The Appeals Process
The Medicare program gives suppliers and beneficiaries the right to appeal claim determinations that the DME MAC made. The purpose of the appeals process is to ensure the correct adjudication, or processing, of your claim. There are 5 levels of the appeals process:
- Redetermination
- Reconsideration
- Administrative Law Judge (ALJ)
- Departmental Appeals Board (DAB) Review
- Federal Court (Judicial) Review
Who can request an appeal?
- Medicare beneficiaries, their authorized representatives, or Medicaid state agencies or parties authorized to act on behalf of Medicaid state agencies for the beneficiaries
- Medicare providers, practitioners, or suppliers participating with the Medicare program and accepting assignment on all services provided, or their authorized representatives
- Medicare providers, practitioners, or suppliers not participating in the Medicare program and not accepting assignment but are held liable for indemnification under Section 1842(I)(1)(A) of the Code of Federal Regulations (CFR)
Suppliers who use a billing agency to handle appeals need to submit a properly executed appointment of representative. Suppliers, or anyone seeking to represent a beneficiary, can use the Form CMS-1696 Appointment of Representative or submit a statement containing all of the required elements.
Each appeal process has specific timelines and requirements:
Appeal Level |
Time Limit for Filing Request |
Monetary Threshold |
---|---|---|
Redetermination |
120 days from the date of receipt of the initial determination or overpayment demand letter |
None |
Reconsideration |
180 days from the date of receipt of the Medicare Redetermination Notice |
None |
Administrative Law Judge (ALJ) |
60 days from the date of receipt of the reconsideration notice |
For requests filed on or before December 31, 2024, at least $180 remains in controversy. For requests filed on or after January 1, 2025, at least $190 remains in controversy. |
Departmental Appeals Board (DAB) Review/Appeals Council |
60 days from the date of receipt of the ALJ decision/dismissal |
None |
Federal Court (Judicial) Review |
60 days from the date of receipt of the Appeals Council decision or declination of review by DAB |
For requests filed on or before December 31, 2024, at least $1,840 remains in controversy. For requests filed on or after January 1, 2025, at least $1,900 remains in controversy. |
Serial Claims for Appeals
Once the reason for denial for one claim in a series is resolved, we will identify other claims for certain HCPCS codes in the same series that denied for the same or similar reasons. We will consider this initial determination when adjudicating the similar claims.
Specifically, this process applies to the following situations:
- Claims with no appeal request
- Claims pending redeterminations
- Claims in the series for which a redetermination was issued, but the timeframe to request a reconsideration by the Qualified Independent Contractor (QIC) has not yet elapsed
We will also communicate the favorable decision(s) to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels.
To view the HCPCS codes that apply to serial claims for appeals, see MLN Matters Article SE17010 Improvements to the Adjudication Process of Serial Claims.
Additional Resources: