Medicare Appeals

Five Types of Medicare Appeals, Medicare 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.

Key points to note if you are considering an appeal:

  1. If a Medicare LCD is inconsistent, silent on an issue or if the Medicare LCD is vague, this issue 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.
  2. If the auditors who performed the appeal made errors, these should be identified, with specific citations to the Generally Accepted Standards that are applicable
  3. Second, statistical sampling sizes used in Medicare audits should be addressed, if applicable in the appeals process

First Level of Appeal: Redetermination

Redeterminations are performed by the Medicare Contractor that made the initial determination of the claim.
Redeterminations must be requested [within] 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

• 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.

(See Second Level of Appeal: Reconsideration by a Qualified Independent Contractor)

• 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

  1. 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
  2. Many corrections need revised information and can be resubmitted.
  3. You may request a reopening of the original claim processing decision by contacting our Telephone Reopening Unit (TRU).
  4. 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.
  5. Each level must be completed for each claim at issue prior to proceeding to the next level of appeal
  6. No appeal can be accepted until an initial determination has been made for the claim
  7. Typically Appeal requests to a MAC may be made in writing or online portal in writing
  8. 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

Additional points to note if you are considering a Medicare appeal:

  1. If a Medicare LCD is inconsistent, silent on an issue or if the Medicare LCD is vague, this issue 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.
  2. If the auditors who performed the appeal made errors, these should be identified, with specific citations to the Generally Accepted Standards that are applicable
  3. Second, statistical sampling sizes used in Medicare audits should be addressed, if applicable in the appeals process


Important Terminology Used by Medicare in the Appeals Process

  1. Amount in Controversy (AIC): The required threshold Level 3 and Level 5 appeal dollar amount remaining in dispute. CMS adjusts the AIC annually by a percentage increase tied to a consumer price index.
  2. Appeal: The process used when a party (for example, a patient, provider, or supplier) disagrees with an initial health care items or services determination or a revised determination.
  3. Appellant: A person or entity filing an appeal.
  4. Attorney Adjudicator: A licensed attorney HHS OMHA employs with knowledge of Medicare coverage and payment laws and guidance, authorized to issue QIC dismissal review decisions and certain Administrative Law Judge (ALJ) hearing requests.
  5. Determination: A decision on payment and claim liability.
  6. Escalation: When an appellant requests moving a reconsideration pending at the QIC level (second level appeal) or higher to the next level because the adjudicator can’t make a prompt decision or dismissal. The appeal must meet the applicable AIC Level 3 and Level 5 requirements and aggregation provisions.
  7. Medicare Redetermination Notice (MRN): A Medicare Administrative Contractor (MAC) letter informing a party about the redetermination decision.
  8. Non-participating: Physicians and suppliers who haven’t signed a Medicare participation agreement but may choose to accept or not accept Medicare assignment on a claim-by-claim basis. Non-participating physicians and suppliers have limited appeal rights.
  9. On-the-Record: A decision based solely on information within the administrative record and evidence sent with the request. There’s no hearing held. Party: A person or entity with standing to appeal an initial determination or subsequent administrative appeal determination or decision.
  10. (QIC): Qualified Independent Contractor (QIC)

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Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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