You know the drill: you provided Medicare-covered, medically necessary services to a patient who has active Medicare coverage. And yet, for some reason, CMS denied your claim. While you could chalk it up to a complicated government payer system and write off the costs of those services, that may not be the best solution—especially if you have the documentation to support the validity of your claim. In that case, you may very well want to appeal Medicare’s decision. To help you do that, here’s (almost) everything you need to know about the Medicare appeals process—specifically, for Original Medicare Parts A and B (adapted from this resource). (For a comparison of the appeals process for Parts A, B, C, and D, check out this resource from the APTA.)

This article is intended to provide a general overview of Medicare’s appeal processes as of the publish date. If you have questions regarding a specific claim decision that may or may not warrant an appeal, please review all CMS appeal resources (Table 7 in this document) and reach out to your local MAC, a Medicare appeals expert, and/or an attorney for counsel.

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There are five levels in Medicare’s claims appeal process:

1. Redetermination by a Medicare Administrative Contractor (MAC)

If you disagree with CMS’s initial decision to deny a claim, then you can file a Request for Redetermination—essentially a review by MAC staff members who had nothing to do with your initial claim determination—within 120 days of receiving the Remittance Advice (RA). Your RA should come with instructions on exactly how to do that. But, just in case, here is the link for Form CMS-20027—and you can learn more about the specific requirements for requesting a redetermination here. You should receive a decision within 60 days of when the MAC received the request—and it will come in the form of either a Medicare Redetermination Notice (MRN) or, if the decision was reversed and the claim has been paid, a revised RA.

CMS Tips

Here are four tips CMS wants you to know regarding this appeal level (and really, all the other appeal levels, too). You—or whomever you choose to represent you—should:

  1. Make all appeals in writing—and always include your name and signature.
  2. Appoint a representative to provide “assistance and expertise” (if you feel like you’re in over your head, that is).
  3. Attach all necessary supporting documentation to the request.
  4. Keep at least one copy of everything you submit during the process.

According to the APTA, “it may be helpful to include a written letter outlining why you disagree with the reason for denial.” Thus, the Association has created template letters for its members (specifically, those wishing to appeal a decision pertaining to modifier 59, a change in practice location, and/or medical necessity).

2. Reconsideration by a Qualified Independent Contractor (QIC)

According to CMS, if you still disagree with the decision rendered by the MAC, then you can submit a request for reconsideration by a QIC within 180 days of receiving the MAC’s decision. Instructions can be found on the MRN or RA. But again, just in case, here is the link for Form CMS-20033—and you can learn more about the specific requirements for requesting a reconsideration here. Most reconsideration decisions are made within 60 days of receipt; however, CMS recommends giving the QIC five to ten extra days for mail delays before escalating your appeal to level three.

CMS Tips

Here are two tips CMS wants you to remember regarding this appeal level. You—or whomever you choose to represent you—should:

  1. “Clearly explain why you disagree with the redetermination decision.”
  2. Submit complete information, including:
    1. A copy of the RA or MRN;
    2. Missing evidence listed on the redetermination notice—as well as any other evidence you believe to be relevant to your request; and
    3. Additional documentation to support your appeal.

It’s important to note that if you submit evidence late (i.e., after filing your reconsideration request), it could delay the decision—or worse, that evidence “may be excluded from consideration at subsequent levels of appeal unless you demonstrate good cause for submitting the evidence late.”

3. Administrative Law Judge (ALJ) hearing or review by the Office of Medicare Hearings and Appeals (OMHA)

If you still disagree with the decision you received in appeal level two—or you didn’t receive a timely decision from QIC and want to escalate your appeal—then you can request an over-the-phone, video-conference, or (under certain circumstances) in-person hearing with an ALJ. Or, if you’d prefer not to attend a hearing, then you can request that an OMHA ALJ or attorney adjudicator “make a decision based on evidence and the administrative record of the appeal (known as an on-the-record decision).” Bear in mind, though, that the dollar amount in controversy (AIC) after the QIC’s decision must meet a certain threshold.

You must file your request within 60 days of receiving the QIC’s reconsideration decision—or, in the case of an untimely response from QIC, 60 days from the expiration of the reconsideration period. Instructions should be available in your reconsideration letter. But, just in case, here are links to the OHMA-100 and -100A (new as of January 2017)—as well as the OHMA-104 (which you’ll file in addition to the OHMA-100 if you’re requesting an on-the-record review). To learn more about this level of the appeal process, click here.

It’s also worth noting that as of 2017, there is a process delay at this level of the appeal process, and OHMA is prioritizing specific Part D prescription drug denial cases. That being said, “new appeal requests are processed as quickly as possible.” And you can expect to receive an Acknowledgement of Request letter when your case makes it into OHMA’s tracking system. You may also qualify to participate in one of OHMA’s pilot programs that are designed to reduce the number of pending ALJ hearing requests: Settlement Conference Facilitation and Statistical Sampling Initiative. If the OHMA isn’t able to make a timely decision on your claim, then you will receive instructions to escalate the case to the next appeal level.

CMS Tips

According to CMS, you—or whomever you choose to represent you—must “send a copy of the ALJ hearing request to all other parties to the QIC reconsideration.” Here are some other good-to-know tidbits from CMS:

  • The Administrative QIC (AdQIC) serves as “the central manager” for all OHMA claim cases—and “in certain situations, the AdQIC may refer the case to the Council [level four] on CMS’ behalf.”
  • If a previous denial is overturned—and there’s no referral to the Council—then the AdQIC will instruct your MAC to pay your claim appropriately within 30 to 60 days.

4. Review by the Medicare Appeals Council (a.k.a Council)

The Medicare Operations Division of the US Department of Health and Human Services (HHS) Departmental Appeals Board (DAB) conducts level-four appeals. So, if you’re displeased with the decision you received from OHMA—or you didn’t receive a decision within a timely window—then you can request the Council to review your appeal within 60 days of receiving the decision (or after the decision timeframe has expired). As in the previous level, your decision letter should come with appeal instructions; but, just in case, here is the link to Form DAB-101 (you can find the electronic version here). And here is a resource for additional information about the Council review process.

Generally speaking, the Council will provide its decision within 90 days of receiving the request for review. However, if the review originally resulted from an escalated appeal, then the Council has 180 days to provide a decision.

CMS Tips

According to CMS, in this level of appeal, you—or whomever you choose to represent you—should:

  • “Send a copy of the Council review request to all the parties included in the OHMA’s decision.”
  • Explicitly state which part—or parts—of the OHMA decision you disagree with, along with your reasoning.

As with the previous level, the AdQIC serves as central manager of this process. If the Council isn’t able to make a timely decision, it will provide you with instructions to escalate the matter. Additionally, if the Council decides to overturn a prior denial, it will instruct the MAC to appropriately pay the claim within 30 to 60 days.

5. Judicial review in US District Court

If you disagree with the Council’s decision—or you haven’t received a decision within a timely manner—then you may file a request for judicial review within 60 days of receiving the Council’s decision or after the ruling timeframe has expired (as long as the AIC meets a certain threshold). According to CMS, the Council’s decision notice—or notice of right to escalation—will contain the information you need to file a claim in US District Court. As you might expect, the US District Court will make the final appeal decision.

Here are some appeals best practices:

In addition to the tips provided above for each appeal level, CMS offers some general best practices to help you make the most of the appeals process, including:

  • “Consolidate as many similar claims as possible into one appeal.”
  • “Include a copy of the decision letter(s) or claim information issued at the previous level.”
  • “Include a copy of the demand letter(s) if appealing an overpayment determination.”
  • “Include all relevant supporting documentation with your first appeal request.”
  • “Include a copy of the Appointment of Representative (AOR) form if the requestor is not a party and is representing a provider/supplier/beneficiary.”
  • “Respond promptly to the contractor requests for documentation.”

In other words, be sure that you’re always providing as much information as is relevant to your appeal in each step—and make responding to requests for additional information a top priority.

It’s also important to note that the defensibility of your documentation will be an important factor in Medicare’s decision to provide payment for services—especially if you’re dealing with a question regarding medical necessity. If you'd like to learn more about defensible documentation, including defensible and not defensible clinical note examples, check out this free guide.

Medicare appeals are no one’s idea of a cakewalk, but as long as you understand the process, you can move through it gracefully—and hopefully, reclaim the payments that should be yours. Have your own best practices for navigating the appeals process? Share them in the comment section below.

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