Medicare Compliance & Reimbursement

Tip: Timelines vary by appeal level.

Whether you’re a Medicare claims novice or master, appealing a denied claim can be daunting. With complicated steps and requirements, it’s easy to mess up and have to start the process all over again.

Reminder: There are five levels of the Medicare appeals process. They include:

• Level 1: Redetermination, which goes through your Medicare Administrative Contractor (MAC).
• Level 2: Reconsideration, which goes through the qualified independent contractor (QIC).
• Level 3: Administrative Law Judge (ALJ) Hearing.
• Level 4: Medicare Appeals Council Department Appeals Board (DAB).
• Level 5: U.S. Federal District Court.

Read on for five challenging questions and the answers.

1. How many days from the date of your denial receipt do you have to file a redetermination with your MAC?

a. 60 days

b. 90 days

c. 120 days

d. 180 days

2. What can you do after receiving your redetermination if you are dissatisfied with the outcome?

a. file a reopening with your MAC

b. request a reconsideration with the QIC

c. submit a new claim to CMS

d. none of the above

3. In the third level of Medicare appeals, you can file an ALJ hearing with the _______________________.

a. MAC in your jurisdiction

b. HHS Office of Inspector General (OIG)

c. Department of Justice (DOJ)

d. Office of Medicare Hearings and Appeals (OMHA)

4. How much must a claim be worth — or the amount in controversy —in a level 5 appeal in calendar year (CY) 2020?

a. $160

b. $500

c. $1250

d. $1670

5. A request for a level 4 appeal, also known as a Medicare Appeals Council review, must be filed with the DAB___________________________.

a. in writing

b. online

c. through a CMS web portal

d. all of the above

Answers: 1.) c 2.) b 3.) d 4.) d 5.) a