3rd – 5th Level of Appeals
Physicians, suppliers, and beneficiaries have the right to appeal claim determinations made by MACs. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by MACs are governed by the Centers for Medicare & Medicaid Services (CMS). As a MAC, CGS handles the first level of appeal, redetermination requests. There are five levels of appeal.
- Original Medicare (Fee-for-service) Appeals
- Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims Decisions
Level of Appeal | Time Limit for Filing Request | Time Limit for Filing Request |
---|---|---|
Third Level of Appeal: Administrative Law Judge![]() |
60 days from the date of receipt of the reconsideration | Current Amount in Controversy (AIC) requirements can be found on the CMS website![]() |
Fourth Level of Appeal: Department Appeals Board (DAB) Review/Appeals Council![]() |
60 days from the date of receipt of the ALJ hearing decision | None |
Fifth Level of Appeal: Federal Court Review![]() |
60 days from date of receipt of the Appeals Council decision | Current AIC requirement can be found on the CMS website![]() |
Posted: 12.14.20