Appeals Process for Medicare

Can you please explain the appeals process for Medicare?

REOPENINGS

•      • NOTE: Medicare has established a process for providers and suppliers to correct minor errors and omissions in claims without pursuing the formal appeals process.
•      • REOPENINGS were established to accomplish this.
•      • The purpose of a REOPENING is to change a Medicare determination that resulted in either an overpayment or underpayment.
•      • Requests for adjustments to claims resulting from clerical errors must be handled through the REOPENING process.
•      • ​​​​​​​Requests must be made within 1 year from the date of the original determination.
•      • ​​​​​​​Most REOPENINGS can be done by telephone.
•      • ​​​​​​​Provider can contact the Medicare Administrative Contractor/Carrier customer service to initiate a REOPENING.

Appealing Medicare Decisions

•      • ​​​​​​​Once an initial claim determination is made, participating physicians generally have the right to appeal.
•      • ​​​​​​​Physicians who do not take assignment have limited appeal rights.
•      • ​​​​​​​Beneficiaries may assign their appeal rights to Physicians who provide them with services or items.

MEDICARE APPEALS PROCESS

•      • ​​​​​​​Medicare Part B provides 5 levels of administrative appeals for Physicians and other Suppliers

1. REDETERMINATION: The First Level of Appeal

2. RECONSIDERATION: The Second Level of Appeal

3. ADMINISTRATIVE LAW JUDGE HEARING: The Third Level of Appeal

4. DEPARTMENT APPEAL BOARD REVIEW: The Fourth Level of Appeal

5. JUDICIAL REVIEW IN FEDERAL COURT: The Fifth Level of Appeal

REDETERMINATION

•      • ​​​​​​​Must be filled within 120 days from the date of initial determination using Form CMS-20027.
•      • ​​​​​​​There is no minimum dollar amount required.
•      • ​​​​​​​Submit the CMS-20027 form to your Medicare Contractor/Carrier.
•      • ​​​​​​​You will receive a decision within 60 days of receipt of your appeal.
•      • ​​​​​​​Refer to Form CMS-20027.

RECONSIDERATION

•      • ​​​​​​​Must be filed within 180 days from date of Redetermination.
•      • ​​​​​​​Using Form CMS-20033.
•      • ​​​​​​​There is no minimum dollar amount required.
•      • ​​​​​​​The RECONSIDERATION is handled by Qualified Independent Contractors (QICs).
•      • ​​​​​​​The Redetermination notice you receive will contain the address of the appropriate QIC if you decide to appeal the Redetermination result.
•      • ​​​​​​​Refer to Form CMS-20033.

ADMINISTRATIVE LAW JUDGE HEARING

•      • ​​​​​​​Must be filed within 60 days from receipt of Reconsideration using Form CMS 5011 A/B.
•      • ​​​​​​​There must be at least $180.00 remaining in controversy.
•      • ​​​​​​​Refer to Form CMS 5011 A/B.

DEPARTMENTAL APPEAL BOARD REVIEW
 Medicare Appeals Council (Council) Review

•      • ​​​​​​​Must be filed within 60 days from the receipt of the ALJ Hearing/Dismissal using From DAB 101.
•      • ​​​​​​​There is no minimum dollar amount required.

JUDICIAL REVIEW IN FEDERAL COURT

•      • ​​​​​​​Must be filed within 60 days from receipt of DAB decision.
•      • ​​​​​​​​​​​​​​There must be at least $1,850.00 remaining in the controversy.

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This is my opinion.

Michael G. Warshaw

DPM, CPC