US · guidance
CMS Pub. 100-06, ch. 6, § 380
Exhibits
B3-13416
Exhibit 1 - Medicare Program - Carrier Appeal Report - Form CMS-2590
MEDICARE PROGRAM - CARRIER APPEAL REPORT - FORM CMS-2590
CARRIER ID ___________________ REPORT PERIOD _____________________
A. CARRIER APPEAL REQUESTS
TOTAL
REVIEWS
(1)
TELEPHONE
REVIEWS
(2)
HEARINGS
(3)
1. OPENING PENDING
2. ADJSTMTS TO PNDNG
3. ADJUSTED PENDING
4. REQUESTS RECEIVED
4A. MED. DOC. DENIALS
5. REQUESTS TRANSFERRED
6. REQUESTS CLEARED
7. NO. OF CLAIMS
8. AMT IN CONTROVERSY
9. AFFIRMATIONS
10. DISMISSED/WITHDRAWN
11. REVERSALS
12. AMOUNT AWARDED
FORM CMS-2590 SCREEN 1
Exhibit 2 - Medicare Program - Carrier Appeals Report - Form CMS-2590
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS-2590
CARRIER ID __________________ REPORT PERIOD _____________________
REVIEW
REQUESTS
REVIEWS
(1)
HEARING
REQUESTS
HEARINGS
(2)
PROCESSING TIMES PROCESSING TIMES
13. REVIEWS- AVERAGE 23. HEARINGS- AVERAGE
14. NBR COMP 1-30 DYS 24. NBR COMP 1-60 DYS
15. NBR COMP 31-45
DYS
25. NBR COMP 61-90 DYS
16. NBR COMP 46-60
DYS
26. NBR COMP 91-120
DYS
17. NBR COMP 60 DYS+ 27. NBR COMP 120 DYS+
PENDING TIMES PENDING TIMES
18. CLOSING PENDING 28. CLOSING PENDING
19. NBR COMP 1-30 DYS 29. NBR COMP 1-60 DYS
20. NBR COMP 31-45
DYS
30. NBR COMP 61-90 DYS
21. NBR COMP 46-60
DYS
31. NBR COMP 91-120
DYS
22. NBR COMP 60 DYS+ 32. NBR COMP 120 DYS+
HEARING RESULTS
OTR
WITH NO
SUBSEQUENT
HEARING
(1)
TELEPHONE
(2)
IN-PERSON
(3)
NBR IN
120 DYS
(4)
33. REVERSALS
34. AFFIRMATIONS
35. TOTAL DECISIONS
36. NBR IN 120 DYS
37. NO PREV OTR HELD
38. PREV OTR COUNTED
39. PREV OTR NOT
COUNTED
FORM CMS-2590 SCREEN 2
Exhibit 3 - Medicare Program - Carrier Appeals Report - Form CMS 2590
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS 2590
CARRIER ID ___________________ REPORT PERIOD _____________________
B. PART B ALJ HEARINGS
TOTAL
(1)
DISPOSITIONS
(2)
B. PART B ALJ
HEARINGS
TOTAL
(1)
40 OPENING PENDING 55. WAIVED -
BEN & PROV
41 ADJUSTMENTS TO
PENDING
56. AMOUNT
AWARDED
42. ADJUSTED OPENING
PENDING
57. CLOSING
PENDING
43. REQUESTS RECEIVED 58. EFFECT.
OF ALJ DEC
44. REQ. FORWARDED TO
ALJ
59. NO. 1-7
DAYS
45. NO. OF CLAIMS
INVOLVED
60. NO. 8-15
DAYS
46. NO. IN 1-7 CALNDR
DAYS
61. NO. 16-30
DAYS
47. NO. IN 1-14 CLNDR
DAYS
62. NO. OVER
30 DAYS
48. AVG TIME TO
FORWARD
49. COMPLETED
50. AMOUNT IN
CONTROVERSY
51. AFFIRMATIONS
52.
DISMISSALS/WITHDRAW
ALS
53. REVERSALS
(FULL/PART)
54. AMOUNT AWARDED
FORM CMS-2590 SCREEN 3
Exhibit 4 - Medicare Program - Carrier Appeals Report - Form CMS-2590
MEDICARE PROGRAM - CARRIER APPEALS REPORT - FORM CMS-2590
CARRIER ID ___________________ REPORT PERIOD ____________________
C. REOPENINGS (CLAIM COUNTS
TOTAL
(1)
PRE-REVIEW
(2)
POST-REVIEW
(3)
POST-HEARING
(4)
63. TOTAL
64. UNFAVORABLE TO
CLAIMANT
65. NO CHANGE
66. FAVORABLE TO CLAIMANT
67. AMOUNT AWARDED
D. LIMITATION OF LIABILITY
(CLAIM COUNTS)
INITIAL
CLAIM
(1)
REVIEW
(2)
HEARING
(3)
ASSIGNED CASES
68. TOTAL NUMBER
CONSIDERED
69. CONSIDERED - NOT
WAIVED
70. WAIVED-BEN. ONLY
71. WAIVED-BEN.& PROV
72. AMT AWARDED
UNASSIGNED CASES
73. TOTAL NUMBER
CONSIDERED
74. PHYS REFUND WAIVED
75. PHYS REFUND UPHELD
FORM CMS-2590 SCREEN 4
History
(Rev. 6, 08-30-02)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
c27f8d9c93af3c5d27ead01fd6770e5cd1f4a46c6e2a8b4f15a7c2ab76eaa328
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