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Medicare Appellants

How to File an Appeal

For both Part A East and Part A West Jurisdictions: You may file a reconsideration request with MAXIMUS Federal Services if your claim for Medicare Part A or Part B of A items or services was denied. Your reconsideration request will be handled by MAXIMUS Federal Services in its Part A East or West project, according to the location where you received such items or services, as illustrated on the following charts:

 

PART A EAST
Alabama, Arkansas, Colorado, Connecticut, Delaware, Florida, Georgia, Louisiana, Maine, Maryland, Mississippi, Massachusetts, New Hampshire, New Mexico, New Jersey, New York, Texas, Oklahoma, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Vermont, Virgin Islands, Virginia, West Virginia, and Washington DC

 

PART A WEST
Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Ohio, Oregon, South Dakota, Utah, Washington, Wisconsin and Wyoming

Standard Reconsiderations

After a FI/AC or A/B MAC has denied a claim for Medicare items or services at the redetermination (first level) stage, a standard reconsideration (second level) request may be filed, as follows:

  • The request must be filed with MAXIMUS Federal Services at either its QIC Part A East or QIC Part A West project address, depending on the jurisdiction involved, as illustrated in the above charts. The proper MAXIMUS address will be indicated on the notice of redetermination.
  • The request must be in writing and submitted via a standard CMS form, or alternatively, the request must contain:
    • The beneficiary’s name;
    • Medicare health insurance claim number;
    • The specific service(s) and item(s) for which the reconsideration is requested and the specific date(s) of service;
    • The name and signature of the party or the representative of the party; and
    • The name of the contractor that made the redetermination.

 

Expedited Reconsiderations

After a Quality Improvement Organization (QIO) has denied a claim for Medicare services provided by a skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, at the expedited redetermination (first level) stage, an expedited reconsideration (second level) request may be filed, as follows:

  • A beneficiary who wishes to obtain an expedited reconsideration must submit a request for the reconsideration to the appropriate QIC, in writing or by telephone, by no later than noon of the calendar day following initial notification (whether by telephone or in writing) following receipt of the QIO's determination;
  • The beneficiary, or his or her representative, must be available to answer questions or supply information that the QIC may request to conduct its reconsideration;
  • The beneficiary may, but is not required to, submit evidence to be considered by the QIC in making its decision.

    A beneficiary requesting an expedited reconsideration may request (either in writing or orally) that the QIC grant an extension of time (not to exceed 14 days) for its reconsideration decision.

    Unless the beneficiary requests an extension, no later than 72 hours after receipt of the request for an expedited reconsideration AND receipt of any medical or other records needed for such reconsideration, the QIC must notify the QIO, the beneficiary, the beneficiary's physician, and the provider of services, of its decision on the reconsideration request.

     
CMS Maximus Federal Services