The five levels in the Medicare appeals process are shown below. Prior to requesting an appeal, a supplier may request changes due to clerical errors or omissions through the Reopenings process.
|Appeal Level||Time Limit for Filing Request||Monetary Threshold to be Met||Time Limit to Complete Request||Where to File||Forms|
|Reopening||One year from initial determination date or after one year from date of receipt due to overpayment via clerical error omissions||None||60 days from receipt date||Contractor|| |
|Redetermination||120 days from initial determination date or 120 days of initial overpayment||None||60 days from receipt date||Contractor|
|Reconsideration||180 days from date of redetermination decision date||None||60 days from receipt date||Qualified Independent Contractor (QIC)|
|Administrative Law Judge||60 days from date of reconsideration decision date||$160 effective 1/1/17||90 days from receipt date||Contractor or HHS OMHA Field Office if heard by QIC|
|Medicare Appeals Council Review (Department Appeals Board (DAB))||60 days from ALJ hearing decision date||None||90 days from receipt date||DAB or ALJ Hearing Office|
|Federal Court Review||60 days from Appeals Council decision date or declination of review by DAB||$1560 effective 1/1/17||None||Refer to DAB decision|| |
- View all Appeals Forms
- Medicare beneficiaries or their authorized representatives, or Medicaid state agencies or parties authorized to act on behalf of Medicaid state agencies for the beneficiaries.
- Medicare providers, practitioners, or suppliers participating with the Medicare program and accepting assignment on all services performed.
- Medicare providers, practitioners, or suppliers not participating in the Medicare program and not accepting assignment where:
- A claim that is denied or payment has been reduced for an item or service that is denied as not being reasonable and necessary under §1862(a)(1);
- The supplier has already collected payment from the beneficiary for the item or service in question under §1842(I)(1)(A); and
- The supplier is claiming that he/she did not know and could not reasonably be expected to know that the item or service would be denied as not being reasonable and necessary under §1862(a)(1).
- A Medicaid State Agency or party authorized to act on behalf of the state.
Time Limit Extension
Time limits may be extended if good cause for late filing is shown. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240 addresses the issue of good cause for extension of the time limit for filing appeals. If good cause is not found, the request for appeal will be dismissed by the contractor.
Appointment of Representative
A beneficiary or supplier can appoint any individual to act as his/her representative in requesting an appeal. A representative may be appointed at any time in the appeals process. The appointment of representative is valid for one year from either 1) the date signed by the beneficiary or supplier making the appointment, or 2) the date the appointment is accepted by the representative, whichever is later. A copy of the completed appointment must be submitted with each appeal request.
The appointment can be made by completing the CMS-1696 - Appointment of Representative form; however, an appointment of representative form is not necessary. A written statement containing all the required elements is also acceptable as a valid appointment of representative. The required elements for a written statement are:
- Name, address, phone number of the beneficiary or supplier;
- Medicare number if the party is the beneficiary;
- Medicare supplier number if the party is the supplier;
- Name, address, phone number of the individual being appointed as representative;
- A statement that the party (beneficiary or supplier) is authorizing the representative to act on their behalf for the claims at issue and a statement authorizing disclosure of individually identifiable information to the representative;
- Signature of the party (beneficiary or supplier) making the appointment and the date signed;
- Signature of the individual being appointed as representative, accompanied by a statement that they accept the appointment and the date signed;
- Prohibition Against Charging a Fee for Representation: A supplier that furnished services to a beneficiary may represent them on their claim or appeal involving those services; however, the supplier may not charge the beneficiary a fee for representation. Further, the supplier being appointed as representative must acknowledge that they will not charge the beneficiary a fee for such representation. The supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.
The beneficiary can also transfer his/her appeal rights to his/her health care provider by completing the Transfer of Appeal Rights form.
- Attorney Representation: If the person representing the party is an attorney, they are not required to sign the representative form or written statement. However, in order to release individually identifiable beneficiary information to an attorney, the beneficiary must sign and complete an appointment naming the attorney or complete a release of information.
- Power of Attorney: A power of attorney is a valid appointment if it contains all of the required elements of an appointment and it authorizes the designated person to conduct the beneficiary's affairs. This can include authorization to conduct personal and financial matters. It can also be a general authorization or may include very specific authorization to pursue benefits under the Medicare program or government entitlement programs. A power of attorney that authorizes the designated person to make health care or medical care decisions alone is not a valid appointment.
- Deceased Beneficiary: If the beneficiary is deceased, the legal representative of the estate may file the appeal request. If there is no legal representative, it may also be filed by any person who has assumed responsibility for settling the decedent's estate. In this situation, there must be proof that the person has assumed responsibility for settling the estate. This proof may be a copy of the will or probate court document.
- Release of Beneficiary Information to Representative: The beneficiary's information cannot be released without their explicit written authorization. In accordance with the Privacy Act, the beneficiary must (1) complete and sign an appointment of representative form naming an individual as their representative, or (2) complete and sign an authorization form explicitly allowing the release of their claim information to the representative.
Filing on Behalf of Beneficiary
An appointment of representative form is not needed if the request for redetermination clearly shows the beneficiary knew of or approved the submission of the request for redetermination (e.g., the request is submitted with the beneficiary's Medicare Summary Notice (MSN) or with a written authorization from the beneficiary). People who often act on behalf of a beneficiary in filing a redetermination request include, but are not limited to: the spouse, parent, daughter or son, sister or brother, or neighbor/friend.
Beneficiary advocacy groups, suppliers, doctors, and Members of Congress may also submit a request for redetermination on behalf of a beneficiary. These requests will be accepted if the request for redetermination clearly shows the beneficiary knew of or approved the submission. In absence of the beneficiary's clear knowledge or approval, an appointment of representative form or written statement is required.
- Noridian Medicare Portal
- Interactive Voice Response (IVR)
- Supplier Contact Center
- Email Redeterminations (Do Not Send Protected Health Information)
- Medical Documentation Checklists
- CMS Medicare Appeals Process
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 29 – Appeals of Claims Decisions
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 34 – Reopening and Revision of Claim Determinations and Decisions
Last Updated Oct 25, 2016