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The Five Levels of The Medicare Appeal Process

medicare appeals pricessBy: Zach Simpson

There might be times when Medicare denies coverage for an item, service, or test that you or your company provided. In the event this occurs you have the right to formally disagree wit the decision and encourage Medicare to change it. Therefore, understanding the appeals process for Medicare claims is vital for all providers. The aim of this article is to give providers a better understanding of the five (5) levels of the Medicare Appeal process, and what must occur at each level.

The Medicare Fee-For-Service (FFS) has five levels in the claims appeal process:

Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)

Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)

Level 3 – Disposition by Office of Medicare Hearings and Appeals (OMHA)

Level 4 – Review by the Medicare Appeals Council (Council)

Level 5 – Judicial review in U.S. District Court

First Level of Appeal: Redetermination By A Medicare Administrative Contractor (MAC)

You must file a request for redetermination within 120 days from the date of receipt of the Electronic Remittance Advice (ERA) or Standard Paper Remittance Advice (SPR) that lists the initial determination.

In order to file a request for redetermination you must file your request in writing by following the instructions in the ERA or SPR. You may use the Medicare Redetermination Request Form (CMS 2-20027), or any written document that contains the required elements listed in the ERA or SPR.

Providers can expect to receive a decision on the request for redetermination within 60 days of receipt. The decision will be received via a Medicare Redetermination Notice (MRN) from your MAC. In the event your decision is reversed, and the claim is paid in full you will receive a revised ERA or SPR.

Second Level of Appeal: Reconsideration By A Qualified Independent Contractor (QIC)

Following the receipt of the notice of redetermination a provider then has 180 days to file a request for reconsideration if they disagree with the MAC redetermination decision.

To file a reconsideration a provider must file their request in writing by following the instructions on the notice of redetermination using the Medicare Reconsideration Request Form (Form CMS-20033), or any written document that contains the required elements listed in the MRN.

Be sure that when you file for a reconsideration that you clearly explain why you disagree with the redetermination decision. In addition, be sure that you or your representative include the following with the submission:

  • Medicare beneficiary’s name
  • A copy of the RA or MRN
  • The beneficiary’s MBI
  • Any missing evidence noted in the redetermination
  • Any other relevant appeal evidence or documentation
  • The name of the MAC that made the redetermination

Once the request for reconsideration is received the QIC will send a decision to all parties within 60 days.

Third Level of Appeal: Disposition By Office of Medicare Hearings and Appeals (OMHA)

In the event you disagree with the reconsideration decision or you wish to escalate your appeal because the reconsideration decision timeframe passed you have one of two options under the OMHA review. Providers can either (1) request an Administrative Law Judge (ALJ) hearing, or (2) request a review of the administrative record by an OMHA attorney adjudicator.  However, be aware that you may request an ALJ hearing only if a certain dollar amount remains in controversy following the QIC’s decision which meets or exceeds the annual threshold established.

This is the first level of appeal that provides you with the opportunity to appear via telephone, video conference, or occasionally in person to explain your position to an ALJ. In the event that you do not wish to appear for a hearing you have the option to request that a decision be made based on the evidence and the administrative record of appeal.

In order to request an ALJ hearing, or a waiver of hearing, providers must file a request within 60 days of receipt of the reconsideration letter or file a request with the QIC for OMHA review after the expiration of the reconsideration period.  The request must be filed in writing by following the reconsideration letter instructions or by completing the Request for ALJ Hearing or Review of Dismissal Form (Form OMHA-100) and the multiple claim attachment form (Form OMHA-100A), as applicable.

Due to the number of appeal requests delays continue in OMHA ALJ hearing assignments. In order to ensure that your appeal request isn’t delayed be mindful that additional delays can result from:

  • Appellant failing to send notice of the hearing request to the other parties
  • The discovery request process
  • Reconsideration-level escalations
  • Request for an in-person hearing
  • Submission of additional evidence not including with the hearing request

Fourth Level of Appeal: Review By the Medicare Appeals Council

If a provider disagrees with the ALJ, or attorney adjudicator disposition, or if they wish to escalate their appeal because the OMHA adjudication timeframe passed, they may request a Council review.

Council review requests must be filed within 60 calendar days of receipt of the OMHA decision or dismissal, or after the OMHA decision timeframe expires without a decision or dismissal. The decision or dismissal is presumed received 5 calendar days after the date of the notice unless evidence shows this did not happen.

In order to request a Council review providers must submit their request in writing, or they may complete the Request for Review of ALJ Medicare Decision/Dismissal (Form DAB-101) or the electronic version accessible through the DAB E-File webpage.

Following the receipt of a request of an OMHA decision or dismissal the Council will issue a decision within 90 days.  If the Council review stems from an escalated appeal, the Council has 180 days from the date of receipt of the request for escalation to issue a decision.

Fifth Level of Appeal: Judicial Review In U.S. District Court

If you disagree with the Council decision, or you wish to escalate your appeal because the Council decision timeframe passed, you may request judicial review. In order to request judicial review you must file a request within 60 days of receipt of the Council’s decision or after the Council decision timeframe expires. Unlike the other levels of appeal this request must be filed as a claim in the U.S. District Court.