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«Open a Text-Only Version Medicare Parts A & B Appeals Process Level 5 Federal Court Level 4 Medicare Appeals Level 3 Council Office of Medicare Level ...»

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Centers for Medicare & Medicaid Services

Open a



Medicare Parts A & B Appeals Process

Level 5

Federal Court

Level 4



Level 3 Council

Office of


Level 2 Hearings and





Level 1


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.

ICN 006562 May 2016 Table of Contents Overview

Appealing Medicare Decisions

Appointing a Representative

First Level of Appeal: Redetermination

Second Level of Appeal: Reconsideration

Third Level of Appeal: ALJ Hearing

Fourth Level of Appeal: Medicare Appeals Council Review

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

Tips for Filing an Appeal

Appeal Process Summary


List of Tables Table 1. Redetermination Frequently Asked Questions (FAQs) and Answers..................3 Table 2. Reconsideration FAQs and Answers

Table 3. ALJ Hearing FAQs and Answers

Table 4. Medicare Appeals Council Review FAQs and Answers

Table 5. Judicial Review in U.

S. District Court FAQs and Answers

Table 6. Appeal Process Summary

Table 7. Resources

Table 8. Hyperlink Table

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

–  –  –

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.

1 Medicare Parts A & B Appeals ProcessAppointing a Representative

At any time, a party may appoint any individual, including an attorney, to represent him or her during the processing of a claim or appeal. The representative helps the party by providing assistance and expertise.

To appoint a representative, the party or representative must complete Form CMS-1696 (Appointment of Representative) or another written document with the same information. The form or other

document must:

• Be in writing

• Be signed and dated by the party and the representative (the representative’s signature must be dated within 30 days of the party’s signature)

• Include a statement appointing the representative to act for the party

• Include a written explanation of the purpose and scope of the representation

• Include the names, phone numbers, and addresses of both the party and the representative

• Include the representative’s professional status or relationship to the party

• Contain a unique identifier of the represented party If the party is the beneficiary, the Medicare number must be included. If the party is a provider or supplier, the National Provider Identifier (NPI) number is requested.

The appointment is valid for 1 year. During this year, the representative may represent the party in subsequent appeal levels on the initial appeal and for any appeals of other claims, unless the party specifically withdraws the representative’s authority.

Requirements for Appointment of Representatives Find the requirements for appointing a representative in the Medicare Claims Processing Manual, Chapter 29, Section 270.

Transfer of Appeal Rights to Non-Participating Physicians and Suppliers Beneficiaries may transfer their appeal rights to non-participating physicians or suppliers who provide the items or services and do not otherwise have appeal rights. To transfer the appeal rights, the beneficiary and non-participating physician or supplier must complete and sign Form CMS-20031 (Transfer of Appeal Rights).

–  –  –

A redetermination is the first level of appeal after the initial determination on a claim. It is a second look at the claim. Table 1 provides questions and answers about redeterminations.

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

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NOTE: The MLN Matters® Article SE0420, Correction of Minor Errors and Omissions Without Appeals provides information about Medicare rules that enable you to correct minor errors and omissions on claims without initiating the appeals process.

–  –  –

If you disagree with the MAC redetermination decision, you may request a reconsideration by a QIC.

A reconsideration is a review of the redetermination decision. Table 2 provides questions and answers about reconsiderations.

Table 2. Reconsideration FAQs and Answers

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Third Level of Appeal: ALJ Hearing If you disagree with the reconsideration decision or wish to escalate your appeal because the reconsideration period passed, you may request an ALJ hearing. The ALJ hearing gives you the opportunity—via video teleconference (VTC), telephone, or occasionally in person—to explain your position to an ALJ. The U.S. Department of Health & Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA), which is independent of CMS, is responsible for the Level 3 Medicare claims appeals. Table 3 provides questions and answers about ALJ hearings.

Table 3. ALJ Hearing FAQs and Answers

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If you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review. The HHS Departmental Appeals Board (DAB) Medicare Operations Division administers the Appeals Council review.

Table 4 provides questions and answers about Appeals Council reviews.

Table 4. Medicare Appeals Council Review FAQs and Answers

–  –  –

If you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed, you may request judicial review. Table 5 provides questions and answers about judicial review in U.S. District Court.

Table 5. Judicial Review in U.

S. District Court FAQs and Answers

–  –  –

Tips for Filing an Appeal Now that we have discussed the five levels in the claims appeals process, here are some best

practices when filing an appeal:

• Starting at Level 1, consolidate into one appeal as many similar claims as possible

• File timely requests with the appropriate contractor

• Include a copy of the decision letter(s) issued at the previous level

• Include a copy of the demand letter(s) if appealing an overpayment determination

• Include a copy of the Appointment of Representative (AOR) form if representing a provider/supplier/beneficiary

• Respond promptly to the contractor requests for documentation

• Sign your request for appeal Find more information about the Medicare overpayment collection process in the Medicare Overpayments Publication.

–  –  –

https://www.hhs.gov/about/agencies/omha/the-appeals-process Appeals Process by Medicare Part MAC Contact https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/ Information Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map Medicare Appeals https://www.hhs.gov/dab/divisions/medicareoperations Council Medicare Learning https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Network® (MLN) MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf Guided Pathways MLN Matters® https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ SE1521 Limiting the MLNMattersArticles/Downloads/SE1521.pdf Scope of Review on Redeterminations or Reconsiderations of Certain Claims OMHA https://www.hhs.gov/about/agencies/omha OMHA Medicare https://www.hhs.gov/about/agencies/omha/about/special-initiatives/appellantAppellant Forum forums Original Medicare https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals Appeals Part C Appeals Medicare Managed Care Appeals & Grievances https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG

–  –  –

Resource Website Part D Appeals Medicare Prescription Drug Appeals & Grievances https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev “Part D Coverage Determinations, Appeals & Grievances” WBT Course https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/WebBasedTraining.html QICs https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ ReconsiderationbyaQualifiedIndependentContractor.html Reopenings https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM4147.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE0420.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c34.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1426.pdf Settlement Effectuation https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ Instructions for the Downloads/R1588OTN.pdf Department of Health Part A Specific Instructions and Human Services https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ (DHHS) Office of Downloads/R1633OTN.pdf Medicare Hearings and Appeals (OMHA) Settlement Conference Facilitation (SCF) Pilot http://www.uscourts.gov/about-federal-courts/court-role-and-structure U.S. District Courts

11 Medicare Parts A & B Appeals ProcessTable 8. Hyperlink Table

Embedded Complete URL Hyperlink Correction of Minor https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Errors and Omissions MLNMattersArticles/Downloads/SE0420.pdf Without Appeals Demonstration with https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Durable Medical Downloads/Formal-Telephone-Demonstration-Fact-Sheet-2016.pdf Equipment (DME) Suppliers Fifth Level of Appeal https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ AIC Threshold Review-Federal-District-Court.html Fifth Level of Appeals https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Review-Federal-District-Court.html First Level of Appeal: https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Redetermination by a RedeterminationbyaMedicareContractor.html Medicare Contractor Form CMS-1696 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/ CMS012207.html Form CMS-20027 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf Form CMS-20031 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20031.pdf Form CMS-20033 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf Form CMS-20034 A/B https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20034AB.pdf Form DAB-101 https://www.hhs.gov/dab/divisions/dab101.pdf Medicare Claims https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ Processing Manual, clm104c29.pdf Chapter 29 Medicare Operations https://www.hhs.gov/dab/divisions/medicareoperations Division Medicare https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ Overpayments MLNProducts/MLN-Publications-Items/CMS1243389.html Publication Office of Medicare https://www.hhs.gov/about/agencies/omha Hearings and Appeals OMHA FAQs https://www.hhs.gov/about/agencies/omha/filing-an-appeal/faqs/requesting-analj-hearing Original Medicare (Fee- https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals For-Service) Appeals 12 Medicare Parts A & B Appeals Process Table 8. Hyperlink Table (cont.) Embedded Complete URL Hyperlink Original Medicare https://www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/ Appeals original-medicare-appeals.html Second Level of Appeal: https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Reconsideration by ReconsiderationbyaQualifiedIndependentContractor.html a QIC Settlement Conference https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlementFacilitation conference-facilitation Statistical Sampling https://www.hhs.gov/about/agencies/omha/about/special-initiatives/statisticalInitiative sampling Third Level of Appeal https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ AIC threshold HearingsALJ.html Third Level of Appeals https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ HearingsALJ.html The Medicare Learning Network® Disclaimers are available at http://go.cms.gov/Disclaimer-MLN-Product.

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