Challenge a Claim Denial With the Medicare Appeals Process
Published on Sat Dec 01, 2001
The Medicare appeals process is designed so beneficiaries and their providers who are dissatisfied with a determination on a claim can have it looked at again. According to CMS, the following are the steps in the current Medicare Part B appeals process:
1. Review. This is the first, formal level of appeal following denial of a Part B claim. The review is an independent, critical examination of the claim file made by carrier representatives not involved in the initial claim decision. A request for review must be made within six months of the date of initial determination on the claim. There is no dollar-amount limit on the claim.
2. Fair hearing. If you are dissatisfied with the determination of the review, you can request a fair hearing within six months of the review decision if the amount in controversy is $100 or more. Hearings are conducted by hearing officers assigned by the carrier. The hearing officer's role is to determine whether the carrier has followed Medicare guidelines in making the decision in question. Three types of hearings can be requested:
On-the-record (OTR) hearing. This hearing is based on the facts on file, including any additional documentation obtained by or furnished to the hearing officer by the claimant or the carrier.
Telephone hearing. This hearing, including testimony and questioning, is conducted over the telephone.
In-person hearing. The claimant has the opportunity to appear at a hearing in person and present testimony supporting the claim or refuting or challenging the information the carrier used to process the claim.
3. Administrative law judge (ALJ) hearing. If you are dissatisfied with the fair-hearing decision, you may request a hearing before an administrative law judge of the Social Security Administration within 60 days of the fair-hearing decision if the amount in controversy is $500 or more.
4. Appeals board. If you are dissatisfied with the outcome of the ALJ hearing, you may request a review before the appeals board of the U.S. Department of Health and Human Services within 60 days of the ALJ decision if the amount in controversy is $500 or more.
5. Federal district court. If you are dissatisfied with the outcome of the appeals-board decision, you may pursue civil action in federal district court within 60 days of the board decision, if the amount in controversy is $1,000 or more.
At each level of the process, you will be notified of the decision and instructed on what steps to take, the time limits, and dollar amounts required to appeal to the next step. CMS performance standards for carriers require most reviews to be completed in 45 days, and most fair hearings to be completed in 120 days. There are no deadlines for the ALJ or appeal board to hear appeals.
Future Changes [...]
