October 19, 2007
Medicare Appeals Process
Once an initial claim determination is made through the Comprehensive Error Rate Testing (CERT) Program providers have the right to appeal the CERT decision through the Medicare Appeals Process.
What is the Medicare Appeals Process?
- The Medicare Appeals Process is intended to offer a party to the appeal a course of action when there is a disagreement with the carrier’s initial claim determination.
There are Five Levels of the Medicare Appeals Process
- First Level of Appeal: Redetermination by a Medicare Contractor
- A redetermination is a reexamination of an initial claim determination by the fiscal intermediary (FI), carrier, or Medicare Administrative Contractor (MAC) personnel who are different from the personnel who made the initial claim determination. The appellant (the person with a right to appeal an initial determination) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.
- Second Level of Appeal: Reconsideration by a Qualified Independent Contractor
- A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. This must be filed within 180 days from the date of receipt of the notice of the redetermination. A Qualified Independent Contractor (QIC) will conduct the reconsideration.
- Third Level of Appeal: Hearing by an Administrative Law Judge (ALJ)
- If at least $110 remains in controversy following the Qualified Independent Contractor's (QIC's) decision, a party to the reconsideration may request an Administrative Law Judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration.
- Fourth Level of Appeal: Departmental Appeals Board (DAB)
- If a party to the Administrative Law Judge (ALJ) hearing is dissatisfied with the ALJ's decision, the party may request a review by the DAB. There are no requirements regarding the amount of money in controversy. The request for DAB 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.
- Fifth Level of Appeal: U.S. District Court Review
- If $1,130 or more is still in controversy following the DAB’s decision, judicial review before a U.S. District Court judge may be requested. The appellant must request a U.S. District Court hearing within 60 days of receipt of the DAB's decision.
Redeterminations
A request for a redetermination must be filed either on Form CMS-20027 or in writing. To link to this form, scroll down to "Related Links" A written request not made on Form CMS-20027 must include the following information:
- Beneficiary name
- Medicare Health Insurance Claim (HIC) number
- 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 representative of the party
The appellant should attach any supporting documentation to their redetermination request. The Carrier will generally issue a decision (either in a letter, a revised remittance advice, or a Medicare Summary Notice) within 60 days of receipt of the redetermination request.
Note: Carriers can no longer correct minor errors and omissions on claims through the appeals process. For information on how to correct minor errors and omissions, please scroll down to Correcting Minor Errors below.
Reconsideration
A written reconsideration request must be filed with a QIC within 180 days of receipt of the redetermination. To request a reconsideration, follow the instructions on your Medicare Redetermination Notice (MRN). A request for a reconsideration may be made on the standard form CMS-20033. This form is mailed with the MRN. If the form is not used, the written request must contain all of the following information:
- Beneficiary's name
- Beneficiary's Medicare health insurance claim (HIC) number
- Specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service
- Name and signature of the party or 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 appropriate QIC. 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, the reconsideration request must contain any evidence noted in the redetermination as missing and any other evidence relevant to the appeal. However, it is not necessary to resubmit information that was already submitted to the contractor that made the redetermination. Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you show good cause for not submitting the evidence.
Reconsideration Decision Notification
Generally, 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 Administrative Law Judge.
ALJ Hearing
Refer to the reconsideration decision letter from the QIC for details regarding the procedures for requesting an ALJ hearing. The standard form CMS-20034 A/B may be used to file a request for an ALJ hearing.
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, and 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 (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 notifying 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 a notice of the hearing request to other parties
- The initiation of discovery if CMS is a party
If the ALJ cannot issue a decision in the applicable timeframe, the ALJ will notify the appellant of their right to escalate the case to the Departmental Appeals Board (DAB).
Please note that the amount in controversy required to request an ALJ hearing is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers. The amount in controversy for 2007 is $110.
Departmental Appeals Board (DAB)
Refer to the ALJ decision for details regarding the procedures to follow when filing a request for DAB review.
Generally, the DAB 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 the ALJ level.
U.S. District Court Review
The DAB's decision will contain information about the procedures for requesting U.S. District Court Review.
Please note that the amount in controversy required to request a judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers. The amount in controversy for 2007 is $1,130.
Correcting Minor Errors:
For situations that fall into the category of a minor error/omission, the provider should request a Reopening. This Reopening Request must be made within one year from the date of notice of the initial determination. A Reopening must state the reason the inquiry is being sent to the Medicare office and can be submitted on the Written Adjust form (see link under Related Links). Below are some examples of requests that may be resubmitted as Reopenings:
- To correct a claim for clerical errors or omissions (i.e. add modifier, correct date of service, correct number of services, place of service, submitted amount, CPT code, etc).
- If benefits are exhausted by primary insurance company
- If Medicare is secondary and we originally denied claim for missing EOB and provider is sending EOB from primary insurance
- Timely filing denials
Related Links:
Centers for Medicare & Medicaid Services (CMS) Original Medicare (Fee-for-service) Appeals http://www.cms.hhs.gov/OrgMedFFSAppeals/01_Overview.asp#TopOfPage
CIGNA Government Services http://www.cignagovernmentservices.com
Redetermination Request Form http://www.cignagovernmentservices.com/partb/pubs/news/2007/0807/cope6337.html
Reopenings Adjustment Request Form http://www.cignagovernmentservices.com/partb/pubs/news/2007/0807/cope6337.html
Please mail your Redeterminations request to the following PO Boxes:
Idaho
CIGNA Government Services
Attn: Redeterminations
PO Box 22990
Nashville, TN 37202
Tennessee
CIGNA Government Services
Attn: Redeterminations
PO Box 23950
Nashville, TN 37202
North Carolina
CIGNA Government Services
Attn: Redeterminations
PO Box 24770
Nashville, TN 37202
