The Five Levels of Original Medicare Appeals
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If you disagree with a decision made by Original Medicare, Part A and Part B, regarding coverage details or cost amounts, you have the right to file an appeal. There are five levels to the Original Medicare appeals process, and if you decide to undertake this process, you’ll start at Level 1.
If you disagree with the decision at the end of any level of appeal, you’ll be able to file at the next level, as necessary. Instructions for reaching the next level of appeal can be found in the decision letter Medicare sends you at the end of any level.
Level 1: Redetermination by the company that handles Medicare claims
Your quarterly Medicare Summary Notice (MSN) provides a list of covered services and supplies that have been billed to Medicare during a three-month period. On this notice, you can see the dollar amounts that were sent to Medicare, and also the amount you’re responsible for paying to the service provider (if any).
You can also use the MSN to find out if Medicare has fully or partially denied your medical claim.
This is where you’ll decide if an appeal is necessary. If you don’t agree with any of the information on the MSN, you can file an appeal, also known as a redetermination. You must do so within 120 days of receiving the MSN that contains the charge you disagree with.
You can file an appeal in any of three ways:
- Download and complete a Redetermination Request Form and send it to the Medicare contractor at the address listed on your MSN.
- Send your appeal to the company handling Medicare claims (this is found in the MSN’s “Appeals Information” section). When doing this, make sure to:
- Circle every applicable item and/or service you disagree with and put in writing why you disagree with the decision (do this on a separate sheet of paper, if necessary).
- Include your name, address, phone number, and Medicare number.
- Sign the MSN document where your signature is necessary. If your doctor or health-care provider contributed any additional information to help your case, include that as well.
- Send a written request to the company that handles Medicare claims (the address can be found in the MSN’s “Appeals Information” section). When doing this, make sure to include:
- Your name and Medicare health insurance claim number
- The specific item(s) and/or service(s) for which you’re requesting a redetermination and the specific date(s) of service
- A written explanation of why you don’t agree with the initial determination
- Your signature. If you’ve appointed a representative, like a doctor or health-care provider, include the name and signature of your representative.
Look for a Medicare Redetermination Notice within 60 days after the Medicare Administrative Contractor (MAC) gets your redetermination request. This notice, which will include the contractor’s decision, can come as part of your quarterly MSN or in a separate letter.
If you disagree with this decision, you can advance your appeal to Level 2 within 180 days after you getting the notice.
Level 2: Reconsideration by a Qualified Independent Contractor
The second level of appeals finds your case reviewed by a Qualified Independent Contractor (QIC) who did not take part in the decision on the first level of the appeal process. The QIC will make a decision following a review of the materials.
You can file a Level 2 appeal in either of two ways:
- Download and complete a Medicare Reconsideration Request Form.
- Send a written request to the QIC that includes all of the following information:
- Your name and Medicare health insurance claim number
- The specific item(s) or service(s) that prompted your reconsideration. Include the dates on which you received the services or items.
- The name of the company that made the redetermination (the company that handled the Medicare claim in Level 1). You can find this information on the Medicare Summary Notice or the redetermination notice.
- A detailed explanation of why you disagree with the decision.
- Your signature or your representative’s signature.
The request should clearly explain why you disagree with the redetermination decision from Level 1. Make sure to state your argument in writing with as much clarity and detail as possible.
The Level 1 redetermination letter will include directions on how to submit a request for reconsideration. Generally, you’ll get a response within 60 days. In situations where you either disagree with the QIC’s decision or you’re waiting for a response longer than 60 days, you can move to the next level of appeals.
The QIC will give you a Medicare Reconsideration Notice. If you disagree with its decision and want to continue to the next appeal level, you must do this within 60 days after you get the notice.
Level 3: Administrative Law Judge hearing
If your appeal reaches Level 3, your case is then heard by an Administrative Law Judge (ALJ), generally by phone or video-teleconference or in some cases, in person. You also have the right to request the ALJ review the information independently and make a decision without hearing your testimony. The ALJ may decide to make a decision without hearing your testimony if he or she feels there is already enough information to reach a decision in your favor.
In order for your case to be eligible for Level 3, it must meet a specific dollar amount, which may change from year to year. You may be able to combine claims to meet the minimum dollar amount.
You’ll send your request to the Office of Medicare Hearings and Appeals (OMHA) Central Operations. You’ll find the appropriate address listed in the Medicare Reconsideration Notice you received in Level 2.
You can file a Level 3 appeal in either of two ways:
- Complete a Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal.
- Send a written request to the OMHA office that will handle your ALJ hearing and include:
- Your name, address, and Medicare health insurance claim number. If you’ve appointed a representative to handle your appeal, that person should include his or her name and address.
- The appeal number included on the Level 2 reconsideration notice, if any
- A list of dates for the items or services you’re appealing
- A detailed written explanation of why you disagree with the Level 2 decision
- Any additional information you feel might help your case. If you can’t include this information with your request, say what you’ll be submitting and when you’ll send it.
Your doctor or other health-care provider can request this level of appeal for you, but you have to submit an Appointment of Representative form.
The ALJ will usually send you a decision within 90 days of receiving your request. You can request that the ALJ to move your case to the next level of the appeal process if his or her decision is delayed beyond the 90-day window.
When you get the ALJ’s decision, if you disagree with it, you have 60 days to request to move to Level 4.
Level 4: Medicare Appeals Council review
In Level 4, the Medicare Appeals Council will review the ALJ’s Level 3 decision. The request can be submitted in either of two ways:
- Complete a Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal form.
- Send a written request to the Medicare Appeals Council that includes:
- Your name and Medicare health insurance claim number. If you’ve appointed a representative to handle your appeal, that person should include his or her name and address.
- The specific item(s) and/or service(s) and specific dates of service you’re appealing.
- A written explanation of why you disagree with the ALJ’s decision, and the date the ALJ’s decision was issued. Be specific as to which part or parts of the decision you disagree with.
- Your signature and the signature of your representative (if you appointed one).
- If you’re moving the case to the next level because the ALJ’s decision hasn’t been reached in more than 90 days, include the name of the hearing office where the request for hearing is pending.
If the Medicare Appeals Council doesn’t respond within 90 days, you can ask the council to move your case to the final level of appeal. If you disagree with the Medicare Appeals Council’s decision, you have 60 days to request judicial review by a federal district court (Level 5).
Level 5: Federal district court judicial review
To get this judicial review, your case must meet a minimum dollar amount, which may change from year to year. You may be able to combine claims to meet this dollar amount. You or your representative can follow the instructions found in the Level 4 review decision to file a Level 5.
You can track your Medicare claims or view electronic MSNs by visiting MyMedicare.gov and setting up your private account. Claims will generally be available within 24 hours after processing.
This article was about Original Medicare, Part A and Part B. Did you know you can add to your Original Medicare coverage? To find out about your Medicare plan options, just enter your zip code where indicated on this page.
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