When claims are denied by Medicare, providers have the right to appeal the decision. In fact, providers can appeal a decision up to five times–all the way to a judicial review in U.S. District Court–if they disagree with the rulings.
But not all denials merit an appeal, and when they do, each level of appeal is different and must be sent to a different contractor. Submitting an unnecessary appeal or submitting an appeal at the wrong level or to the wrong party can cause delays or dismissals, or even cause you to forfeit your appeal rights.
Wondering if an appeal is your next step? Here’s how to know when you should appeal, at what level, and where to send it.
When to Appeal
If you receive a rejected claim, for instance, that means the claim was “unprocessable” based on the information provided. Rejected claims cannot be appealed. Often, claims are rejected because information is missing or a code is invalid. When claims are rejected, they can simply be resubmitted with additional and/or valid information.
Denied claims, on the other hand, contain sufficient information to process but are not paid (or applied to the beneficiary’s deductible and coinsurance) because of Medicare policies or issues with the information. For example, if the claim does not support medical necessity, the expenses were incurred before or after the beneficiary was covered by Medicare, or add-on codes were billed when the same physician did not perform and bill the primary code, the claim will be denied.
When a claim is denied because the information submitted was incorrect, often the claim can be reopened using a Clerical Error Reopening (CER). CERs can be used to fix errors resulting from human or mechanical errors on the part of the party or the contractor. For instance, if a claim is denied because it is a duplicate charge, but upon investigation, you find that the wrong date of service was entered, you can simply reopen the claim with the correct date of service using a CER.
When a claim is denied for reasons that cannot be addressed with a CER, it’s time to begin the appeal process. All appeals must be made in writing, and there are five appeal levels:
- Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)
- Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)
- Level 3 – Decision by Office of Medicare Hearings and Appeals (OMHA)
- Level 4 – Review by the Medicare Appeals Council (Council)
- Level 5 – Judicial review in U.S. District Court
Level 1 Appeal – Redetermination
The first stage of the appeal process, requesting a redetermination, must be done within 120 days from the date of receipt of the Electronic Remittance Advice (ERA) or Standard Paper Remittance Advice (SPR) that lists the initial determination.
Level one appeals should be sent to the MAC who completed the claims processing, which for Indiana providers is WPS Government Health Administrators. WPS-GHA accepts appeals through the WPS Government Health Administrators Portal, fax, or mail. The written request should be made using the Redetermination Request form or in a letter with all of the following information:
- Beneficiary name
- Medicare ID
- Date(s) of service for which the initial determination was issued (you must report dates in a manner that comports with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form)
- Which item(s), if any, and/or service(s) are at issue in the appeal
- Name and a signature of the party or representative of the party
The MAC then reviews and completes the level one appeal and sends a letter or new remittance notice with the results. Both the letter and remittance notice include level two appeal filing instructions. Providers must follow these instructions if they disagree with the level one decision.
Level 2 Appeal – Reconsideration
Level two appeals, or requesting a reconsideration, must be submitted to a Qualified Independent Contractor (QIC) within 180 days from the date of receipt of the redetermination decision. There is no minimum monetary threshold to request a reconsideration.
Reconsiderations must be requested in writing and should include either a completed CMS 20033 form or a letter with all of the following information:
- Beneficiary name
- Medicare ID
- Specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service
- Name of the party or the authorized or appointed representative of the party
- Name of the contractor that made the redetermination
- Any missing documentation identified in the notice of redetermination
Maps of the QIC jurisdictions, mailing addresses and website information for all QICs are available in “Downloads” under “QIC Maps” on the Second Level of Appeal webpage at CMS.gov.
The request should also clearly explain any disagreement with the redetermination and should include any evidence or allegations of fact or law related to the issue(s) in dispute. A copy of the Medicare Redetermination Notice (MRN) or Remittance Advice (RA), and any other relevant documentation, should be sent with the reconsideration request to the appropriate QIC.
QICs can dismiss reconsideration requests if the party requests to withdraw the appeal or if the appeal contains certain defects, such as late filing. When a reconsideration is dismissed, providers have two options to continue the reconsideration request. They can request a review by an Administrative Law Judge (ALJ,) or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA), or they can simply request that the QIC vacate the dismissal.
As well, if a QIC is unable to complete its reconsideration within 60 days of receipt of the request, the QIC must send a notice to the parties and advise them of the right to escalate the appeal to OMHA. If the party chooses to escalate the appeal to OMHA, a written request must be filed with the QIC in accordance with instructions on the escalation notice.
Otherwise, reconsideration decisions are generally sent within 60 days of the request and will contain detailed information on further appeals rights, where applicable.
Level 3 Appeal – Decision by Office of Medicare Hearings and Appeals (OMHA)
Parties who are dissatisfied with a QIC’s reconsideration decision may request a hearing before an ALJ. However, to do so, the amount remaining in controversy must meet the annual threshold requirement, which is $180 for 2022. Requests for Level 3 hearings or reviews must be made within 60 days of receipt of the reconsideration decision.
Requests for hearings must be requested in writing and should include either a completed Form OMHA-100 (address on form) or a letter with all of the following information:
- The name, address, and Medicare number of the beneficiary whose claim is being appealed, and the beneficiary’s telephone number if the beneficiary is the appealing party and not represented
- The name, address, and telephone number, of the appellant, when the appellant is not the beneficiary
- The name, address, and telephone number, of the authorized or appointed representative, if any.
- The Medicare appeal number or document control number, if any, assigned to the QIC reconsideration or dismissal notice being appealed
- The dates of service of the claim(s) being appealed
- The reasons the appellant disagrees with the QIC’s reconsideration or other determination being appealed
Those who do not wish to have a hearing conducted may choose to have the case decided with only a review of the administrative record. To do so, appellants waive their right to have an oral hearing by filling out Form OMHA-104 and submitting it with the request for review by OMHA.
For OMHA Decisions following a QIC reconsideration, an ALJ or attorney adjudicator issues a decision, dismissal order, or remand to the QIC within 90 calendar days from the date the request for a hearing is received and will contain detailed information on further appeals rights, where applicable. For escalated cases resulting from QIC dismissals or delays, an ALJ or attorney adjudicator generally issues a decision, dismissal order, or remand to the QIC within 180 calendar days from the receipt of the request.
As with earlier appeal levels, if a decision, a dismissal, or remand order is not issued within the specified time frame, the appellant may send a request to OMHA asking that the appeal be escalated to the Medicare Appeals Council (the Council).
Level 4 Appeals – Review by the Medicare Appeals Council
Parties dissatisfied with OMHA’s decision or dismissal may request a review by the Council, a component of the Department of Health & Human Services, Departmental Appeals Board. There is no minimum monetary threshold for a Council review.
A request for Council review must be filed within 60 days of receipt of the notice of OMHA’s decision or dismissal. The request must be made in writing and must specify the parts of the decision or action that the party disagrees with and why they disagree. The appellant should also include a copy of the disputed decision with the appeal.
- Beneficiary name
- Medicare ID
- The specific service(s) or item(s) for which the review is requested
- The specific date(s) of service
- The date of the ALJ’s decision or dismissal order
- The name of the party or the representative of the party
For Council reviews filed after an OMHA Decision, a decision or dismissal order will be issued by the Council within 90 calendar days from the date the request for hearing is received and will contain detailed information on further appeals rights, where applicable. For cases resulting from escalation of an OMHA Request, the Council will issue a decision, dismissal order, or remand to the QIC, within 180 calendar days from the receipt of the request. Cases not adjudicated within these timelines may be escalated to Federal district court.
Level 5 – Judicial review in U.S. District Court
Parties dissatisfied with the Council’s decision may request review in Federal court within 60 calendar days after the date it receives notice of the Council’s decision. In order to request judicial review, the amount remaining in controversy must meet the annual threshold requirement, which is $1,760 for 2022. This is the final level of appeal.
For more information, visit the Original Medicare (Fee-for-Service) Appeals webpage at CMS.gov.
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