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Last Modified: 6/13/2013
Location: FL, PR, USVI
Business: Part A, Part B
Appeals of claims decisions
Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.
The five levels of appeals, listed in order, are:
Appeal level |
Time limit for filing request |
Where to file an appeal |
|---|---|---|
First level: Redetermination |
120 days from the initial claim determination
|
Medicare administrative contractor (MAC) |
Second level: Reconsideration |
180 days from the redetermination decision
|
Qualified independent contractor (QIC) |
Third level: Administrative law judge hearing (ALJ) |
60 days from the date of the reconsideration decision
|
Office of Medicare Hearings and Appeals |
Fourth level: Medicare Appeals Council |
60 days from the date of the ALJ decision
|
Departmental Appeals Board |
Fifth level: Judicial review: |
60 days from the date of the Medicare Appeals Council decision
|
Federal District Court |
Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.
Part B clerical reopening
A clerical error could occur when one of the following happens to your claims:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service
There are two options for conducting a clerical reopening of a claim:
• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
.First level of appeal: Redetermination
A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) 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.
First Coast Service Options (First Coast) redetermination forms for Part A
First Coast redetermination forms for Part B
Centers for Medicare & Medicaid Services (CMS) redetermination form
Second level of appeal: Reconsideration
A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.
First Coast reconsideration forms for Part A
First Coast reconsideration forms for Part B
CMS reconsideration form
Third level of appeal: Hearing by an administrative law judge (ALJ)
If at least $140 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. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).
By clicking here 
you will find information on the OMHA website.
you will find information on the OMHA website.The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.
CMS ALJ form
Fourth level of appeal: Review by the Medicare Appeals Council
If a party to the an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare 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. By clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.
you will find information on the Medicare Operations Division/Medicare Appeals Council.The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.
Departmental Appeals Board form for filing an appeal with the Medicare Appeals Council:
Fifth level of appeal: Judicial review
If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.
• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.
Additional resources
Within the First Coast and CMS websites you will find information related to the five levels in the Part A and Part B appeals process.
First Coast links
CMS links
CMS resource materials available for download
CMS Internet-only manuals: Publication 100-04
