• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • Donate Now
  • Sign Up

Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

  • Eligibility/Enrollment
  • Coverage/Appeals
    • Medicare Costs (2020 & 2021)
    • Self Help Materials – Toolkits & More
  • Topics
    • Basic Introduction to Medicare
    • COVID-19 and Medicare
    • Medicare Costs (2020 & 2021)
    • Home Health Care
    • Improvement Standard and Jimmo News
    • Nursing Home / Skilled Nursing Facility Care
    • Outpatient Observation Status
    • Part B
    • Part D / Prescription Drug Benefits
    • Medicare for People Under 65
    • Medicare “Reform”
    • All Other Topics
    • Resources
      • Infographics
  • Publications
    • CMA Alerts
    • Fact Sheets & Issue Briefs
    • Infographics
    • The Medicare Handbook
    • SNF Enforcement Newsletter
    • Elder Justice Newsletter
    • Medicare Facts & Fiction
    • Articles by Topic
  • Litigation
    • Litigation News
    • Cases
    • Litigation Archive
    • Amicus Curiae Activities
  • Newsroom
    • Press Releases
    • Editorials & Letters to the Editor
    • CMA Comments, Responses, and Letters
    • Medicare Facts & Fiction
    • CMA in the News
  • About Us
    • Mission Statement
    • CMA FAQs
    • Personnel & Boards
    • The Center for Medicare Advocacy Founder’s Circle
    • Connecticut Dually Eligible Appeals Project
    • Ossen Medicare Outreach, Education and Advocacy Project
    • National Medicare Advocates Alliance
    • National Voices of Medicare Summit
    • CMA Webinars
    • Products & Services
    • Testimonials
    • Career, Fellowship & Internship Opportunities
    • Contact Us
  • Support Our Work
    • Donate Now
    • Join the Center for Medicare Advocacy Founder’s Circle
    • Take Action
    • Share Your Health Care Story
    • Tell Congress to Protect Our Care
    • Listen to Medicare & Health Care Stories
    • Sign Up

Appeal Steps

Print Friendly, PDF & Email

 

Standard Appeals Process for Part A and Part B:

1. Redetermination

  • No minimum claim amount
  • Must be filed within 120 days of receipt of "Initial Determination"
  • Filed with Medicare Contractor
  • Reviewed and decided by Medicare Contractor

2. Reconsideration Determination

  • No minimum claim amount
  • Must be filed within 180 days of receipt of "Redetermination"
  • Filed with Qualified Independent Contractor (QI C)
  • Reviewed by Qualified Independent Contractor (QI C)
  • Decisions must be issued within 60 days, or case can be escalated to ALJ, below

3. Administrative Law Judge (ALJ) Hearing

  • Amount in controversy must be at least $140.00 in 2014, and will be $150.00 for 2015**
  • Must be filed within 60 days of receipt of "Reconsideration Determination"
  • Filed with Office of Medicare Hearings and Appeals (OMHA)
  • Reviewed and decided by an Administrative Law Judge from the U.S. Dept of Health and Human Services

4. Medicare Appeals Council (MAC)

  • Amount in controversy must be at least $140.00 in 2014, and will be $150.00 for 2015**
  • Must be filed within 60 days of receipt of ALJ "Hearing Decision"
  • Filed with U.S. Dept of Health and Human Services
  • Reviewed and decided by U.S. Dept of Health and Human Services Medicare Appeals Council

5. Judicial Review

  • Amount in controversy must be at least $1430.00 in 2014, and will be $1460.00 for 2015**
  • Must be filed within 60 days of receipt of "MAC Decision"
  • Filed with U.S. District Court
  • Reviewed and decided by U.S. District Court

Expedited Review

Beneficiaries may seek "expedited review " of a skilled nursing facility, home health, hospice or comprehensive outpatient rehabilitation facility (CORF) services discharge or termination.

 

Expedited review is available in cases involving a discharge from the provider of services, or a termination of services A reduction in service is not considered a termination or discharge for purposes of triggering expedited reviewexcept in the case of skilled nursing facility care when the reduction of care from daily to intermittent will mean that the beneficiary is no longer eligible for Part A coverage. For home health care and CORF services, a successful appeal requires that a physician certify that "failure to continue the provision of such services is likely to place the individual's health at risk."

 

The provider must give the beneficiary a general, standardized notice at least two days in advance of the proposed end of the service. If the service is fewer than two days, or if the time between services is more than two days, then notice must be given by the next to last service. The notice describes the service, the date coverage ends, the beneficiary 's financial liability for continued services, and how to file an appeal.

 

A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination with the QIO in the state in which the beneficiary is receiving the services at issue. The request may be made in writing or by telephone, but the request must be made no later than noon of the calendar day following receipt of the provider 's notice of termination. If the QIO is unavailable to accept the beneficiary’s request, the beneficiary must submit the request by noon of the next day the QIO is available. At that time, the beneficiary is given a more specific notice that includes a detailed explanation of why services are being terminated, a description of any applicable Medicare coverage rules and information on how to obtain them, and other facts specific to the beneficiary’s case. The beneficiary is not financially liable for continued services until two days after receiving the notice , or the termination date specified on the notice , whichever is later.

 

Coverage of the services at issue continues until the date and time designated on the termination notice, unless the QIO reverses the provider’s service termination decision. If the QIO’s decision is delayed because the provider did not timely supply necessary information or records, the provider may be liable for the costs of any additional coverage, as determined by the QIO. If the QIO finds that the beneficiary did not receive valid notice, coverage of the provider services continues until at least 2 days after valid notice has been received. Continuation of coverage is not required if the QIO determines that coverage could pose a threat to the beneficiary 's health or safety.

 

If the QIO upholds the decision to terminate services or discharge the beneficiary, the beneficiary may request expedited reconsideration, orally or in writing, by noon of the calendar day following the QIO's initial notification. The reconsideration will be conducted by the QIC, which must issue a decision within 72 hours of the request. If the QIC does not comply with the time frame, the beneficiary may "escalate " the case to the administrative law judge level.

 

Beneficiaries retain the right to utilize the standard appeals process rather than the new expedited process in all situations. A QIO may review an appeal from a beneficiary whose request is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.

Special Rules for Hospital Claims

Hospital inpatients denied Medicare during their stay may request an "expedited

review’ " of a Medicare denial by the QIO. These expedited requests must be decided by the QIO within three working days.

 

Under previous regulations, a hospital inpatient who received a denial notice from the hospital and requested review immediately avoided being charged until the QIO issued an initial determination. However, the new expedited appeals regulations protect only those inpatients who did not know or could not reasonably have been expected to know that payment would not be made from liability .

 

A beneficiary may request reconsideration review by the QIC for an unfavorable decision . If the reconsideration decision is unsatisfactory and at least $200 remains in controversy, the beneficiary may request an ALJ hearing. Hearing requests must be made within 60 days of receipt of the notice of the reconsideration decision. The hearing request should be made in writing and should be filed with the entity identified in the reconsideration notice.

 

If the hearing request is unsatisfactory, a beneficiary may request a review from the Medicare Appeals Council (MAC). The request must be made within 60 days of receipt of the hearing decision. If $2,000 remains in controversy after the hearing, the case may proceed into United States District Court.

Medicare Advantage ("Medicare Part C", "Medicare Managed Care") Appeals & Grievances

A Medicare Advantage (MA) enrollee also has the right to appeal if the MA plan denies coverage for a service.  An MA plan is required to provide enrollees with information regarding the appeals process as part of the plan materials.  The appeals procedures for Medicare Part C, including the timeframes for requesting appeals,  are different than the appeal procedures for traditional Medicare.  In MA cases, initial determinations are known as "organization determinations. " Organization determinations as well as the next level of review, reconsideration determinations , are made by the MA plan. If a reconsidered decision is denied in whole or in part, it is sent automatically to the Part C Independent Review Entity (IRE), an external review organization hired by CMS to review Medicare Advantage reconsidered decisions. The IRE decision may be appealed to an ALJ, as in Part A or Part B appeals above.

In addition, MA plans are required to have internal grievance procedures. The MA plan must provide information to members regarding this grievance process in the plan’s written membership rules, along with timetables and information about the steps necessary to utilize the grievance process. Grievance procedures are separate and distinct from the appeals procedures.  The grievance procedures are to be used in all cases that do not involve an "organization determination. " For example, controversies about hours of service, location of facilities, or courtesy of personnel would go through the grievance process.  A grievance must be filed either orally or in writing no later than 60 days after the circumstance giving rise to the grievance.

_______________________

**Amount in controversy is increased by the percentage increase in the medical care component price index.

Primary Sidebar

Easy Access to Understanding Medicare

The Center for Medicare Advocacy produces a range of informative materials on Medicare-related topics. Check them out:

  • Medicare Basics
  • CMA Alerts
  • CMA Webinars
  • Connecticut Info & Projects
  • Health Care Stories
  • Se habla Español

Sign Up for CMA Alerts

Jimmo v. Sebelius

Medicare covers skilled care to maintain or slow decline as well as to improve.

Improvement Isn’t Required. It’s the law!

Read more.

Latest Tweets

  • Our statement with @CANHR_CA and the Michigan Elder Justice Initiative recommends key issues of the Nursing Home Re… https://t.co/9nSwt3tAwT, Jan 15
@CMAorg

Footer

Stay Connected:

  • Contact Us
  • Sitemap
  • Products & Services
  • Copyright/Privacy

© 2021 · Center for Medicare Advocacy