Medicare Releases Revised Parts A & B Appeals Process Booklet
Medicare has posted its revised Parts A & B Appeals Process Booklet on the Medicare Learning Network (MLN). The booklet informs health care professionals about each level of appeal in Medicare Fee-For-Service (FFS) as well as resources on related topics including appointing an individual to represent you during the claim and appeals process. A list of resources and websites for dealing with appeals is also provided.
Medicare FFS has five levels in the claims appeal process:
- 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 Each level has its own timeframes and processes for filing and receiving a determination.
The booklet contains tables that outline and compare the steps for each level of appeal. It also offers the following tips:
- Make all appeal requests in writing
- Starting at Level 1, consolidate all similar claims into one appeal
- File timely requests with the appropriate entity
- Include a copy of the decision letter(s) or claim information issued at the previous level(s)
- Include a copy of the demand letter(s) if appealing an overpayment determination
- Include all relevant supporting documentation with your first appeal request
- Include a copy of the Appointment of Representative (AOR) form if the requestor is not a party and is representing the appellant
- Respond promptly to requests for documentation
- Sign your request for appeal
Additional information about appeals can be found on the Original Medicare (Fee-For-Service) Appeals web page.