When to file an appeal
Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.
The five levels of appeals, listed in order, are:
Appeal level Time limit for filing request Where to file an appeal
First level: Redetermination 120 days from the initial claim determination Medicare administrative contractor (MAC
Second level: Reconsideration 180 days from the redetermination decision Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ) 60 days from the date of the reconsideration decision Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council 60 days from the date of the ALJ decision Departmental Appeals Board
Fifth level: Judicial review: 60 days from the date of the Medicare Federal District Court
Submit request by:
Monetary threshold for requests made on or after January 1, 2015: $1,460. For requests made on or after January 1, 2016, the threshold is $1,500.
Federal District Court
Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.
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