Medicare Appeals for Providers Physicians and Other Suppliers

Medicare Appeals for Providers, Physicians, and Other Suppliers © 2009 Cengage Learning. All Rights Reserved

Back to Civics! Cabinet-level departments (e. g. DHHS) and their administrative agencies (e. g. CMS) have rulemaking and adjudication authority. § General rule in administrative law is that all administrative remedies (e. g. reconsideration, etc. ) must be exhausted before filing suit in court. § © 2009 Cengage Learning. All Rights Reserved

Legislative Changes n Benefits Improvement and Protection Act of 2000 (BIPA) – Reconsiderations conducted by QICs n Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) – Shortened time limits © 2009 Cengage Learning. All Rights Reserved

Five Levels of the Appeal Process Redetermination by Medicare Administrative Contractor (MAC) n Reconsideration by Qualified Independent Contractor (QIC) n Administrative Law Judge (ALJ) hearing n Appeals Council/ Departmental Appeals Board (DAB) review n Judicial review in U. S. District Court n © 2009 Cengage Learning. All Rights Reserved

Redeterminations n n Paper review by carrier/MAC; must be by an employee not involved in initial determination Request must be in writing or on Form CMS 20027; file within 120 days from date of receipt of the initial claim determination Supporting documentation should be attached MAC generally issues decision (letter or revised remittance advice) within 60 days of receipt of the redetermination request © 2009 Cengage Learning. All Rights Reserved

Reconsiderations n n n Review by QIC; allows independent review of medical necessity issues by panel of physicians or other health care professionals Request must be in writing or on Form CMS 20033; file within 180 days of receipt of redetermination Supporting documentation and/or copy of Medicare Redetermination Notice (MRN) should be attached On-record review Decisions within 60 days of receipt of reconsideration request © 2009 Cengage Learning. All Rights Reserved

ALJ Hearing Review of QIC’s reconsideration is allowable if claim in controversy is at least $110 n Request must be within 60 days of receipt of reconsideration n Request must be on hearing request form or in writing; appellants must send notice to all parties n © 2009 Cengage Learning. All Rights Reserved

ALJ Hearing contd. n n Hearings are held by video-teleconference or telephone; in-person hearings are allowable on case-by-case basis if good cause exists If no hearing, decisions may be on the record Decisions generally rendered within 90 days of receipt of hearing request; timeframe may be extended for cause If no timely decision, case may be escalated to Appeals Council © 2009 Cengage Learning. All Rights Reserved

Appeals Council/ Departmental Appeals Board n n Review of ALJ’s decision is allowable; there is no additional requirement regarding amount of claim Request must be submitted in writing within 60 days of receipt of ALJ’s decision; must specify the issues and findings that are being contested Decisions usually rendered within 90 days of receipt of request; timeframe may be extended for cause If no timely decision, case may be escalated to judicial review (federal court) level © 2009 Cengage Learning. All Rights Reserved

Judicial Review in U. S. District Court Review of Appeals Council decision is allowable if claim is $1, 090 or more n Request/complaint must be filed within 60 days of receipt of Appeals Council’s decision n © 2009 Cengage Learning. All Rights Reserved