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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.

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