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. 

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

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To ensure timely processing of your application, make certain to completely fill out the application and provide all required supporting documentation at the time of filing. Section 17 of the Medicare enrollment application lists the supporting documentation that you will need to submit with your enrollment application. Once you have completed the application, you should mail it to the Medicare contractor servicing your state.  A contractor can generally process your application within 60 days if you submit a complete application with all required supporting documentation.  It will take longer to be enrolled if you are a provider or supplier that requires a State survey or accreditation.  If you have any questions about the enrollment process, please contact your Medicare contractor.

Source: https://questions.cms.hhs.gov

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If you are in the Original Medicare Plan, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are required by law to file Medicare claims for covered services and supplies that you receive. You should not need to file any Medicare claims.

Medicare claims must be filed within one full calendar year following the year in which the services were provided. For example, if you see your physician on March 30, 2009, the Medicare claim for that visit must be filed by December 31, 2010.

Is My Pharmacy or Supplier Enrolled in Medicare?

If the answer is no, you will be responsible for the entire bill for any drugs or supplies purchased. Important information you need to know before you make your purchase.

Note: This information on filing a Medicare claim only applies if you are in the Original Medicare Plan. If you get your Medicare health care through a Managed Care Plan or a Private Fee-for-Service Plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims.

My Provider or Supplier Accepts Medicare Assignment

You pay your share of the bill (coinsurance and deductibles) to the provider or supplier. The provider or supplier files a Medicare claim. Medicare pays its share of the bill directly to the provider or supplier.

My Physician or Supplier Does Not Accept Medicare Assignment

Note: Only physicians and suppliers can decide not to accept assignment.

If your physician or supplier does not accept assignment for covered services, your physician or supplier may require that you pay most or all of the bill at the time you receive services or supplies. However, the physician or supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you.

Medicare cannot pay you its share of the bill until a Medicare claim is filed. You should take the following steps if your doctor or supplier does not file the Medicare claim in a timely manner.

Step 1

Contact Your Physician or Supplier: Call your physician or supplier directly and ask the physician or supplier to file a Medicare claim.

Step 2

Contact 1-800-Medicare: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call 1-800-Medicare (1-800-633-4227). Also ask 1-800-Medicare for the exact time limit for filing a Medicare claim for the service or supply that you received.

IMPORTANT: There is a time limit for filing a Medicare claim. If a claim is not filed within this time limit, Medicare cannot pay you its share. The time limit may be as short as 15 months or as long as 27 months depending on when you received the service or supply.

It is important that you ask 1-800-Medicare what the time limit is for filing your claim.

Step 3

When You Should File a Claim: You should only need to file a Medicare claim in very rare situations. You should only file a Medicare claim yourself when:

• you have completed steps 1 and 2 above; AND
• the physician or supplier still has not filed the Medicare claim; AND
• it is close to the time limit for filing your Medicare claim. (For example, if your time limit is 15 months, you should consider filing a Medicare claim if the physician or supplier has not filed the Medicare claim 12 months after you received the service or supply).

To file a Medicare claim yourself, you will need to print out and complete the form called Patient’s Request for Medical Payment, Form CMS 1490S. The form is available for download on cms.hhs.gov in the CMS Forms section.

Once there, you will need to do three things: (1) print out the 1490S form; (2) select and print out the applicable instructions; and (3) review all of the information on this page about how to file a claim form.

To file a Medicare claim yourself, call 1-800-Medicare and ask for the proper form for a Medicare beneficiary to file a claim. 1-800-Medicare can also answer your questions about how to complete the claim form.If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing.

You can fill out the “1-800 Medicare Authorization to Disclose Personal Health Information” form. Call 1-800-MEDICARE (1-800-633-4227) to get a copy of the form, or you can download the form in the Medicare Online Forms section of this web site.

For a list of physicians in your area who always accept assignment, use the Physician and Other Healthcare Professional Directory on this web site.

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