Redetermination Time Limit Calculator

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Last Updated Sep 22, 2014

Appeals

If you are dissatisfied with an initial claim determination, you have the right to request an appeal. There are many appeal levels and each level must be processed before proceeding to the next level. The table shown below includes information on each of the appeal levels, the amount in controversy thresholds and the time limits for filing an appeal.

Appeal Level Time Limit for Filing Request Monetary Threshold to be Met Time Limit to Complete Appellant's Request Where to File Forms
Redetermination 120 days from date of receipt of the notice initial determination None 60 days from the date of receipt AB MAC (Noridian)
Reconsideration 180 days from date of receipt of the redetermination None 60 days from the date of receipt Qualified Independent Contractor (QIC)
Administrative Law Judge (ALJ) Hearing 60 days from the date of receipt of the reconsideration $140 until 12/31/2014

$150 effective 1/1/2015
90 days from the date of receipt Intermediary or HHS OMHA Field Office if heard by QIC
Medicare Appeals Council Review (Departmental Appeals Board (DAB)) 60 days from the date of receipt of the ALJ hearing decision None 90 days from the date of receipt DAB or ALJ Hearing Office
Federal Court Review 60 days from date of receipt of DAB decision or declination of review by DAB $1430 until 12/31/2014

$1460 effective 1/1/2015
None Refer to DAB decision
  • Refer to DAB decision

 

Who Can Request an Appeal

  • Medicare beneficiaries or their authorized representatives, or Medicaid state agencies or parties authorized to act on behalf of Medicaid state agencies for 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 physician has already collected payment from the 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 the state

Time Limit Extension

These time limits may be extended if good cause for late filing is shown. Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240 This link takes you to an external website. 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.

Resources

Last Updated May 22, 2015