How to File an Appeal

For 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. Part A encompasses the following jurisdictions:

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

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 the address listed below. This MAXIMUS address will be indicated on the notice of redetermination.
  • QIC Part A West standard reconsideration requests should be mailed to:
          Maximus Federal Services, Inc., Medicare Part A West, 3750 Monroe Avenue, Suite 706, Pittsford, NY 14534-1302
  • 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.

 

Reconsideration Request form for Standard Appeals

Click here to download request form.

Expedited Reconsiderations

*Please note that effective 9/1/16, QIC Part A West appeal requests should be directed to MAXIMUS Federal Services.

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 MAXIMUS Federal Services, 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;
  • West Jurisdictions:
    • The expedited request should be directed to the MAXIMUS QIC Part A West
    • QIC Part A West verbal expedited appeals can be directed to the MAXIMUS Federal Services West expedited toll free telephone # at 1-866-950-6509
    • Alternatively, Part A West written expedited appeals may be faxed to MAXIMUS Federal Services at ­­­­1-585-869-3365
  • 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.

 

For information about the availability of auxiliary aids and services, please visit:
http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

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