Medicare Appeals Process

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

Medicare Parts A & B Appeals Process

ICN 006562 May 2016

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Level 1 MAC

Level 2 Independent Organization

Level 3 Office of Medicare

Hearings and Appeals

OMHA

Level 4 Medicare Appeals Council

Level 5 Federal Court

Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare).

The Hyperlink Table, Table 8, at the end of this document, provides the complete URL for each hyperlink.

Table of Contents

Overview ...........................................................................................................................1

Appealing Medicare Decisions .........................................................................................1

Appointing a Representative.............................................................................................2

First Level of Appeal: Redetermination .............................................................................3

Second Level of Appeal: Reconsideration ........................................................................4

Third Level of Appeal: ALJ Hearing ..................................................................................5

Fourth Level of Appeal: Medicare Appeals Council Review .............................................7

Fifth Level of Appeal: Judicial Review in U.S. District Court .............................................8

Tips for Filing an Appeal ...................................................................................................8

Appeal Process Summary ................................................................................................9

Resources.......................................................................................................................10

List of Tables

Table 1. Redetermination Frequently Asked Questions (FAQs) and Answers ..................3

Table 2. Reconsideration FAQs and Answers...................................................................4

Table 3. ALJ Hearing FAQs and Answers .........................................................................5

Table 4. Medicare Appeals Council Review FAQs and Answers ......................................7

Table 5. Judicial Review in U.S. District Court FAQs and Answers ..................................8

Table 6. Appeal Process Summary ...................................................................................9

Table 7. Resources .........................................................................................................10

Table 8. Hyperlink Table ..................................................................................................12

1

Overview

This publication provides health care professionals with information about each level of appeal in Original Medicare (Parts A and B), as well as additional resources for information on related topics. It describes how the Medicare appeals process applies to providers and participating physicians and suppliers. In this publication, the pronouns “I” or “you” refer to parties and appellants participating in an appeal.

Find more information about appeals on the Original Medicare (Fee-For-Service) Appeals webpage and beneficiary-specific information about appeals on the Medicare.gov Original Medicare Appeals webpage.

Appealing Medicare Decisions

There are five levels in the claims appeal process under Original Medicare:

Level 1

Redetermination by a Medicare Administrative Contractor (MAC)

Level 2

Reconsideration by a Qualified Independent Contractor (QIC)

Level 3

Hearing before an Administrative Law Judge (ALJ)

Level 4

Review by the Medicare Appeals Council (Appeals Council)

Level 5

Judicial review in United States (U.S.) District Court

Make all appeal requests in writing.

Helpful Terms Amount in Controversy (AIC): The threshold dollar amount remaining in dispute that is required for a Level 3 and Level 5 appeal. The AIC increases annually by a percentage increase tied to a consumer price index. Appeal: The process used when a party (for example, a beneficiary, provider, or supplier) disagrees with an initial determination or a revised determination for health care items or services. Appellant: A person or entity filing an appeal. Determination: A decision made to pay in full, pay in part, or deny a claim. Escalation: When an appellant requests that an appeal pending at the QIC level or higher be moved to the next level because the adjudicator was not able to make a decision within a specified time. Non-Participating: Physicians and suppliers who choose to either accept or not accept Medicare assignment on a claim-by-claim basis. Non-participating physicians and suppliers have limited appeal rights. Party: A person or entity with a right to appeal an initial determination or subsequent administrative appeal decision.

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Appointing a Representative

At any time, a party may appoint any individual, including an attorney, to represent him or her during the processing of a claim or appeal. The representative helps the party by providing assistance and expertise.

To appoint a representative, the party or representative must complete Form CMS-1696 (Appointment of Representative) or another written document with the same information. The form or other document must:

• Be in writing • Be signed and dated by the party and the representative (the representative’s signature must be

dated within 30 days of the party’s signature)

• Include a statement appointing the representative to act for the party • Include a written explanation of the purpose and scope of the representation • Include the names, phone numbers, and addresses of both the party and the representative • Include the representative’s professional status or relationship to the party • Contain a unique identifier of the represented party

If the party is the beneficiary, the Medicare number must be included. If the party is a provider or supplier, the National Provider Identifier (NPI) number is requested.

The appointment is valid for 1 year. During this year, the representative may represent the party in subsequent appeal levels on the initial appeal and for any appeals of other claims, unless the party specifically withdraws the representative’s authority.

Requirements for Appointment of Representatives Find the requirements for appointing a representative in the Medicare Claims Processing Manual, Chapter 29, Section 270.

Transfer of Appeal Rights to Non-Participating Physicians and Suppliers

Beneficiaries may transfer their appeal rights to non-participating physicians or suppliers who provide the items or services and do not otherwise have appeal rights. To transfer the appeal rights, the beneficiary and non-participating physician or supplier must complete and sign Form CMS-20031 (Transfer of Appeal Rights).

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3 Medicare Parts A & B Appeals Process

First Level of Appeal: Redetermination

A redetermination is the first level of appeal after the initial determination on a claim. It is a second look at the claim. Table 1 provides questions and answers about redeterminations.

Table 1. Redetermination Frequently Asked Questions (FAQs) and Answers

Question Answer

When must I file a request?

You must file a request for redetermination within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination.

How do I file a request?

File your request in writing by following instructions provided in the RA. Your request must be sent to the address listed on the RA or filed in person (or follow instructions from your MAC on filing electronically). You may also file a request for redetermination by completing Form CMS-20027 (Medicare Redetermination Request Form – 1st Level of Appeal). Find more information about the requirements for requesting a redetermination on the First Level of Appeal: Redetermination by a Medicare Contractor webpage. REMEMBER

• You, or your representative, must include your name and signature • Attach any supporting documentation to your redetermination request

Is there a minimum AIC requirement?

No.

Who makes the decision?

MAC staff unassociated with the initial claim determination perform the redetermination.

How long does it take to make a decision?

MACs generally issue a decision within 60 days of receipt of the request for redetermination. You will receive notice of the decision via a Medicare Redetermination Notice (MRN) from your MAC, or if the initial decision is reversed and the claim is paid in full, you will receive a revised RA.

NOTE: The MLN Matters® Article SE0420, Correction of Minor Errors and Omissions Without Appeals provides information about Medicare rules that enable you to correct minor errors and omissions on claims without initiating the appeals process.

4

Second Level of Appeal: Reconsideration

If you disagree with the MAC redetermination decision, you may request a reconsideration by a QIC. A reconsideration is a review of the redetermination decision. Table 2 provides questions and answers about reconsiderations.

Table 2. Reconsideration FAQs and Answers

Question Answer

When must I file a request?

You must file a request for reconsideration within 180 days of receipt of the MRN or RA.

How do I file a request? File your request in writing by following instructions provided on the MRN or RA. You may also file a request for reconsideration by completing Form CMS-20033 (Medicare Reconsideration Request Form – 2nd Level of Appeal). Find more information about the requirements for requesting reconsideration on the Second Level of Appeal: Reconsideration by a QIC webpage.

REMEMBER • Clearly explain why you disagree with the redetermination decision • You, or your representative, must include your name and signature • You should submit:

A copy of the RA or MRN Any evidence noted in the redetermination as missing Any other evidence relevant to the appeal Any other useful documentation

Documentation submitted after you file the reconsideration request may extend the QIC’s decision timeframe. NOTE: Evidence not submitted at the reconsideration level may be excluded from

consideration at subsequent levels of appeal unless you demonstrate good cause for submitting the evidence late.

Is there a minimum AIC requirement?

No.

Who makes the decision?

The QIC conducts the reconsideration, which is an independent review of the initial determination, including the redetermination and all issues related to payment of the claim. The reconsideration may include review of medical necessity issues by a panel of physicians or other health care professionals.

How long does it take to make a decision?

Generally, a QIC sends a decision to all parties within 60 days of receipt of the request for reconsideration. If the QIC cannot complete its decision in the applicable timeframe, it will inform you of your rights and the procedures to escalate the case to an ALJ. NOTE: Before escalating your appeal to an ALJ, if you do not receive a decision

on the reconsideration within 60 days, consider allowing an additional 5 to 10 days for mail delays.

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NOTE: On January 1, 2016, CMS launched a new Demonstration with Durable Medical Equipment (DME) Suppliers called the Formal Telephone Discussion Demonstration. The Demonstration provides selected suppliers who have filed a reconsideration request the opportunity to participate in a formal recorded telephone discussion with the DME QIC.

Third Level of Appeal: ALJ Hearing

If you disagree with the reconsideration decision or wish to escalate your appeal because the reconsideration period passed, you may request an ALJ hearing. The ALJ hearing gives you the opportunity—via video teleconference (VTC), telephone, or occasionally in person—to explain your position to an ALJ. The U.S. Department of Health & Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA), which is independent of CMS, is responsible for the Level 3 Medicare claims appeals. Table 3 provides questions and answers about ALJ hearings.

Table 3. ALJ Hearing FAQs and Answers

Question Answer

When must I file a request?

You must file a request for an ALJ hearing within 60 days of receipt of the reconsideration decision letter or after the expiration of the reconsideration period.

How do I file a request?

File your request in writing by following instructions provided in the reconsideration letter. You may also request an ALJ hearing by completing Form CMS-20034 A/B (Request for Medicare Hearing by an Administrative Law Judge). Find more information about the requirements for requesting an ALJ hearing on the Office of Medicare Hearings and Appeals webpage. If you do not want a VTC or telephone hearing, you may ask for an in-person hearing, but you must demonstrate good cause. The ALJ determines whether the case warrants an in-person hearing on a case-by-case basis. You may also ask the ALJ to make a decision without a hearing (on-the-record). REMEMBER

• You must send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. If you are requesting the case be escalated to the Appeals Council, you must send a copy of the request to all other parties and to the ALJ.

• The ALJ sets hearing preparation procedures. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and the parties to the hearing.

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Table 3. ALJ Hearing FAQs and Answers (cont.)

Question Answer

Is there a minimum AIC requirement?

Yes. You may only request an ALJ hearing if a certain dollar amount remains in controversy following the QIC’s decision. The Third Level of Appeal AIC threshold is updated annually. Find out how the AIC amount is calculated on the OMHA FAQs webpage.

Who makes the decision?

The ALJ makes the decision. If the ALJ cannot complete its decision in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to the Appeals Council. The ALJ forwards the decision and case file to the Administrative QIC (AdQIC), which serves as the central manager for all ALJ Original Medicare claim case files. In certain situations, the AdQIC may refer the case to the Appeals Council on CMS’ behalf. If no referral is made to the Appeals Council, and the ALJ decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim, according to the ALJ decision, within 30–60 days.

How long does it take to make a decision?

Due to a record number of appeal requests, there continues to be a delay in OMHA ALJ hearing assignments. OMHA remains committed to processing ALJ hearing requests in the order received and as quickly as possible, given pending requests and adjudicatory resources. OMHA prioritizes Part D prescription drug denial cases that qualify for expedited status and Medicare beneficiary issues. Additional delay can result from:

• Appellant’s failure to send notice of the hearing request to other parties • The discovery request process • Reconsideration-level escalations • Request for an in-person hearing • Submission of additional evidence not included with the hearing request

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. NOTE: New appeal requests are processed as quickly as possible. You will

receive an Acknowledgement of Request letter after your case is entered in to the OMHA case tracking system. Find more information on these timeframes on the Office of Medicare Hearings and Appeals webpage.

NOTE: As part of the efforts to reduce the outstanding number of ALJ hearing requests, OMHA implemented two pilot programs, Settlement Conference Facilitation (SCF) and Statistical Sampling Initiative. SCF is an alternative dispute resolution process that uses mediation principles. Statistical Sampling Initiative applies to appellants with a large volume of claim disputes.

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Fourth Level of Appeal: Medicare Appeals Council Review

If you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review. The HHS Departmental Appeals Board (DAB) Medicare Operations Division administers the Appeals Council review. Table 4 provides questions and answers about Appeals Council reviews.

Table 4. Medicare Appeals Council Review FAQs and Answers

Question Answer

When must I file a request?

You must file your request for Medicare Appeals Council review within 60 days of receipt of the ALJ’s decision or after the ALJ ruling timeframe expires.

How do I file a request? File your request in writing by following the instructions provided by the ALJ. You may also request an Appeals Council review by completing Form DAB-101 (Request for Review of ALJ Medicare Decision/Dismissal). Find more information about the requirements for requesting an Appeals Council review following an ALJ decision or dismissal on the Medicare Operations Division webpage. REMEMBER

• Explain which part of the ALJ decision you disagree with and your reasons for the disagreement

• You must send a copy of the Appeals Council review request to all the parties included in the ALJ’s decision

Is there a minimum AIC requirement?

No.

Who makes the decision?

The Appeals Council makes the decision. If the Appeals Council cannot complete its decision in the applicable timeframe, it will inform you of your rights and procedures to escalate the case to U.S. District Court. The Appeals Council forwards the decision and case file to the AdQIC, which serves as the central manager for all Appeals Council Original Medicare claim case files. If the Appeals Council decision overturns a previous denial (in whole or in part), the AdQIC notifies the MAC that it must pay the claim according to the Appeal Council’s decision within 30–60 days.

How long does it take to make a decision?

Generally, the Appeals Council issues a decision within 90 days from receipt of a request for review of an ALJ decision. If the Appeals Council review stems from an escalated appeal, then the Appeals Council has 180 days from the date of receipt of the request for escalation to issue a decision. A decision may take longer due to a variety of reasons. If the Appeals Council does not issue a decision within the applicable timeframe, you may ask the Appeals Council to escalate the case to the judicial review level. If you are requesting escalation to U.S. District Court, a copy of the request must be sent to all other parties and to the Appeals Council.

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

If you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed, you may request judicial review. Table 5 provides questions and answers about judicial review in U.S. District Court.

Table 5. Judicial Review in U.S. District Court FAQs and Answers

Question Answer

When must I file a request?

You must file a request for judicial review within 60 days of receipt of the Appeals Council’s decision or after the Appeals Council ruling timeframe expires.

How do I file a request? The Appeals Council’s decision (or notice of right to escalation) contains information on how to file a claim in U.S. District Court.

Is there a minimum AIC requirement?

Yes. You may only request judicial review if a certain dollar amount remains in controversy following the Medicare Appeals Council decision. The Fifth Level of Appeal AIC threshold is updated annually.

Who makes the decision?

The U.S. District Court makes the decision.

Tips for Filing an Appeal

Now that we have discussed the five levels in the claims appeals process, here are some best practices when filing an appeal:

• Starting at Level 1, consolidate into one appeal as many similar claims as possible • File timely requests with the appropriate contractor • Include a copy of the decision letter(s) issued at the previous level • Include a copy of the demand letter(s) if appealing an overpayment determination • Include a copy of the Appointment of Representative (AOR) form if representing a

provider/supplier/beneficiary

• Respond promptly to the contractor requests for documentation • Sign your request for appeal

Find more information about the Medicare overpayment collection process in the Medicare Overpayments Publication.

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Appeal Process Summary

A summary of each appeal level is provided in Table 6.

Table 6. Appeal Process Summary

Level Summary of review process

Who performs the

review?

When must you request an appeal?

When should you get a decision?

AIC

1st Level - Redetermination

Document review of initial claim determination

MAC Up to 120 days after you receive initial determination

60 days No

2nd Level - Reconsideration

Document review of redetermination (you should submit any evidence not previously presented at this level)

QIC Up to 180 days after you receive MRN/RA

60 days No

3rd Level - ALJ Hearing

May be an on- the-record review or an interactive hearing between parties

ALJ Up to 60 days after you receive notice of QIC decision or after expiration of the applicable QIC reconsideration timeframe if you do not receive a decision

May be delayed due to volume

Yes*

4th Level - Medicare Appeals Council Review

Document review of ALJ’s decision or dismissal (but you may request oral arguments)

Appeals Council

Up to 60 days after you receive notice of ALJ’s decision or after expiration of the applicable ALJ hearing timeframe if you do not receive a decision

90 days if appealing an ALJ decision or 180 days if ALJ review time expired without an ALJ decision

No

5th Level - Judicial Review

Judicial review U.S. District Court

Up to 60 days after you receive notice of Appeals Council decision or after expiration of the applicable Appeals Council review timeframe if you do not receive a decision

No statutory time limit

Yes*

* The AIC threshold is updated annually. For the current amount, refer to the Related Links section for Third Level of Appeal or Fifth Level of Appeal webpages.

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Resources

For more information, refer to the resources in Table 7.

Table 7. Resources

Resource Website

Appeals Laws, Regulations, and Guidance

Social Security Act, Section 1869 https://www.ssa.gov/OP_Home/ssact/title18/1869.htm

42 Code of Federal Regulations (Part 405, Subpart I) https://www.gpo.gov/fdsys/pkg/CFR-2015-title42-vol2/pdf/CFR-2015-title42-vol2- part405-subpartI.pdf

Medicare Claims Processing Manual, Chapter 29 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c29.pdf

Appeals Process by Medicare Part

https://www.hhs.gov/about/agencies/omha/the-appeals-process

MAC Contact Information

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/ Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map

Medicare Appeals Council

https://www.hhs.gov/dab/divisions/medicareoperations

Medicare Learning Network® (MLN) Guided Pathways

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNEdWebGuide/Downloads/Guided_Pathways_Provider_Specific_Booklet.pdf

MLN Matters® SE1521 Limiting the Scope of Review on Redeterminations or Reconsiderations of Certain Claims

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1521.pdf

OMHA https://www.hhs.gov/about/agencies/omha

OMHA Medicare Appellant Forum

https://www.hhs.gov/about/agencies/omha/about/special-initiatives/appellant- forums

Original Medicare Appeals

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals

Part C Appeals Medicare Managed Care Appeals & Grievances https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG

“Part C Appeals: Organization Determinations, Appeals & Grievances” Web-Based Training (WBT) Course https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/WebBasedTraining.html

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Table 7. Resources (cont.)

Resource Website

Part D Appeals Medicare Prescription Drug Appeals & Grievances https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev “Part D Coverage Determinations, Appeals & Grievances” WBT Course https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/WebBasedTraining.html

QICs https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ ReconsiderationbyaQualifiedIndependentContractor.html

Reopenings https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM4147.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE0420.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c34.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1426.pdf

Settlement Effectuation Instructions for the Department of Health and Human Services (DHHS) Office of Medicare Hearings and Appeals (OMHA) Settlement Conference Facilitation (SCF) Pilot

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ Downloads/R1588OTN.pdf Part A Specific Instructions https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ Downloads/R1633OTN.pdf

U.S. District Courts http://www.uscourts.gov/about-federal-courts/court-role-and-structure

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Table 8. Hyperlink Table

Embedded Hyperlink

Complete URL

Correction of Minor Errors and Omissions Without Appeals

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE0420.pdf

Demonstration with Durable Medical Equipment (DME) Suppliers

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Downloads/Formal-Telephone-Demonstration-Fact-Sheet-2016.pdf

Fifth Level of Appeal AIC Threshold

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Review-Federal-District-Court.html

Fifth Level of Appeals https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ Review-Federal-District-Court.html

First Level of Appeal: Redetermination by a Medicare Contractor

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ RedeterminationbyaMedicareContractor.html

Form CMS-1696 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/ CMS012207.html

Form CMS-20027 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms20027.pdf

Form CMS-20031 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20031.pdf

Form CMS-20033 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf

Form CMS-20034 A/B https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20034AB.pdf

Form DAB-101 https://www.hhs.gov/dab/divisions/dab101.pdf

Medicare Claims Processing Manual, Chapter 29

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ clm104c29.pdf

Medicare Operations Division

https://www.hhs.gov/dab/divisions/medicareoperations

Medicare Overpayments Publication

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/MLN-Publications-Items/CMS1243389.html

Office of Medicare Hearings and Appeals

https://www.hhs.gov/about/agencies/omha

OMHA FAQs https://www.hhs.gov/about/agencies/omha/filing-an-appeal/faqs/requesting-an- alj-hearing

Original Medicare (Fee- For-Service) Appeals

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals

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Table 8. Hyperlink Table (cont.)

Embedded Hyperlink

Complete URL

Original Medicare Appeals

https://www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/ original-medicare-appeals.html

Second Level of Appeal: Reconsideration by a QIC

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ ReconsiderationbyaQualifiedIndependentContractor.html

Settlement Conference Facilitation

https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlement- conference-facilitation

Statistical Sampling Initiative

https://www.hhs.gov/about/agencies/omha/about/special-initiatives/statistical- sampling

Third Level of Appeal AIC threshold

https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ HearingsALJ.html

Third Level of Appeals https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals/ HearingsALJ.html

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Medicare Parts A & B Appeals Process