Dispute a Denial of Medicare Benefits
After medical services are provided, private-sector Medicare contractors make claims-payment decisions for patients receiving benefits under original fee-for-service Medicare.
The right to appeal unfavorable decisions is a five-step process that starts with standard or expedited review by the entity making the original determination, with progression through administrative channels to federal court, if necessary. Expedited review protects the rights of beneficiaries receiving home health, nursing home, rehabilitation hospital and hospice services for those who are about to be discharged due to unfavorable Medicare decisions on duration of benefits.
Beneficiaries and Medicare-participating health-care providers can file Medicare appeals when a claim is denied or partially denied.
Instructions
1. Request a redetermination from the fiscal intermediary, carrier or Medicare administrative contractor that denied the claim. This must be done in writing within 120 days of the denial. The Resources section contains a link to the redetermination request form.
Any supporting documents attached to the request must demonstrate why the item or service is medically necessary. Decisions are usually made within 60 days of the request and may be in the form of a letter, revised remittance advice or a Medicare Summary Notice.
2. File a request for reconsideration from the Qualified Independent Contractor (QIC) if dissatisfied with the redetermination decision. The request must be in writing and within 180 days of receiving the redetermination decision.
The reconsideration request form in the Resources section should be filled out and sent to the QIC with a copy of the redetermination decision and any supporting documents. Within 60 days, the QIC will send its decision to all parties and advise of any additional appeal rights.
3. Request an administrative law judge (ALJ) hearing within 60 days if the amount remaining in controversy meets the threshold for ALJ appeals ($130 in 2010). The standard form for requesting an ALJ hearing is in the Resources section.
ALJ hearings are generally held by video-teleconference (VTC) or by telephone, but you can request an in-person hearing. The ALJ usually makes a decision within 90 days of the request.
4. Request review by the Medicare Appeals Council if dissatisfied with the ALJ decision. The request must be in writing and within 60 days of receiving the ALJ decision. The ALJ decision will include details on the procedures you need to follow in filing your request.
Medicare Appeals Council decisions are issued within 90 days of receiving the review request.
5. File a request for judicial review in federal district court within 60 days If the amount remaining in controversy meets the threshold ($1,220 in 2010). The Medicare Appeals Council's decision will provide the necessary information on procedures for requesting judicial review.
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