Corporate

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).  Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims Decisions and the Original Medicare (Fee-for-service) AppealsExternal Website Web page for additional information.

There are five levels of appeal. As a MAC, CGS handles the first level of appeal, redetermination requests.

Level Time Limit for Filing Request Monetary Threshold to be Met
Redetermination 120 days from the date of receipt of the notice of initial determination None
Reconsideration 180 days from the date of receipt of the redetermination. NOTE: If a party requests QIC review of a contractor's dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor's dismissal notice. None
Administrative Law Judge (ALJ) Hearing 60 days from the date of receipt of the reconsideration Current Amount in Controversy (AIC) requirements can be found on the CMS websiteExternal Website. See §250 for additional information.
Departmental Appeals Board (DAB) Review/Appeals Council 60 days from the date of receipt of the ALJ hearing decision None
Federal Court Review 60 days from date of receipt of the Appeals Council decision Current AIC requirement can be found on the CMS websiteExternal Website. See §345 for additional information.

The beneficiary or their representative may request an appeal on any service processed for them. Provider and Suppliers may appeal services for which assignment was accepted. For unassigned claims, providers/suppliers may act as the beneficiary's representative if the beneficiary signs an authorization statement (such as form CMS-1696External PDF). In addition, provider/suppliers may request a redetermination on an unassigned claim if Medicare B denied the service as not reasonable and necessary or the provider/supplier billed in excess of the Limiting Charge and the provider/supplier is required to refund any fees collected from the beneficiary.

NOTE: Please be sure you send your Appeal requests to the correct contractor. Check HERE for details!

Updated: 10.28.19

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