Appeals


Appeal Time Limit Calculator

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If you disagree with Medicare’s decision on how a pilot claim was processed, you may request an appeal. This is the only time the appeals process should be used.

Appeal: A request to review a claim when there is dissatisfaction with the original determination. An appeal is a review process and is an independent re-examination of an initial claim determination.

A claim must be appealed within 120 days from the date on the Medicare Pilot Program for Asbestos Related Disease Remittance Advice (RA). An appeal decision letter will be mailed to the provider or supplier who submitted the appeal.

Appeals 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 Remittance Advice
  • Supporting documentation – may include order, operative report, office notes, etc.
  • Advance Beneficiary Notice of Noncoverage (ABN) signed by beneficiary, if applicable
  • Legible signatures are required on all forms and documentation.

Mail or Fax Appeal:

Noridian
PO Box 6761
Fargo ND 58108-6761

Fax: 1-866-352-6158

Commonly Asked Questions:

Q.  Who can submit an appeal?
A.  The following persons can submit an appeal:

  1. Medicare Provider
  2. Beneficiary
  3. 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 This link takes you to an external website. 

Q.  When should an appeal be submitted?
A. Appeals must be submitted within 120 days from the date of receipt of the RA.

Q.  How long does an appeal take to be processed?
A. Noridian has 60 days from the date of receipt to process the appeal request.

Q. Is there more than one level of appeal for the Medicare Pilot Program for Asbestos Related Disease, similar to Fee-for-Service Medicare?
A. No. There is only one level of appeal.

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. Phone the Medicare Pilot Program for Asbestos Related Disease Contact Center at 1-888-469-9464.