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The Appeals Process
Pub. 100-04, Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims Decisions
The Medicare program has a process in place for you to challenge the initial Medicare determination on a claim. This process is called the Appeals Process. There are five different levels of the Appeals Process:
- Level I – Redetermination.
- Level II - Reconsideration.
- Level III - Administrative Law Judge (ALJ) Hearing.
- Level IV - Departmental Appeals Board (DAB) Review.
- Level V - U.S. District Court Review.
Level I - Redetermination
All requests for the first level of appeal (Redetermination) must be made in writing.
All initial claims determinations, including those for overpayments and medical review, will need to go through redetermination, regardless of the amount in controversy.
A party who is dissatisfied with an initial Medicare Part B coverage determination may request that the carrier, Upstate Medicare Division (UMD), review such determination. The request for an appeal must be filed within 120 days of the date of receipt of the notice of the initial determination.
Providers/suppliers or the party authorized to act on behalf of the provider, are responsible for submitting documentation, if any, that supports the contention that the initial determination was incorrect under Medicare coverage and payment policies. The request for an appeal must not only identify the initial determination with which the party is dissatisfied, but must also meet the requirements for the contents of an appeal request outlined below.
Please complete Form CMS-20027, Medicare Redetermination Request Form, or the Medicare Part B Provider Request for Redetermination  form to express disagreement with the initial determination. If a fully-completed Form CMS-20027 is not used, then the redetermination request must contain the following information:
- Beneficiary name;
- Medicare Health Insurance Claim (HIC) Number;
- The specific service(s) and/or item(s) for which the redetermination is being requested;
- The specific date(s) of the service; and
- The name and signature of the party or the representative of the party.
Request for a redetermination should be mailed to:
Redeterminations
Upstate Medicare Division
PO Box 5200
Binghamton, NY 13902-5200
Level II - Reconsideration
The following criteria must be followed when requesting a reconsideration:
- The request must be in writing.
- The request must be filed within 180 days from date of receipt of the redetermination.
The second level of appeal will be conducted by the Qualified Independent Contractor (QIC). Reconsideration request must be submitted to the QIC at:
First Coast Service Options, Inc.
QIC Part B North Reconsiderations
P.O Box 45208
Jacksonville, FL 32232-5208
If you are not satisfied with the reconsideration determination, you may request a hearing from an Administrative Law Judge (ALJ).
Level III - Administrative Law Judge (ALJ) Hearing
The following criteria must be met when requesting an Administrative Law Judge (ALJ) hearing:
- The ALJ hearing must be requested in writing.
- The amount that must remain in controversy for ALJ hearing requests made on or after January 1, 2008, is $120. You may combine appeals for the hearing to meet amount remaining in controversy requirement.
- The request must be filed within 60 days after receipt of the notice of the QIC's reconsideration decision.
You should send your ALJ request to the QIC office that performed your resonsideration. The mailing address for your ALJ request will be included in your reconsideration letter.
If you are not satisfied with the ALJ’s decision, you may request a Departmental Appeals Board (DAB) Review.
Level IV - Departmental Appeals Board (DAB) Review
The following criteria must be met when requesting a Departmental Appeals Board Review:
- The Departmental Appeals Board (DAB) Review must be requested in writing.
- There is no amount in controversy.
- The request must be filed within 60 days from the date of receipt of the ALJ hearing decision.
The mailing address for your DAB request will be included with your ALJ letter.
If you are not satisfied with the DAB decision, you may request a U.S. District Court Review.
Level V - U.S. District Court Review
The following criteria must be met when requesting a U.S. District Court Review:
- The U.S. District Court Review must be requested in writing.
- The amount that must remain in controversy for U.S. District Court review requests made on or after January 1, 2008, is $1,180.
- The request must be filed within 60 days from date of receipt of the Departmental Appeals Board (DAB) Review decision or declination of review by DAB.
The mailing address for your U.S. District Court Review will be included with your Departmental Appeals Board (DAB) letter.
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