Redetermination Decision Notification

For all of the services included in the appeal request, when the redetermination decision results in the total reversal of an initial non-coverage decision, UGS will send a decision letter only to the party who requested the appeal. If the provider did not initiate the appeal, notification of the decision is found as an adjustment on a Remittance Advice reflecting the covered charges.

However, if the beneficiary called the Beneficiary Complaints department stating that the services were not received, and this call resulted in the denial of the services in question, the beneficiary will receive a copy of the fully favorably redetermination letter. This is the only exception.

A redetermination decision letter will be issued to all parties if the initial non-coverage decision is affirmed or only partially reversed.

Before submitting an appeal, it is important that the provider research all possible reasons for the non-covered charges. The provider should first compare the Remittance Advice with the processed bill on-line to determine which charges were not covered, then review pages 4 and 32 of the claim for the Medical Review reason codes associated with the non-covered charges. The explanation of the reason code, and any required provider action related to the reason code, should be confirmed by using the Reason Code file.

Clearly identifying the reason for the non-covered charges will prevent time spent filing unnecessary appeal requests. It will also help the provider determine if the denial should be appealed.

Appeals of Billing Errors

DO NOT SUBMIT AN ORIGINAL UB-92 TO THE APPEAL DEPARTMENT. This can result in the creation of a duplicate claim. It will interfere with the correction of coding errors by the Claims Department or can interfere with the Appeal redetermination review.