You should not take no for an answer if you believe the service was reasonable and necessary.
There are up to four additional levels of appeals you can use if Medicare denies payment
for doctor, hospital, skilled nursing facility, home health, ambulance, lab or durable medical equipment services.
As of January 1, 2006, the appeal levels for Medicare Part A and Part B are the same.
If the Medicare carrier or intermediary denies your initial appeal
- Appeals must be decided within specific timeframes. If these deadlines are missed, your cases could be elevated to the next level.
- Deadlines for requesting appeals can be extended if good cause exists (for example, you were hospitalized or you are unrepresented and are elderly).
, you can ask for a Reconsideration
(review by a Qualified Independent Contractor). The amount in question does not matter.
Note: In 2008, Medicare began replacing fiscal intermediaries, carriers and regional home health intermediaries with Medicare Administrative Contractors (MACs). These MACs will process claims for both Medicare Part A and Part B in assigned regions. There are 15 A/B MAC regions. To find out who you should call with billing issues and whether your state has been assigned to a MAC region, call 800-MEDICARE.
- You must request a Reconsideration within 180 days (six months) of receiving the decision on your initial appeal.
- The QIC generally has 60 days to issue a decision.
For information on what a carrier or intermediary is, click on the "Why does my MSN come from a private insurance company?" link in the GO TO box.
If the Qualified Independent Contractor (QIC) denies your appeal
, you can ask for an Administrative Law Judge (ALJ) Hearing
, if the claim(s) in question totals at least $140 in 2013
If the ALJ denies your appeal
- You must request a hearing within 60 days of receiving the decision from the QIC.
- ALJ’s must generally decide your case within 90 days.
, you can ask for a Medicare Appeals Council
(MAC) review. The amount in question does not matter.
If the MAC denies your appeal
- You must request a hearing within 60 days of receiving the decision on your ALJ hearing.
- The MAC must generally decide your case within 90 days.
, you can request a judicial review in a Federal District Court
, if the claim(s) in question total at least $1,400 in 2013
- You must request a hearing within 60 days of receiving the MAC decision.
Your case can be reopened at each level of appeal (except federal district court) if the time limit for requesting an appeal has expired or all levels of appeal have been completed:
- For any reason within one year of the date of the decision.
- Within 4 years if there is new, material evidence to submit.
- At any time if the case involved fraud or was based on an obvious clerical error or error in the evidence.
The request must be made in writing to the entity that made the determination. If it decides not to reopen your case or to uphold its initial denial, you will not be able to appeal this decision.
To find out how you can get free help with your appeal, click on the link in the GO TO box.