Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. There are five levels in the Medicare Part A and Part B appeals process. The levels are:

First Level of Appeal:    Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).

Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)

Third Level of Appeal:   Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

Fourth Level of Appeal: Review by the Medicare Appeals Council

Fifth Level of Appeal:    Judicial Review in Federal District Court

 

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices with beneficiaries enrolled in the original Medicare (fee-for-service) plan are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.

For more detailed information and timeframes about the Expedited Determination Appeals Process, go to the Expedited Determination Appeals Process page on the left.

For more detailed information about each level of appeal, go to the left side of this page or scroll down to the “Related Links Inside CMS” section. To see a diagram of the original Medicare (fee-for-service) standard and expedited appeals process, go to the “Downloads” section below. 

Downloads
Appeals Process Diagram [PDF, 16 KB] 
Related Links Inside CMS
Changes to the Medicare Claims Appeal Procedures [PDF, 513 KB]  

Changes to the Medicare Claims Appeal Procedures; Continuation of Effectiveness and Extension of Timeline for Publication [PDF, 51 KB]  

MLN The Medicare Appeals Process Brochure [PDF, 1.23 MB]  

Source: http://www.cms.hhs.gov/OrgMedFFSAppeals/

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