicare Pilot Program for Asbestos Related Disease Explanation of Benefits (EOB). An EOB is a summary of the services or items received.
Medicare Pilot Program for Asbestos Related Disease Appeals Request Form [PDF]
Items Needed for an Appeal:
- Medicare Pilot Program for Asbestos Related Disease Appeal Request Form [PDF]
- Medicare Pilot Program for Asbestos Related Disease Explanation of Benefits (EOB)
- Supporting Documentation - Contact your doctor’s office to get any medical information that may help your case
- Advance Beneficiary Notice of Noncoverage (ABN) – You should have a copy of this if your doctor’s office had you sign one
Helpful Hints for Submitting Your Appeal:
Mail or Fax Appeal To:
PO Box 6761
Fargo ND 58108-6761
If you need assistance with submitting an appeal, please contact your Care Coordinator at 1-888-469-9464.
Commonly Asked Questions:
Q. Who can submit an appeal?
A. The following persons can submit an appeal:
- Medicare Provider
- Beneficiary Representative - If the requester is not the beneficiary or the provider, a CMS-1696 form, Appointment of Representative, must be completed and submitted with this appeal request. This form can be found at: http://www.cms.gov/cmsforms/downloads/cms1696.pdf .
Q. When should I submit my appeal?
A. If you decide to file an appeal, you must submit the appeal within 120 days from the date of the EOB.
Q. How quickly will my appeal be processed?
A. Noridian has 60 days to process your appeal once received. You will receive an appeal decision letter from Noridian in the mail.
Q. How do I check the status of my appeal if it has been more than 60 days and I have not received a response?
A. Contact the Medicare Pilot Program for Asbestos Related Disease Contact Center at 1-888-469-9464.