Home Health & Hospice Week

Be sure you know the five levels of the Medicare appeals process. Before you can request an appeal, you must have a processed claim that Medicare has either fully or partially denied, says RN Shelly Dailey, Medicare home health and hospice clinical consultant at HHH Medicare Administrative Contractor National Government Services.

The five levels of appeals include:

Level 1: Redetermination, which goes through your MAC. For a redetermination Level 1 appeal to be considered complete, the provider must include all of the following information: the beneficiary’s name; the Medicare beneficiary number; the requested service; the date of service; and the name and signature of the requesting individual. If all of these elements are not included with your initial Level 1 appeal, your MAC will dismiss the case as incomplete, Dailey says.

Level 2: Reconsideration, which goes through the qualified independent contractor (QIC). Requests for Level 2 appeals can only be made in writing.

Level 3: Administrative Law Judge Hearing (ALJ). Requests for Level 3 appeals can be made in writing only. Also, your claim must be worth at least $160 to file a Level 3 appeal.

Level 4: Medicare Appeals Council Department Appeals Board (DAB). Claims for a Level 4 appeal must also be worth at least $160.

Level 5: U.S. Federal District Court. Claims for a Level 5 appeal must be worth at least $1,630.