There are five levels of Medicare appeals:

  1. Redetermination
  2. Reconsideration
  3. Administrative Law Judge Hearing (ALJ Hearing)
  4. Medicare Appeals Council
  5. Federal Court

Each of these levels has steps that must be followed. In each of these five levels of appeal: You have the right to have someone help you or represent you in your appeal. If you choose to have someone represent you, you must submit documentation evidencing valid representation. More information about each level is listed below.

The First Level Appeal: Redetermination

If you submitted a claim to Medicare and you were denied either full or partial payment, you can appeal this payment denial. This is called a request for redetermination.

The Second Level Appeal: Reconsideration

If you are not happy with the redetermination decision, you can request a reconsideration. To request a standard reconsideration, you must submit a written appeal request to Maximus.

The independent review by Maximus includes:

  1. Maximus sends you or your representative (if you have one) an acknowledgement letter notifying you that your appeal request was received.
  2. Maximus will request a copy of the case file from the applicable MAC.
  3. Maximus carefully reviews:
    • Medicare regulations
    • all the information in your case file, and
    • any additional information that you provide
  4. For appeals involving medical necessity, your case is reviewed by a Clinical Panel made up of licensed health care professionals.
  5. Maximus makes a decision within 60 calendar days from receipt of the appeal request for a standard reconsideration.
  6. Additional information that is submitted may extend the decision time frames.
  7. Maximus renders a reconsideration decision.
    • Maximus will issue a letter detailing the outcome of the reconsideration review. A copy of the letter will be sent to all parties to the appeal. The MAC will also be notified of the decision.
    • If Maximus renders an unfavorable or partially favorable decision, the decision letter will provide instructions for requesting an ALJ Hearing.

Your Rights in a Reconsideration Review with Maximus:

  • You have the right to submit additional information pertinent to your appeal. If you wish to submit additional information, please send the information to the following address.

QIC Part B DME Project
Maximus, Inc.
Medicare DME QIC
3750 Monroe Avenue
Suite 777
Pittsford, NY 14534

  • You have the right to have a representative assist you with your appeal
  • You have the right to ask for Maximus letters in a language you understand.
  • You have the right to a copy of everything in your file.
  • You have the right to receive a written appeal decision from Maximus.

The Third Level Appeal: ALJ Hearing

If you do not agree with the Reconsideration Decision rendered by Maximus, you can ask for a hearing with an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals (OMHA).

To qualify for an ALJ Hearing, you must meet the minimum amount in controversy requirement. The amount in controversy is adjusted each year. Please visit the CMS website at https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals to obtain the amount in controversy for the year in which you file your appeal.

You must submit your request for an ALJ Hearing in writing to the OMHA office with jurisdiction over your appeal.

  1. The ALJ office will schedule your hearing. The ALJ office will provide you with details relative to your hearing, including date, time and mode of hearing.
  2. The hearing can be held “on the record,” which means that the ALJ would consider all the written evidence without the need to hear oral testimony.
  3. The ALJ makes a decision based on your case file and the information given at the hearing.
  4. The ALJ will send a copy of the decision to all parties to the appeal and the Administrative QIC (AdQIC). The ALJ may send a copy of the decision to Maximus.

The Fourth Level Appeal: Medicare Appeals Council Review

If you are unhappy with the decision made by the ALJ, you may be able to ask for Medicare Appeals Council review of your case. This board is part of the federal department that runs the Medicare program.

The Fifth Level Appeal: Federal Court

If you are unhappy with the decision made by the Medicare Appeals Council, you may be able to take your case to a federal court. The amount in controversy is adjusted each year. Please visit the CMS website at https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals to obtain the amount in controversy for the year in which you file your appeal.

The CMS Medicare Learning Network also has published an overview of the five level appeals process.

More about your rights and who can help you

To get more information about your appeal rights:

To get help with your appeal:

  • Call your local Bar Association or legal aid program. If you do not have much money, these offices may be able to help you with your appeal.
  • Talk to a private lawyer who may charge you a fee.
  • Call 1-800-MEDICARE to request the telephone number of your State Health Insurance Assistance Program.

 

For information about the availability of auxiliary aids and services, please visit:
http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html