Medicare Appeals Process

Medicare Parts A & B Appeals Process

ICN 006562 May 2016

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Level 1 MAC

Level 2 Independent Organization

Level 3 Office of Medicare

Hearings and Appeals

OMHA

Level 4 Medicare Appeals Council

Level 5 Federal Court

Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare).

The Hyperlink Table, Table 8, at the end of this document, provides the complete URL for each hyperlink.

Table of Contents

Overview ……………………………………………………………………………………………………………1

Appealing Medicare Decisions ……………………………………………………………………………..1

Appointing a Representative…………………………………………………………………………………2

First Level of Appeal: Redetermination …………………………………………………………………..3

Second Level of Appeal: Reconsideration ………………………………………………………………4

Third Level of Appeal: ALJ Hearing ……………………………………………………………………….5

Fourth Level of Appeal: Medicare Appeals Council Review ………………………………………7

Fifth Level of Appeal: Judicial Review in U.S. District Court ………………………………………8

Tips for Filing an Appeal ………………………………………………………………………………………8

Appeal Process Summary ……………………………………………………………………………………9

Resources………………………………………………………………………………………………………..10

List of Tables

Table 1. Redetermination Frequently Asked Questions (FAQs) and Answers ………………3

Table 2. Reconsideration FAQs and Answers………………………………………………………….4

Table 3. ALJ Hearing FAQs and Answers ……………………………………………………………….5

Table 4. Medicare Appeals Council Review FAQs and Answers ………………………………..7

Table 5. Judicial Review in U.S. District Court FAQs and Answers …………………………….8

Table 6. Appeal Process Summary ………………………………………………………………………..9

Table 7. Resources ……………………………………………………………………………………………10

Table 8. Hyperlink Table ……………………………………………………………………………………..12

1

Overview

This publication provides health care professionals with information about each level of appeal in Original Medicare (Parts A and B), as well as additional resources for information on related topics. It describes how the Medicare appeals process applies to providers and participating physicians and suppliers. In this publication, the pronouns “I” or “you” refer to parties and appellants participating in an appeal.

Find more information about appeals on the Original Medicare (Fee-For-Service) Appeals webpage and beneficiary-specific information about appeals on the Medicare.gov Original Medicare Appeals webpage.

Appealing Medicare Decisions

There are five levels in the claims appeal process under Original Medicare:

Level 1

Redetermination by a Medicare Administrative Contractor (MAC)

Level 2

Reconsideration by a Qualified Independent Contractor (QIC)

Level 3

Hearing before an Administrative Law Judge (ALJ)

Level 4

Review by the Medicare Appeals Council (Appeals Council)

Level 5

Judicial review in United States (U.S.) District Court

Make all appeal requests in writing.

Helpful Terms Amount in Controversy (AIC): The threshold dollar amount remaining in dispute that is required for a Level 3 and Level 5 appeal. The AIC increases annually by a percentage increase tied to a consumer price index. Appeal: The process used when a party (for example, a beneficiary, provider, or supplier) disagrees with an initial determination or a revised determination for health care items or services. Appellant: A person or entity filing an appeal. Determination: A decision made to pay in full, pay in part, or deny a claim. Escalation: When an appellant requests that an appeal pending at the QIC level or higher be moved to the next level because the adjudicator was not able to make a decision within a specified time. Non-Participating: Physicians and suppliers who choose to either accept or not accept Medicare assignment on a claim-by-claim basis. Non-participating physicians and suppliers have limited appeal rights. Party: A person or entity with a right to appeal an initial determination or subsequent administrative appeal decision.