Appealing a Medicare Denial

If you have received a claim denial from your Medicare contractor you do have the right to submit an appeal.  If you do not take assignment on the claim, your appeal rights can be limited.

  See section at the bottom on Clerical Reopening when an appeal is not indicated.

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
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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).

By clicking here you will find information on the OMHA website.

Fourth level of appeal: Review by the Medicare Appeals Council
If a party to 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.

By clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.

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.

Additional resources

Within the CMS websites you will find information related to the five levels in the Part A and Part B appeals process.

• CMS Appeals Web resources

• CMS Appeals process flowchart

CMS resource materials available for download

• MLN - The Medicare Appeals Process Brochure

CMS Internet-only manuals: Publication 100-04

• Chapter 29– Appeals of Claims Decisions

• Chapter 34– Reopening and Revision of Claim Determinations and Decisions

Minor errors or omissions on some Part B claims can be corrected for reprocessing using the clerical reopening process.

There are two ways to initiate this process:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone re-openings on certain claims.  For the IVR reopening request help sheet, click here

• For reopening requests in writing, use the clerical reopening .

Common clerical errors consist of:

• 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