Podiatry Coding & Billing Alert

Question: I filed a claim for a Part B patient with my Medicare Administrative Contractor (MAC), but it was rejected by Medicare. I intend to challenge this decision. Can you explain the different levels of the Medicare appeals process?

AAPC Forum Participant

Answer: The Medicare appeals process consists of five stages. Prior to initiating an appeal, you need a claim that Medicare has either completely or partially rejected. The stages of appeals include the following:

• Level 1: Redetermination, which goes through your 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.

Note: If every one of these elements are not included with your initial level 1 appeal, your MAC will dismiss the case as incomplete.

• 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 (ALJ) hearing. Requests for level 3 appeals can be made in writing only. Also, the amount in controversy must be at least $180 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 $180.
• Level 5: U.S. Federal District Court. Claims for a level 5 appeal must be worth at least $1,840.