Who Can Request an Appeal?

  • Medicare beneficiaries or his/her authorized representatives, or Medicaid state agencies or parties authorized to act on behalf of Medicaid state agencies for beneficiaries
    • An appointment of representative form is not needed if the request for redetermination clearly shows  beneficiary knew of or approved the submission of request for redetermination (e.g., request is submitted with beneficiary's Medicare Summary Notice (MSN) or with a written authorization from beneficiary). People who often act on behalf of a beneficiary in filing a redetermination request include, but are not limited to: 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 request for redetermination clearly shows beneficiary knew of or approved submission. In absence of beneficiary's clear knowledge or approval, an appointment of representative form or written statement is required.

  • Medicare providers, practitioners, or suppliers participating with Medicare program and accepting assignment on all services performed
  • Medicare providers, practitioners, or suppliers not participating in 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 physician has already collected payment from beneficiary for item or service in question under §1842(I)(1)(A); and
    • The physician is claiming that he/she did not know and could not reasonably be expected to know that 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 state
     

Last Updated Oct 25, 2018