Medicare’s Levels of Appeal

When Medicare makes a decision about a claim, you may not always agree with their determination of costs or coverage for services you received.  Fortunately, you do have the right to file an appeal. 

There are five levels in Medicare’s Appeal Process.  In the first four, if the party reviewing your case is unable to make a decision on time, they may send you a letter asking if you would like to skip to the next step.

The first step is a Redetermination by Medicare.  To receive a redetermination, you must file a written request within 120 days of receiving your notice.  You will send this request to the company that sent you your Medicare Summary Notice.  This notice will contain instructions on how to file. A decision will usually be made within 60 days.

If you don’t agree with the redetermination decision, you can ask for reconsideration by a Qualified Independent Contractor (in writing, within 180 days from when you get your Redetermination Notice). This contractor wasn’t involved in the first decision and will usually make a decision approximately 60 days after receiving your appeal.  (Your Redetermination Notice will tell you how to request this reconsideration). 

If you still don’t agree with the decision, you can request, in writing, a hearing with an Administrative Law Judge (explained in your reconsideration notice).  You must file this request within 60 days after receiving your reconsideration notice, and there is a minimum case dollar amount necessary in order to proceed.  Usually, the judge will make a decision about 90 days after you appeal. 

The next step, if the outcome isn’t satisfactory, is requesting a review by the Medicare Appeals Council.  Your request must be filed within 60 days from when you receive your Administrative Law Judge decision, which will contain details about how to file this next request.  The Medicare Appeals Council should make a decision within 90 days.

The final step is review by a Federal court (provided your case meets the minimum dollar requirement).  Your request for this final step must be made in writing within 60 days from receiving the Medicare Appeals Council’s decision. 

If you disagree with a decision made by Medicare, this process is in place to protect you.  The five steps are designed to give you ample opportunity to have your case heard and to receive fair treatment and impartial consideration.

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