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Medicare Appellants

Part A Appeal Types and Your Rights

There are five levels of Medicare appeals:

  1. The first level appeal is called a redetermination. Redeterminations regarding claim denials currently are processed by either Fiscal Intermediaries/Affiliated Contractors (FIs/ACs) or Part A and B Medicare Administrative Contractors (A/B MACs). Expedited redeterminations regarding service terminations are processed by Quality Improvement Organizations (QIOs).
  2. A Reconsideration is the second level of appeal. If you are unhappy with an FI/AC, A/B MAC or QIO redetermination, you can appeal to MAXIMUS Federal Services QIC Part A and request a Reconsideration.
  3. The third level of appeal is an Administrative Law Judge Hearing (ALJ Hearing). If MAXIMUS Federal Services renders an unfavorable or partially favorable decision, you may seek a third level appeal, called an ALJ Hearing. To qualify for an ALJ Hearing, you must meet the $120 minimum amount in controversy requirement($140 is the new minimum amount for an ALJ hearing filed on or after 1/1/2013).
  4. The fourth level of appeal is to the Medicare Appeals Council. If you are unhappy with the ALJ Hearing decision, you may ask the Medicare Appeals Council to review your case.
  5. The fifth level of appeal is Federal Court. If the amount involved is $1180 or more ($1400 is the minimum amount for federal court review filed on or after 1/1/2013), you have the right to continue your appeal by asking a Federal Court Judge to review your case.

Click on the CMS flowchart to see an overview of the five level Original Medicare (Parts A and B Fee-For-Service) Appeals process for both standard and expedited reconsideration cases.

Each of these levels has steps that must be followed. In each of these five levels of appeal: You have the right to have someone help you or represent you in your appeal. If you choose to have someone represent you, you must submit documentation evidencing valid representation.

The First Level Appeal: Redetermination

If you submitted a claim to Medicare and you were denied either full or partial payment, you can appeal this payment denial. This is called a request for redetermination.

If you were receiving Medicare covered services from a skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or a hospice, and those services are being terminated, you can appeal the termination decision to a QIO. This is called an expedited redetermination.

The Second Level Appeal: Reconsideration

If you are not happy with the redetermination decision, you can request a reconsideration. To request a standard reconsideration, you must submit a written appeal request to MAXIMUS Federal Services. To request an expedited reconsideration, you may submit either a written appeal request or a verbal telephone request to MAXIMUS Federal Services

The independent review by MAXIMUS Federal Services includes:

  1. MAXIMUS Federal Services sends you or your representative (if you have one) an acknowledgement letter notifying you that your appeal request was received.
  2. MAXIMUS Federal Services will request a copy of the case file from the applicable FI/AC, A/B MAC, or QIO.
  3. MAXIMUS Federal Services carefully reviews:
    • Medicare regulations
    • all the information in your case file, and
    • any additional information that you provide
  4. For appeals involving medical necessity, your case is reviewed by a Clinical Panel made up of licensed health care professionals.
  5. MAXIMUS Federal Services makes a decision in
    • 72 hours from receipt of all case file information for an expedited reconsideration
    • Within 60 days from receipt of the appeal request for a standard reconsideration
  6. Additional information that is submitted may extend the decision time frames.
  7. MAXIMUS Federal Services renders a reconsideration decision.
    • MAXIMUS Federal Services will issue a letter detailing the outcome of the reconsideration review. A copy of the letter will be sent to all parties to the appeal. The FI/AC, A/B MAC, or QIO will also be notified of the decision.
    • If MAXIMUS Federal Services renders an unfavorable or partially favorable decision, the decision letter will provide instructions for requesting an ALJ Hearing.

Your Rights in a Reconsideration Review with MAXIMUS Federal:

  • You have the right to submit additional information pertinent to your appeal.

    Our King of Prussia, Pennsylvania location will close at the end of June. Effective immediately, all mail must be sent to the following addresses:

    QIC Part A East Project
    MAXIMUS Federal Services, Inc.
    Medicare Part A East
    3750 Monroe Avenue
    Suite 701
    Pittsford, NY 14534-1302
    QIC Part A West Project
    MAXIMUS Federal Services, Inc.
    Medicare Part A West
    3750 Monroe Avenue
    Suite 706
    Pittsford, NY 14534-1302
  • You have the right to have a representative assist you with your appeal
  • You have the right to ask for MAXIMUS Federal Services letters in a language you understand.
  • You have the right to a copy of everything in your file.
  • You have the right to receive a written appeal decision from MAXIMUS Federal Services.

The Third Level Appeal: ALJ Hearing

If you do not agree with the Reconsideration Decision rendered by MAXIMUS Federal Services, you can ask for a hearing with an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals (OMHA).

To qualify for an ALJ Hearing, you must meet the $120 minimum amount in controversy requirement($140 is the new minimum amount for an ALJ hearing filed on or after 1/1/2013).

You must submit your request for an ALJ Hearing in writing to the OMHA office with jurisdiction over your appeal. Click here to determine the appropriate OMHA office.

  1. The ALJ office will schedule your hearing. The ALJ office will provide you with details relative to your hearing, including date, time and mode of hearing.
  2. The hearing can be held “on the record,” which means that the ALJ would consider all the written evidence without the need to hear oral testimony.
  3. The ALJ makes a decision based on your case file and the information given at the hearing.
  4. The ALJ will send a copy of the decision to all parties to the appeal and the Administrative QIC (AdQIC). The ALJ may send a copy of the decision to MAXIMUS Federal Services.

The Fourth Level Appeal: Medicare Appeals Council (MAC) Review

If you are unhappy with the decision made by the ALJ, you may be able to ask for Medicare Appeals Council (MAC) review of your case. This board is part of the federal department that runs the Medicare program.

The Fifth Level Appeal: Federal Court

If you are unhappy with the decision made by the Medicare Appeals Council (MAC), you may be able to take your case to a federal court. The dollar value of your medical care must be at least $1180 ($1400 is the minimum amount for federal court review filed on or after 1/1/2013) to go to a federal court.

The CMS Medicare Learning Network also has published an overview of the five level appeals process. Click the CMS Medicare Appeals Process Overview Brochure to access the information.

More about your rights and who can help you

To get more information about your appeal rights:

To get help with your appeal:

  • Call your local Bar Association or legal aid program. If you do not have much money, these offices may be able to help you with your appeal.
  • Talk to a private lawyer who may charge you a fee.
  • Call 1-800-MEDICARE to request the telephone number of your State Health Insurance Assistance Program.

 

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