Medicare Appeals

Five Types of Medicare Appeals in Part B

There are five types of Medicare Appeals. The process differs slightly for Medicare Part A, Medicare Part B fee for service, Medicare Part C (Medicare Advantage) and Medicare Part D (Drug) Process

The discussion and information below pertains to Medicare Part B Appeals.

1. Redetermination
2. Reconsideration
3. Administrative Law Judge
4. Appeals Council
5. Federal Court

Generally Medicare refers to Medicare National Coverage Determinations (or Medicare NCDs) and Medicare Local Coverage Determinations (Medicare LCDs) as part of the basis for its appeals.

If a Medicare LCD is inconsistent, silent on an issue or if the Medicare LCD is vague, this issues need to be addressed during the appeals process.  A Medicare Medical Billing Expert Witness may need to be a part of the appellant’s team as well as representation by an attorney during at least the later appeal phases.

First Level of Appeal: Redetermination

Redeterminations are performed by the Medicare Contractor that made the initial determination of the claim.
Redeterminations must be requested 120 days from the date of receipt of the notice initial determination (MSN or RA).
The notice of initial determination is presumed to be received five days from the notice’s date unless there is evidence to the contrary.
At the first level of appeal, there is, according to one Medicare Administrative Contractor (MAC), no monetary threshold to be met for the amount in controversy (AIC).

Written requests for Redetermination may be made on official CMS forms such as the CS 20027

MEDICARE REDETERMINATION REQUEST FORM CMS-20027 Form located on the CMS website
• Part B Redetermination Request Form – Level 1 – This is an example for one MAC (National Government Services) for Medicare Part B Contracts

Redetermination Requests

A written request not made on one of the CMS-20027 forms must include the following information:
• Beneficiary name
• Medicare Beneficiary Identifier (MBI)
• Name and address of the physician/supplier of item/service
• Specific service and/or item (s) for which a redetermination is being requested
• Specific date (s) of service
• Name and signature of the party or the authorized or appointed representative of the party
• Indicate the group number if the claim was processed under the group
• Date of initial determination (claim number is acceptable)

The appellant should attach any supporting documentation to their redetermination request.

Contractors will generally issue a decision (either a letter or a revised remittance advice) within 60 days of receipt of the redetermination request.

Required Documentation

The carrier documentation to support the case must be included. Documentation may include:
1. Billing Forms
2. Clinical summaries
3. Consultation reports
4. Copies of communications between physician and/or patient, hospital, carrier, laboratory, etc.
5. Documentation of severity or acute onset
6. Medical history
7. Nurse’s notes
8. Plan of treatment
9. Referrals
10. Test results
11. X-ray reports

Each MAC Jurisdiction has a MAC with its own address for appeals.

Second Level of Appeal: Reconsideration

The second level of appeal is the reconsideration request and is carried out by the QIC.
• Time limit to initiate = 180 days from date of receipt of redetermination decision
• Time limit to complete the review = 60 days
• Amount in controversy = no minimum amount

1. To request a reconsideration, follow the instructions on the Medicare Redetermination Notice (MRN).

2. A request for a reconsideration may be made on Form CMS-20033. This form will be mailed with the MRN.

Required Documentation

If the form is not used, the written request must contain all of the following information:

• Medicare Beneficiary Identifier (MBI)
• Specific service(s) and/or item(s) for which the reconsideration is requested
• Specific date(s) of service
• Name and signature of the party or the authorized or appointed representative of the party
• Name of the contractor that made the Redetermination

The request should clearly explain why you disagree with the Redetermination.

A copy of the MRN and any other useful documentation should be sent with the reconsideration request to the QIC identified in the MRN.

Documentation that is submitted after the reconsideration request has been filed may result in an extension of the timeframe a QIC has to complete its decision.

Further, any evidence noted in the Redetermination as missing and any other evidence relevant to the appeal must be submitted prior to the issuance of the reconsideration decision.

Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent appeal levels unless you show good cause for submitting the evidence late.

Reconsideration Decision Notification

Reconsiderations are conducted on-the-record, and, in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration.

The decision will contain detailed information on further appeals rights if the decision is not fully favorable.

If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ.

Third Level of Appeal: Administrative Law Judge (ALJ) Hearing

The third level of appeal is an ALJ hearing.
• Time limit to initiate = 60 days from the date of receipt of reconsideration (QIC decision)
• Time limit to complete the review = 90 days
• Amount in controversy = $160
Note: The amount that must remain in controversy for ALJ hearing requests filed on or before 12/31/2017 is $160. This amount will remain at $160 for ALJ hearing requests filed on or after 1/1/2018.
Your request must specifically state that an ALJ hearing is desired, and the request must be signed.
For complete details on the content required for a request for a hearing, refer 3211741
• Federal regulations (42 CFR Section 405.1014),
• Office of Medicare Hearings and Appeals (OMHA) website
Send the completed form for Medicare Hearing by an Administrative Law Judge to the local Office of Medicare Hearings and Appeals field office specified in your reconsideration determination.

ALJ hearings are generally held by video-teleconference (VTC) or by telephone.

If you do not want a VTC or telephone hearing, you may ask for an in-person hearing.

An appellant must demonstrate good cause for requesting an in-person hearing.

The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis.

Appellants may also ask the ALJ to make a decision without a hearing (an on-the-record).

Hearing preparation procedures are set by the ALJ. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and all parties to the hearing.

The ALJ will generally issue a decision within 90 days of receipt of the hearing request.

This timeframe may be extended for a variety of reasons including, but not limited to:
• the case being escalated from the reconsideration level
• the submission of additional evidence not included with the hearing request
• the request for an in-person hearing
• the appellant’s failure to send notice of the hearing request to other parties
• and the initiation of discovery if CMS is a party.
If the ALJ does not issue a decision within the applicable timeframe, you may ask the ALJ to escalate the case to the Appeals Council level.

The provider must include the following when requesting an ALJ hearing:
• Witness’s name (if applicable)
• Reasons for disagreement with the hearing officer’s decision
• Date of the carrier denial
• Surgery or treatment reports; and
• Any medical documentation that supports the case

Fourth Level of Appeal: Appeals Council Review

If a party to the ALJ hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Appeals Council.

There are no requirements regarding the amount of money in controversy.

The request for Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ’s decision and must specify the issues and findings that are being contested. (Refer to the ALJ decision for details regarding the procedures to follow when filing a request for Appeals Council review.)

In general, the Appeals Council will issue a decision within 90 days of receipt of a request for review.

That timeframe may be extended for various reasons, including but not limited to the case being escalated from an ALJ hearing.

If the Appeals Council does not issue a decision within the applicable time frame, you may ask the Appeals Council to escalate the case to the Judicial Review level.

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

The fifth level of appeal is carried out by the Federal District Court (U.S. District Court).
• Time limit to initiate = 60 days from date of receipt of Medicare Appeals Council decision
• Effective for Federal District Court requests filed on or before 12/31/2018, the amount in controversy is $1,600. This amount will increase to $1,630 for appeals to the Federal District Court filed on or after 1/1/2019.

The Appeals Council’s decision will contain information about the procedures for requesting a judicial review.

Appeals for Judicial Review are sent to the U.S. Department of Health and Human Services

You will be notified 20 days prior to the hearing

The judge will review the case in light of Medicare laws and regulations

It will be within 30 to 60 days in which you will receive a written ruling from the judge describing the factual findings and reasoning for the decision based on the evidence from the hearing included in the record

The judge’s decision is binding

Notes to Appellant Providers

Providers should be aware that there is no need to appeal a claim if the provider has made a minor error or omission in filing the claim, which caused the claim to be denied

Many corrections need revised information and can be resubmitted.

You may request a reopening of the original claim processing decision by contacting our Telephone Reopening Unit (TRU).

The TRU representatives are available when you wish to revise the initial determination or Redetermination of a specific service or claim for minor clerical errors.

Each level must be completed for each claim at issue prior to proceeding to the next level of appeal

No appeal can be accepted until an initial determination has been made for the claim

Typically Appeal requests to a MAC may be made in writing or online portal in writing

Contacting the Telephone Reopening Unit (TRU) for National Government Services Providers
When requesting a reopening over the phone, you must be prepared to provide the following information:
• Beneficiary’s name
• Medicare Beneficiary Identifier (MBI)
• Your full name (first and last name)
• Your phone number
• Provider’s name
• Provider’s number
• Date(s) of service in question
• Reason for request

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Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been quoted in the Wall Street Journal, New York Times, and National Public Radio.

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