When Medicare denies a claim for health care items or services under Medicare Part A (hospital coverage) or Part B (doctor's office coverage), you have the right to appeal if you disagree with this decision.
There are up to five potential levels of standard appeals that Medicare beneficiaries or health care providers may pursue if a Part A or B claim is denied. The first three levels of the appeals process are surprisingly "user friendly" as long as you understand and follow the instructions at each level of appeal, particularly with respect to the time deadlines for filing your appeal. There may also be a minimum claim amount in dispute requirement, also called the amount in controversy (AIC).
If a hospital or nursing facility is trying to discharge you earlier than you think you should be discharged, you can file an expedited appeal. See our articles on appealing a hospital discharge and appealing a Discharge Order from a nursing or rehab facility. The rest of this article will discuss regular appeals.
Medicare hires private contractors to process claims for Medicare services. After your claim is processed, you will receive a Medicare Summary Notice (MSN) which states whether Medicare will cover or pay for the specific items or services you received from your health care provider. This is also called the initial determination.
The Medicare Summary Notice will provide a reason if your claim for a particular hospital charge or doctor visit was denied. For example, it might say that the service or item at issue was not "medically reasonable or necessary." The Medicare Summary Notice will contain instructions for filing a Level 1 appeal.
The first level of a standard claim appeal is called a Request for Redetermination and is a "paper review" of your claim. That means that you will not need to appear in person; the redetermination will be made on the basis of your medical records. The same Medicare contractor that processed your Medicare claim will make a new and independent review of your claim file and make a new decision. The individual who originally processed your claim, however, is not the same individual who will review your claim on appeal.
There is no minimum amount in controversy (AIC) required for a Level 1 appeal. You must, however, file a written, signed Request for Redetermination within 120 days of receiving your Medicare Summary Notice and follow the directions on the MSN regarding where and how to file your Request for Redetermination.
If you are not satisfied with the Level 1 decision because it is not in your favor, you may file a Request for Reconsideration by a Qualified Independent Contractor (QIC). The QIC conducts a new and independent on-the-record review of your claim.
There is no minimum amount in controversy (AIC) required for a Level 2 appeal. You must, however, file a written Request for Reconsideration within 180 days of receiving the Level 1 Redetermination Decision. You must send your Request for Reconsideration and any material you want the QIC to consider to the QIC location identified in the Level 1 Redetermination Decision.
If the Level 2 decision was not decided in your favor and you still disagree with the denial, you may file a Level 3 Request for Hearing with the Office of Medicare Hearings & Appeals (OMHA) before an administrative law judge, also called an "ALJ."
The minimum amount in controversy for a Level 3 appeal is at least $130 (in 2012). The amount in controversy requirement changes annually and will be indicated in your Level 2 Reconsideration Decision. You must file your Request for Hearing within 60 days of receiving the Level 2 Decision.
OMHA and its ALJs are independent of Medicare and are part of the U.S. Department of Health & Human Services. Most hearings are held by telephone or by videoconference (VTC) from one of numerous remote hearing sites. You may also have an in-person hearing at one of the four field offices if you can show the ALJ that "good cause" exists for you to appear in person. In some cases, the ALJ may decide to forgo a hearing altogether and may decide the case "on-the-record," when the evidence in the claim file supports a decision in your favor.
You should consider whether to talk to a lawyer before requesting an ALJ hearing. While you are allowed to being an attorney to represent you, it is not required at the hearing. That is because the hearings are considered an informal proceeding and you are not required to know the rules of evidence to present your case. If you don't want to hire a lawyer, you can appoint a personal representative, such as a spouse, friend, caregiver, or patient advocate to appear on your behalf.
You may present witnesses at the hearing. The ALJ may ask other witnesses, including physicians or other experts, to attend and testify at your hearing. You will be able to ask questions of any witness who testifies at your hearing. All hearings are conducted under oath and will be audio recorded.
If you receive an unfavorable Level 3 ALJ decision, or the ALJ dismissed your case, you have 60 days from the date shown on the ALJ decision to file a written Request for Review with the Medicare Appeals Council (MAC).
At this level of appeal, the remaining amount in controversy (AIC) must be at least $130.00 (in 2012).
The MAC review is conducted on-the-record and is independent of the OMHA review and the Level 3 ALJ review. You should consider seeking legal assistance before requesting a Medicare Appeals Council Review.
If you disagree with the MAC's Level 4 decision and the amount in controversy (AIC) is at least $1,350 (in 2012), you may file a civil action in your local federal district court. The MAC's Notice of Decision will give you information about filing a civil action. Your lawsuit must be filed within 60 days of receiving the unfavorable MAC Decision. As this is a formal court proceeding, you'll need to hire a Medicare or Social Security lawyer before filing a lawsuit.
This is the last level of appeal available to you.
For a comprehensive reference book, see Nolo's book Social Security, Medicare, and Government Pensions, by Attorney Joseph Matthews.