Pathology/Lab Coding Alert

Question: My Medicare MAC denied a claim I submitted, and I want to appeal the decision. What are the appeals levels for Medicare?

Colorado Subscriber

Answer: There are five levels of the appeals process. Before you can request an appeal, you must have a processed claim that Medicare has either fully or partially denied, says Shelly Dailey, MSN, BSN, RN, CPHM, with Medicare National Government Services.

Note: The higher levels of appeals have a dollar requirement per claim. The five levels of appeals include:

• Level 1: Redetermination, which goes through your Medicare Administrative Contractor (MAC). Caution: 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: US Federal District Court. Claims for a Level 5 appeal must be worth at least $1,630.