Carrier appeals process for redeterminations and Over payment appeal address
The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.
For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.
The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.
There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.
The five levels of appeal are as follows:
1st Level - Redetermination
Time limit to file request: 120 days from date of receipt of the initial determination notice
Monetary threshold: None
Request is sent directly to the carrier
2nd Level - Reconsideration
Time limit to file request: 180 days from date of receipt of the redetermination
Monetary threshold: None
Request is sent directly to the QIC
3rd Level - Administrative Law Judge (ALJ) Hearing
Time limit to file request: 60 days from the date of receipt of the reconsideration
Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).
4th Level - Departmental Appeals Board (DAB) Review
Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision
Monetary threshold: None
5th Level - Federal Court Review
Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB
Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.
Overpayment appeals address
The address for overpayment appeals is as follows:
First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248
Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr...
Procedure code and description 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous ele...
CPT CODE and Description 90785 - Interactive complexity (List separately in addition to the code for primary procedure) 90791 - Psychi...
procedure code and description 93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOW...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...
Procedure code and description 95806 - Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory air...
Procedure code and description 95004 Percut Tests w/ Extrac Immed React # Allergy testing - Percut allergy skin tests - Percutaneous ...