Levels of appeals of claims decisions -- when to file an appeal

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Home ► Appeals ► Levels of appeals of claims decisions -- when to file an appeal

Last Modified: 6/16/2017 Location: FL, PR, USVI Business: Part A, Part B

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Calculate the time limit for filing each level of appeal

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 Enter initial claim determination date Submit request by:	Medicare administrative contractor (MAC)
Second level: Reconsideration	180 days from the redetermination decision Enter date of redetermination decision Submit request by:	Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)	60 days from the date of the reconsideration decision Enter date of reconsideration decision Submit request by: *Monetary threshold for requests filed January 1, 2015-December 31, 2016: $150. For requests made on or after January 1, 2017, the threshold is $160.	Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council	60 days from the date of the ALJ decision Enter date of ALJ decision Submit request by:	Departmental Appeals Board
Fifth level: Judicial review:	60 days from the date of the Medicare Appeals Council decision Enter date of Medicare Appeals Council decision Submit request by: *Monetary threshold for requests made January 1, 2016-December 31, 2016: $1,500. For requests made on or after January 1, 2017, the threshold is $1,560.	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.

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