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.

Time limit for
filing request
Where to file
an appeal
First level: Redetermination 120
days from the initial claim determination
administrative contractor (MAC)
Second level: Reconsideration 180
days from the redetermination decision
independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)  60
days from the date of the reconsideration decision               Submit request by:
Monetary threshold for requests filed before December 31, 2014: $140
Monetary threshold for requests filed on or after January 1, 2015:
of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council 60
days from the date of the ALJ decision
Appeals Board
Fifth level: Judicial review:  60
days from the date of the Medicare Appeals Council decision                                 Submit request by:
Monetary threshold for requests made before December 31, 2014:
Monetary threshold for requests made on or after January 1, 2015: $1,460.
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.

Part B clerical reopening

A clerical error could occur when one of the following happens to your claims:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service

There are two options for conducting a clerical reopening of a claim:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.
• For the IVR reopening request help sheet, click here .
• For reopening requests in writing, use the clerical reopening .

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $140 remains in controversy following the qualified independent contractor’s (QIC’s) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to the an ALJ hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ’s decision, and must specify the issues and findings that are being contested.
The resources below are external to the First Coast and CMS websites, but are being offered for your convenience. First Coast and CMS are not responsible for the content or maintenance of these external sites.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council’s decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council’s decision.
• The Medicare Appeals Council’s decision will contain information about the procedures for requesting judicial review.

Difference between appeal and Grievance

Appeal: A type of complaint a member (or an authorized representative) makes when the member disagrees with an action taken or wants Amerigroup to reconsider a decision. Complaint: Any expression of dissatisfaction to a Medicare health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made orally or in writing. This can include concerns about the operations of providers or Medicare health plans such as: waiting times, the demeanor of health care personnel, the adequacy of facilities, the respect paid to enrollees, the claims regarding the right of the enrollee to receive services or receive payment for services previously rendered. It also includes a plan’s refusal to provide services to which the enrollee believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievance and/or appeal process.

Grievance: Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare  health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

An Appointment of Representative (AOR) Form is required if someone other than the member is filing a complaint or appeal on behalf of the member. There are some exceptions: Medical Doctors are not required to fill out an AOR when initiating an appeal for a Part C (Medical Appeal). However, The Centers for Medicare & Medicaid Services (CMS) require an AOR from Medical Doctors for Part D (Pharmacy) appeals, except for expedited Part D appeals. Personal Representative Forms will not be accepted in lieu of an AOR. The appeal timeframe will start once the AOR is signed by the member and representative and returned to the Medicare Complaints Appeals and Grievances (MCAG) department.

Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim
Q. Can someone other than a Medicare beneficiary request a Medicare appeal on an unassigned claim?

A. Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696 external link). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal.
Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal.
The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Additional records submission during appeals FAQ

Q: During the appeal process, at what point can additional records be submitted?
A: Additional medical records may be submitted at the redetermination level (1st level) and the reconsideration level (2nd level). If your appeal is a result of a recovery auditor (RA) determination, the RA will forward the medical records they receive to the affiliated contractor, or First Coast Service Options Inc.

Departmental appeals board (DAB) FAQ
Q: Who makes up the Departmental Appeals Board (DAB), which is the fourth level in the appeals process?

A: The DAB includes the board itself (supported by the Appellate Division), Administrative Law Judges (ALJs) (supported by the Civil Remedies Division), and the Medicare Appeals Council (supported by the Medicare Operations Division). Thus, the DAB has three adjudicatory divisions, each with its own set of judges and staff, as well as its own areas of jurisdiction. The DAB also has a leadership role in implementing alternative dispute resolution (ADR) across the department, since the DAB chair is the designated dispute resolution specialist under the Administrative Dispute Resolution Act of 1996.

Amount in controversy (AIC) FAQ
Q: What does the term “amount in controversy” mean?

A: The amount in controversy (AIC) is the minimum threshold amount in dispute you must have in order to request the administrative law judge (ALJ) and judicial review levels in the appeal process. Click here external link for the current AIC for the ALJ level; click here external link for the current AIC for the Federal judicial review.

What is considered a relevant appeal FAQ
Q: Is there a resource for providers or beneficiaries that outlines what services or items can be appealed?

A: All claims or claim line items that have been denied may be appealed. You can follow the guidelines outlined in the resource listed below.

Resubmission of denied claim FAQ
Q: Can we resubmit a claim that was denied by the recovery auditor (RA) if we determine the incorrect code was submitted
A: No, you must submit a redetermination (the first level of the appeals process). There are edits in the fiscal intermediary shared system (FISS) that will prevent you from performing an adjustment against the denied claim or submitting a new claim for the same dates of service.

Reason codes for denied claims FAQ
Q: What are the reason code ranges for claims when they have denied?

A: For claims that have been reviewed by the medical review department and denied, the reason code will start with a “5”. If your claim was denied through the fiscal intermediary shared system (FISS) the reason code will start with a “7”, which is a non-medical denial.
Click here for the description of a Medicare Part A reason code. Enter the reason code into the box and click the submit button.

Appeals FAQs
Q: Can I resubmit or adjust a claim when an appeal is processing?

A: It is not recommended to submit a new or adjusted claim when the appeal is pending.
Resubmitting or adjusting the claim does not reduce the processing timeframe for the appeal. In fact, it may result in an appeal dismissal or delay the processing time for the outstanding appeal. This matter affects appeals at various levels.
Note: Adjustments to the initial claim or claim resubmission for the same service on the same date of service do not extend the appeal rights on the initial determination. Click here for information on when to file an appeal for each of the five levels.