The New Medicare Appeals Process
Uniform Appeal Procedures for Part A and B
The Centers for Medicare and Medicaid Services have put in place a new appeals process for Medicare Part A and B which is significantly different from the appeals procedure you may be familiar with. The new appeals process applies a uniform process for Medicare Part A and Part B appeals, revises time frames for filing appeals and issuing decisions, and establishes a new appeal entity, the Qualified Independent Contractor (QIC), to conduct reconsiderations.
Expansion of Appeal Rights
Prior to the changes in the appeal process, there were significant differences in the appeals process for Part A and Part B claims. A Part A provider was only permitted to appeal claims when certain conditions were met and did not have the direct right to appeal claims when services failed to meet the requirements of a covered benefit. The new regulations allow all providers to have direct appeal rights with regard to all Medicare initial determinations.
New 6 Step Appeal Process
| 1. |
Initial Determination: Providers will continue to be notified of initial determinations by the Medicare contractor in writing in the form of a Remittance Advice to providers. A contractor must issue initial determinations within 30 days or interest will accrue on the claim. |
| 2. |
First Level of Appeal - Redetermination: A provider will be required to file a redetermination request in writing within 120 days of receiving the initial determination. The contractor is required to mail or otherwise transmit notice of its redetermination decision within 60 days. This 60 day timeframe can be extended by 14 days each time the provider submits additional evidence to the contractor. |
| 3. |
Second Level of Appeal - Reconsideration: A provider who is dissatisfied with a redetermination decision of a contractor will be permitted to file a request for reconsideration to be conducted by the QIC. This request must be filed within 180 days of receiving the notice of redetermination. The QIC reconsideration stage is an "on-the-record" review (as opposed to an in-person hearing review previously afforded to Part B providers). The QIC will review the initial determination, the redetermination, and all issues relating to the payment of the claim together with all evidence submitted by the provider. Within 60 days of receiving the request for reconsideration, the QIC must either (i) notify all parties of the reconsideration decision; or (ii) notify the provider that it cannot complete the reconsideration by the deadline and offer the provider the opportunity to escalate the appeal to an administrative law judge (ALJ). |
| 4. |
Third Level of Appeal - Administrative Law Judge Hearing: A provider who is dissatisfied with an reconsideration decision may request an ALJ hearing. The request must be filed within 60 days after receipt of notice of the QIC decision and must meet a $100 amount in controversy requirement. ALJ hearings can be conducted in-person, by video-conference or by telephone. |
| 5. |
Fourth Level of Appeal - Medicare Appeals Council Review: The fourth level of the appeals process is review by the Medicare Appeals Council (MAC). A MAC review request must be filed within 60 days after receipt of the ALJ's decision or dismissal. After reviewing all of the evidence in the administrative record, the MAC is required to make a decision or remand the case back to an ALJ. If the MAC fails to make a decision within 90 days, the provider may request that the appeal be escalated to federal district court. |
| 6. |
Federal District Court Review: The final step in the appeals process is judicial review in federal district court. |
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