WPS Posts Medicare “Appeals Navigator” on Website

Wisconsin Physicians Service (WPS), the Medicare Part B contractor for Michigan, Indiana, Iowa, Kansas, Missouri and Nebraska, recently added an “Appeals Navigator” tool to its website to assist health care providers providers in navigating the Medicare appeals process by asking a series of questions and leading providers to the correct form and department.  The tool was added to both the WPS J8 website (for Michigan and Indiana providers) and the J5 MAC Part B website (for Iowa, Kansas, Missouri and Nebraska providers).

The tool helps health care providers understand if their denial is appealable and also helps representatives obtain the appropriate forms.  If the denial is determined to be appealable based on the responses provided, the user is directed to the appropriate redetermination forms and fax forms.

Although this tool only assists health care providers with the first level of the Medicare appeal (redetermination), the redetermination decision letter should include the forms and information necessary for providers to file the next level of appeal – reconsideration.  Likewise, the reconsideration decision will provide information for appealing the claim to the Office of Medicare Hearings and Appeals (OMHA) for a hearing before an Administrative Law Judge (ALJ).  While most claims are resolved at the ALJ level, providers may also consider appealing a denial to the Medicare Appeals Council (MAC) and ultimately to Federal Court.

For information on how our health lawyers assist providers with navigating these stages of Medicare appeals, please see our audit consulting page.

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