After a Medicare Administrative Contractor (MAC) processes your claim for Medicare coverage or payment, you will receive a Medicare Summary Notice (MSN). It explains whether Medicare will pay for your services and how much (if any) you must pay. If Medicare will not pay for the services, the MSN should provide the reason why coverage is denied. If you are not satisfied with Medicare’s determination, you may file an appeal. The 5 potential levels of appeal are described below.
Level 1: Redetermination
If you want to appeal Medicare’s initial determination, you must submit a written, signed request for redetermination within 120 days of receiving the determination. The MSN will direct you where and how to file the request (they can no longer be filed at Social Security offices). The Medicare Administrative Contractor you appeal to must issue a decision within 60 days of receiving your request.
To support your case, ask your provider to write and submit a letter describing your medical condition; why the treatment, service or equipment you received is medically necessary; and how it meets Medicare’s criteria for coverage. You can also include any appropriate medical records.
Level 2: Reconsideration by Qualified Independent Contractor (QIC)
If the redetermination is not in your favor, you can file a request for reconsideration by the QIC within 180 days (this timeframe may be extended for good cause). The QIC will conduct an external review of your appeal and issue a decision within 60 days of receiving your request. You can request an extension of 14 days. Also, a 14-day extension is added each time additional evidence is submitted to the QIC.
If the QIC does not issue a timely decision, you can request for the appeal to be escalated to the next level — an Administrative Law Judge (ALJ) review. Once a request for escalation is made, the QIC has 5 days to either issue a decision or send a request to the ALJ level.
California’s QIC for Part A and durable medical equipment (DME) is Maximus, Inc.; for Part B it is C2C Solutions Inc.
Level 3: Administrative Law Judge (ALJ) Review
If your reconsideration is denied by the QIC, you have the right to a fair hearing before an ALJ if the amount in dispute is at least $180 (in 2023). You can make this request by submitting a completed Form OMHA-100 (available on medicare.gov).
You have 60 days from the date of the QIC decision to file a request for an ALJ hearing. The ALJ has 90 days to issue a decision, but can extend the timeframe for various reasons, such as submission of new evidence or request for an in-person hearing. In addition, if an appeal is escalated without a QIC decision, the ALJ timeframe is extended to 180 days.
ALJ hearings take place at the federal Department of Health and Human Services, which only has 4 offices nationwide with ALJs. As a result, ALJ hearings are commonly held by video teleconference or over the phone. An in-person hearing can be requested at the ALJ’s discretion, if you can should good cause as to why the hearing should be held in person.
Level 4: Medicare Appeals Council (MAC)
If the ALJ decides against you and you want to continue the appeals process, you have 60 days to request a review by the Medicare Appeals Council. The ALJ’s decision letter has information about how to file this request. Council reviews are not conducted in person; the Council reviews the relevant documents and issues a decision. The Council has 90 days to issue a decision, but this timeframe can be extended for several reasons.
Level 5: Federal Court
If the Medicare Appeals Council rules against you and the amount in dispute is at least $1,850 (in 2023), you can file a lawsuit in federal district court within 60 days. You will probably need legal assistance, and the process will likely be time-consuming.
Note: You should consider seeking legal advice before requesting an ALJ, Medicare Appeals Council, or federal court review.