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Summit Medicare Documentation Article VI
THE MEDICARE APPEALS PROCESS
Introduction
Getting paid for what you do sometimes involves appealing claim denials. In the
case of Medicare, the government maintains specific protocols for the appeals
process. The following outline will assist you in knowing what is required to
appeal a Medicare denial.
NOTE: The Summit recommends and encourages DCs to appeal ALL improperly
denied claims (even if it is only one claim); historically, many DCs do not.
Remember that appealing is not only a service to your patient, who has a right to
have their payable covered services reimbursed, but also is a service to your
profession.
Overview

When an initial claim determination is made, and the claim is denied,
participating physicians have the right to appeal.

Physicians who do not take assignment on claims have limited appeal rights.

Beneficiaries may transfer their appeal rights to non-participating physicians
who did not accept assignment (and therefore do not have appeal rights).
Form CMS-20031 must be completed and signed by the beneficiary and the
non-participating physician to transfer the beneficiary’s appeal rights.

All appeal requests must be made in writing.
Medicare offers five levels in the Part B appeals process. The levels, listed in
order, are:
1. Redetermination (performed by the carrier/MAC);
2. Reconsideration (performed by a Qualified Independent Contractor);
3. Hearing (performed by an Administrative Law Judge);
4. Review (performed by the Medicare Appeals Council (within the
Departmental Appeals Board); and
5. Judicial Review (in U.S. District Court).
The First Level of Appeal: Redetermination
A redetermination is the examination of a claim by carrier/MAC personnel who
are different from the personnel who made the initial determination. The
appellant (the individual filing the appeal) has 120 days from the date of the initial
claim determination to file an appeal. A minimum monetary threshold is not
required to request a redetermination.
Requesting a Redetermination
A request for a redetermination may be filed on Form CMS-20027 available at
http://www.cms.gov/cmsforms/downloads/cms20027.pdf. In addition, a
contractor-specific version can usually be found on the contractor’s web site.
A written request not made on Form CMS-20027 must include:

Beneficiary name

Medicare Health Insurance Claim Number (HICN)

Specific service and/or item(s) for which a redetermination is being requested

Specific date(s) of service

Name and signature of the party or the representative of the party
The appellant should include supporting documentation with their
redetermination request. Contractors will generally issue a decision (either a
letter or a revised remittance advice) within 60 days of receipt of the
redetermination request. The redetermination request should be sent to the
contractor that issued the initial determination/denial.
The Second Level of Appeal: Reconsideration
If dissatisfied with the outcome of the redetermination, a reconsideration may be
requested. A QIC (Qualified Independent Contractor) will conduct the
reconsideration. The QIC reconsideration process allows for an independent
review of medical necessity issues by a panel of physicians or other health care
professionals. A minimum monetary threshold is not required to request a
reconsideration.
Requesting a Reconsideration
A written reconsideration request must be filed within 180 days of the
redetermination. To request a reconsideration, follow the instructions on the
Medicare Redetermination Notice (MRN). A request for a reconsideration may
be made on Form CMS-20033, which can be found here:
http://www.cms.gov/cmsforms/downloads/cms20033.pdf. Again, a contractorspecific
version can usually be found on the contractor’s web site.
If the form is not used, the written request must contain all of the following
information:

Beneficiary name

Medicare Health Insurance Claim (HIC) number

Specific service(s) and/or item(s) for which the reconsideration is requested

Specific date(s) of service

Name and signature of the party or the authorized or appointed
representative of the party

Name of the contractor that made the redetermination
The request for reconsideration should clearly explain why you disagree with the
redetermination. A copy of the MRN, and any additional documentation you feel
may be useful, should be sent with the reconsideration request to the QIC
identified in the MRN.
Documentation that is submitted after the reconsideration request has been filed
may result in an extension of the timeframe a QIC has to complete its decision.
Further, any evidence noted in the redetermination as missing, and any other
evidence relevant to the appeal, must be submitted prior to the issuance of the
reconsideration decision. Evidence not submitted at the reconsideration level
may be excluded from consideration at subsequent levels of appeal unless you
show good cause for submitting the evidence late.
Reconsideration Decision Notification
Reconsiderations are conducted “on-the-record” (based on the information
submitted) and, in most cases, the QIC will send its decision to all parties within
60 days of receipt of the request. The decision will contain detailed information
on further appeals rights, if the decision is not fully favorable. If the QIC cannot
complete its decision in the applicable timeframe, it will inform the appellant of
their right to escalate the case to an Administrative Law Judge.
The Third Level of Appeal and Beyond
Our next article will focus on the last three levels of appeal, with a focus on what
is perhaps the most significant level, the Administrative Law Judge (ALJ), Level
3. Historically, the ALJ level has proven to be the most favorable level for
providers (although the vast majority have been won prior to reaching this level).
For further information on these subjects and others, please refer to the sources
for this article which include: CMS publications, the CMS manual system, and the
ACA web site (http://www.acatoday.org/medicare).
The members of the Summit Subcommittee on Documentation are Dr. Carl
Cleveland III, Dr. Farrel Grossman, Dr. John Maltby, Dr. Peter Martin, Ms. Susan
McClelland, Dr. Ritch Miller, Dr. Frank Nicchi, Mr. David O’Bryon and Dr. Frank
Zolli. Dr. Miller served as principal author of this article with contributions from
members of the subcommittee and documentation working group.