CMS: Appeal Requests

Field	Data Type	Description
Participant First Name	Text	Participant’s first name.
Participant Last Name	Text	Participant’s last name.
Medicare Beneficiary Identifier	Text	MBI of the participant if available. “NA” if the participant is not a Medicare beneficiary. Dashes removed.
Participant ID	Text	Pace Organization member ID for the participant.
Enrollment Type	Text	Options Medicare only Medicaid only Dual Eligible Private Pay
Person who Submitted the Appeal	Text	Options Participant Caregiver Family
Date Appeal Received	Date	In the format of MM/DD/YYYY.
Time Appeal Received	Timestamp	In the format of HH:MM Only enter for expedited appeals.
Expedited	Text	“Y” if it was expedited. “N” otherwise.
Extension	Text	“Y” if an extension was applied when processing an expedited appeal. “N” if an expedited appeal wasn’t extended. “NA” otherwise.
Category of the Appeal/ Appeal Type	Text	Options Decreased Center Attendance Denial of Enrollment Dentures Durable Medical Equipment Glasses Hearing Aid Home Modification(s) Increased Center Attendance Increased Home Care Involuntary Disenrollment Medical Procedure Medical Supplies Nursing Facility Placement – Long Term Nursing Facility Placement – Respite Nursing Facility Placement – Short Term Specialist Consultation or Visit Surgical Procedure Transportation Other
Description of the Appeal/ Specific Issue	Text
Third-party reviewer or committee credentials	Text	“NA” if the appeal was not reviewed by a third-party reviewer
Request Disposition	Text	Options Approved Denied Partially Denied Withdrawn
Reason for Denial	Text	“NA” if the appeal was approved or withdrawn.
Date of Written Notification	Date	In format of MM/DD/YYYY.
Time of Written Notification	Time	In the format of HH:MM. “NA” if the appeal was not expedited.
Date Service Provided	Date	In the format of MM/DD/YYYY.