Every provider’s goal is to submit a claim to Medicare and receive payment for medical services provided. If Medicare denies the claim, do you know your appeal rights as a provider? There are five different levels of appeal that can be submitted, all to different entities.

 

First level of appeal

The first level of appeal must be submitted to the Medicare Administrative Office (MAC) that is financially responsible for the claim. For the appeal to be processed, it must be submitted within 120 days from the initial claim decision. The first level appeal is also known as a reconsideration.

Second level of appeal

What happens if the MAC denied the first level appeal or redetermination? As a provider, you have 180 days from the MAC’s dismissal date to submit a second-level appeal, also known as a reconsideration. The second level appeal is reviewed by a Qualified Independent Contractor (QIC). Keep in mind that the claim and documentation have already been reviewed by two different levels prior to QIC. Any new relevant documentation must be submitted to support the reason for the disagreement with the initial claim and with the redetermination decision.

Third level of appeal

If you are still dissatisfied with the decision from MAC and QIC, a third-level appeal can be submitted to an Administrative Law Judge or can also be reviewed by an attorney adjudicator at the Office of Medicare Hearings and Appeals. The timeline to submit an ALJ request is 60 days from the date of the second level decision. To submit an ALJ, the amount being disputed must meet a threshold calculated each year. Just like the above two appeals, an ALJ must be submitted in writing. A third level appeal is a bit more interesting as it requires the hearing to be held over the phone, and at times may require a video teleconference; although extremely rare, it may even be in person.

Fourth level of appeal

Fourth level appeals are reviewed by the Medicare Appeals Council within the Department of Health & Human Services. Same as the third level appeal, the timeline is 60 days from the previous level decision, but unlike the third level appeal, there is no requirement regarding the dollar amount being disputed.

Fifth level of appeal

The highest of all appeals for Medicare claims are reviewed by the Federal court. The timely filing for a final fifth level appeal is also 60 days from the decision of the Medicare Appeals Council. Just like the third level appeal, there must be a minimum dollar amount that is being disputed.

For any appeal to be successful, you must:

  • Submit the appeal timely.
  • Submit the appeal with all supporting documentation.
  • Include a copy of the decision from the prior level.
  • Respond to any request timely.

 

If either the provider or the individual receiving a medical service disagrees with the decision from Medicare to deny a claim, the claim can be appealed at multiple levels. Know your rights!