Can you please explain the Medicare Appeals process?

Appealing Medicare Decisions

1. 1. The appropriate forms are available and can be downloaded on the website of your Medicare Administrative Contractor.
2. 2. MEDICARE APPEALS PROCESS:  Medicare Part B provides 5 levels of administrative appeals for Physicians and other Suppliers.
3. 3. APPEALING MEDICARE DECSIONS: 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 my assign their appeal rights to Physicians who provide them with services or items.

FIVE LEVELS IN THE APPEALS PROCESS

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 $160.00 remaining in controversy. Refer to Form CMS 5011 A/B.

DEPARTMENTAL APPEAL BOARD REVIEW:

Must be billed 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 $1,560.00 remaining in the controversy.

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.

REOPENING: 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. Providers can contact the Medicare Contractor/Carrier customer service to initiate a REOPENING.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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