Original Medicare:
The Appeals Process

Step One: Filing a Request for Redetermination
Step Two: Filing a Request for Reconsideration
Step Three: Administrative Law Judge (ALJ) Hearing
Step Four: Medicare Appeals Council (MAC) Review
Step Five: Judicial Review

III. Expedited Appeals for Termination of Services

Step One: Receiving the Notice of Medicare Provider Non-Coverage
Step Two: Requesting an Expedited Determination
Step Three: Expedited Reconsideration
Step Four: Administrative Law Judge (ALJ) Hearing
Step Five: Medicare Appeals Council (MAC) Review
Step Six: Judicial Review

There are two types of appeals processes that a Medicare beneficiary may need to use:

1. Coverage and Payment: The first type of appeal may be used when Medicare has denied coverage or payment for health care services that the beneficiary has already received. This type of appeal is typically encountered when a beneficiary receives a notice from Medicare that payment is denied.

2. Expedited: This type of appeal arises when a Medicare beneficiary currently receiving hospital care, skilled nursing facility care, outpatient rehabilitation facility care, hospice, or home health care suddenly receives notice that the care they are receiving will no longer be covered by Medicare.

In both instances, the denial of Medicare coverage may be appealed, and the appeal may progress through a number of stages. The stages for both types of appeals are outlined below. A flowchart depicting the various stages in the appeals process is also available.

II. Coverage and Payment Appeals

A. The Initial Coverage Determination

The ability to appeal an adverse Medicare coverage decision begins when a beneficiary receives notice of Medicare’s initial determination of coverage. The beneficiary will be notified after medical services have been rendered by either a Medicare Summary Notice or an Explanation of Medicare Benefits.

The initial coverage determination notice must inform the beneficiary whether or not the claim will be covered by Medicare, the reason for any denial, and how the Medicare beneficiary may appeal a determination of non-coverage.

See 42 C.F.R. §§ 405.920 - 405.928.

B. Stages of a Medicare Appeal

Step One: Filing a Request for Redetermination

Who: Medicare beneficiaries, their representative, doctor, provider, or supplier of medical services or equipment can request a redetermination of any denial of Medicare coverage.
When: The request for redetermination must be filed within 120 days of receiving the initial coverage determination. A person is assumed to have received the initial coverage determination within five days of the date that is printed on the initial determination notice.
How: A request for redetermination must be addressed to the Medicare contractor indicated on the initial coverage determination notice. It must be in writing. The request can be made using a standardized form, CMS-20027, or by writing a letter that includes all of the following elements:

       o The beneficiary's name;
       o The Medicare health insurance claim number;
       o The medical service or item for which the redetermination is being requested;
       o The specific date of the service; and
       o The name and signature of the party or their representative.

What: The request must explain why the initial determination was wrong and should include any evidence that the beneficiary believes should be considered by the contractor in making its redetermination. See HAP’s How to Help on a Medicare Appeal for suggestions on deciding what to include.
What Happens Next: The Medicare contractor reviews the information included in the request for redetermination and decides whether the claim should be covered by Medicare. The decision is communicated to the beneficiary in a Notice of Redetermination letter. If the contractor determines that Medicare should not cover the claim, the appealing party may request a reconsideration by following the steps set forth in the Notice of Redetermination letter.

See 42 C.F.R. §§ 405.940 - 405.946.

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Step Two: Filing a Request for Reconsideration

Who: Medicare beneficiaries, their representative, doctor, provider, or supplier of medical services or equipment can request reconsideration. A request for reconsideration may only be filed after a request for redetermination resulted in Medicare coverage being denied again.
When: The request for reconsideration must be filed within 180 days of receiving the Notice of Redetermination, though this time frame may be extended for good cause. Good cause is not defined under law, but it has been interpreted to mean circumstances outside of the beneficiary’s control.
How: A request for reconsideration must be addressed to the Qualified Independent Contractor (QIC) indicated on the Notice of Redetermination. It must be in writing. The request can be made using a standardized form, CMS-20033, or by writing a letter that includes all of the following elements:

       o The beneficiary's name;
       o The Medicare health insurance claim number;
       o The medical service or item for which the reconsideration is being requested;
       o The specific date of the service;
       o The name and signature of the party or their representative; and
       o The name of the contractor that made the redetermination.

What: The request must explain why the initial determination and redetermination were wrong. It should state any facts or laws that support the explanation being asserted. All evidence that supports the facts set forth in the request, and any evidence that was identified in the notice of redetermination as missing should be included. See HAP’s How to Help on a Medicare Appeal for suggestions on deciding what to include.
What Happens Next: The QIC reviews the information included in the request for reconsideration and, within 60 days, decides whether the claim should be covered by Medicare. If the QIC determines that Medicare should not cover the claim (and the amount in controversy exceeds the threshold amount), the appealing party may request a hearing before an Administrative Law Judge (ALJ). A party may also seek ALJ review through a process called “escalation” if the QIC fails to issue its decision in a timely manner. Expedited access to judicial review may also be possible at this stage in certain cases.

See 42 C.F.R. §§ 405.960 - 405.970; 42 C.F.R. §405.990

Step Three: Administrative Law Judge (ALJ) Hearing

Who: Medicare beneficiaries, their representative, doctor, provider, or supplier of medical services or equipment can request an ALJ hearing of claims where the amount in controversy exceeds a threshold amount ($120 in 2008). A request for an ALJ hearing may be filed after a request for reconsideration has resulted in Medicare coverage being denied again. An ALJ hearing request may also be filed where the QIC fails to issue its decision in a timely manner.
When: The request for an ALJ hearing must be filed within 60 days of receiving the Notice of Reconsideration or letter of dismissal from the QIC. An extension of this deadline may be granted when good cause is shown.
How: A request for an ALJ hearing must be addressed to the entity specified in the reconsideration notice. A copy of this request must also be mailed to all other parties in the matter. The request must be made either by submission of the standardized form CMS-20034A/B or in a separate written document that contains all of the following elements:

       o The name, address, and Medicare health insurance claim number of the beneficiary whose claim is being appealed;
       o The name and address of the appellant, when the appellant is not the beneficiary;
       o The name and address of designated representatives, if any;
       o The document control number assigned to the appeal by the QIC, if any;
       o The dates of service;
       o The reasons the appellant disagrees with the QIC's reconsideration or other determination being appealed; and
       o A statement of any additional evidence to be submitted and the date it will be submitted.

What Happens Next: The ALJ will conduct a hearing. The hearing is likely to be conducted using video-teleconferencing, but it may also be conducted over the telephone or in person. The ALJ considers all of the information in the record, as well as new information submitted before or during the hearing. The ALJ will issue a notice of decision within 90 days of receipt of the request for an ALJ hearing. If the ALJ determines that Medicare will not cover the claim, the appealing party may, within 60 days, seek review before the Medicare Appeals Council (MAC). A party may also seek MAC review through a process called “escalation” if the ALJ fails to issue its decision in a timely manner. Expedited access to judicial review may, in certain circumstances, also be possible.

See 42 C.F.R. § 405.1000– 405.1022; 42 C.F.R.§405.990

Step Four: Medicare Appeals Council (MAC) Review

Who: Medicare beneficiaries, their representative, doctor, provider, or supplier of medical services or equipment can request a MAC review. Alternatively, the MAC itself may request to review the ALJ determination. A request for a MAC review may be filed upon receipt of an unfavorable ALJ notice of determination. It may also be filed where the ALJ fails to issue a timely notice of determination.
When: The request for a MAC review must be filed within 60 days of receiving the notice of decision from the Administrative Law Judge. If a written request for extension of this deadline is filed with the MAC and the MAC determines that good cause for granting the extension exists, the deadline may be extended.
How: A request for a MAC review may be made using a standardized CMS form, if available, or in a written document that contains all of the following elements:

        o The beneficiary's name;
        o The Medicare health insurance claim number;
        o The specific service(s) or item(s) for which the review is requested;
        o The specific date(s) of service;
        o The date of the ALJ's final action, if any;
        o If the party is requesting escalation from the ALJ to the MAC, the hearing office in which the appellant's request for hearing
           is pending;
        o The name and signature of the party or the representative of the party; and
        o Any other information CMS may decide.

What: The request for review must identify the parts of the ALJ’s decision that are believed to be incorrect. It must explain why the ALJ’s decision is incorrect by referring to the specific law and/or facts at issue.
What Happens Next: Parties to the MAC review may submit written statements that outline their position in relation to the facts in the case and the law at issue. Parties may also request to present an oral argument on the matter. The MAC is not required to allow oral arguments, but it may permit them if the case raises an important question of law, policy, or fact and it determines that written statements by the parties are not sufficient. The MAC will issue a decision within 90 days of the request for MAC review.

See 42 C.F.R. §§ 405.1100 - 405.1132

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Step Five: Judicial Review

Who: Any party to a MAC review may request judicial review. An action for judicial review may be filed upon receipt of an unfavorable MAC determination. Judicial review may also be sought upon the failure of a MAC to issue a decision within 90 days. Only claims with an amount in controversy that exceeds the threshold amount ($1,180 in 2008) are eligible for judicial review.
When: An action in federal court must be filed within 60 days of receiving the MAC’s decision or within 60 days of receiving notice that the MAC will be unable to complete a timely determination of the matter. Where a request for a time extension is filed with the MAC and the MAC determines that good cause for the delay exists, this time limit on filing in federal court may be extended.
How: A complaint, naming the Secretary of HHS as defendant, in his or her official capacity, must be filed with the appropriate U.S. District Court.
What: The complaint is a statement of facts and a demand for judicial relief filed by the person appealing the MAC decision. A complaint begins the judicial process—all prior stages of the Medicare appeal having been purely administrative. In administrative proceedings, the decisionmaker is an official of, or has been appointed by, the Department of Health and Human Services. The filing of a complaint is the first stage of a Medicare appeal that will be decided by a judge, who is independent of any party.
What Happens Next: As in any civil legal proceeding, both parties will be able to file statements as to their position in the case, file motions to dispose of the case before trial, engage in discovery, and choose to settle or proceed to trial. If the case proceeds to trial, the judge will issue a decision. The decision entered by the judge may be appealed to the same extent that other legal actions may be appealed.

See 42 C.F.R. § 405.1130-1136; 42 CFR §405.990

III. Expedited Appeals for Termination of Services

A. Introduction

All Medicare beneficiaries are entitled to request an expedited process for having their Medicare claims examined or reviewed when existing health care services, including hospitalization, hospice, home health, outpatient rehabilitation, and skilled nursing facility care, are to be imminently terminated. Below is a summary of the appeal rights and procedures that apply.

B. Hospital Discharge Appeal Rights

See also 42 C.F.R. § 405.1206

C. Termination of Comprehensive Outpatient Rehabilitation Facility, Home Health, Hospice, or Skilled Nursing Facility Appeal Rights

Step One: Receiving the Notice of Medicare Provider Non-Coverage

Who: The provider of comprehensive outpatient rehabilitation facility (CORF) care, home health agency (HHA) care, hospice care, or skilled nursing facility (SNF) care must issue a Notice of Medicare Provider Non-Coverage to the Medicare beneficiary. If the Medicare beneficiary is unable to understand the nature and meaning of the notice, the notice must be delivered to the beneficiary’s representative.
When: The Notice of Medicare Provider Non-Coverage must be issued to the Medicare beneficiary or his/her representative no later than two days before the proposed end of services. The provider continues to remain liable for expenses related to the care of the beneficiary up until two days after delivery of the notice or a later date as stated in the notice.
What: The Notice of Medicare Provider Non-Coverage must inform the beneficiary or his/her representative of the date that coverage of services ends and the date that the beneficiary's financial liability for continued services begins. It must also describe of the beneficiary's right to an expedited determination, how to request one, and the beneficiary’s rights during the appeals process.
What Happens Next: The beneficiary decides whether or not they disagree with the decision to discontinue services. If the beneficiary disagrees with the decision to terminate services, he/she may request a review of this decision, called an expedited determination.

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Step Two: Requesting an Expedited Determination

Who: The beneficiary or his/her representative may request an expedited determination.
When: The request must be submitted, in writing or by telephone, to the Quality Improvement Organization (QIO) for the state in which the beneficiary resides. The request must be received by noon of the day following the day in which the beneficiary received the Notice of Medicare Provider Non-Coverage. If the QIO is not available (i.e., closed for the weekend), the request must be submitted by noon of the next day that the QIO is available. The QIO will accept and process an untimely request, but financial beneficiary protections and the 72-hour time frame for QIO review, as discussed below, will not apply.
What: If the services that are proposed to end are those provided by non-residential providers (i.e., home health agencies and comprehensive outpatient rehabilitation facilities), the beneficiary’s physician must certify that the beneficiary's health will be placed at significant risk if the services are terminated.

If the services that are proposed to end are those provided by residential providers (i.e., hospice, skilled nursing facility care), the beneficiary need only express disagreement with the plan to end services in order to make a valid request for determination.
In both cases, a beneficiary is permitted to submit evidence to the QIO to aid in its decisionmaking. See HAP’s How to Help on a Medicare Appeal for suggestions on what evidence to include in the request for expedited determination.
What Happens Next: If a timely request for determination was made, three things happen next:

1. Detailed Notice of Non-Coverage: By the end of the same day in which the provider is notified by the QIO that the beneficiary has requested expedited review, the provider must give the beneficiary a Detailed Notice of Non-Coverage. This notice must state:

a) Why, specifically, the services are either no longer reasonable and necessary or are no longer covered;
b) Any applicable Medicare coverage rule or policy;
c) Details specific to the beneficiary and relevant to the coverage determination that are sufficient to advise the beneficiary of the applicability of the coverage rule or policy to the beneficiary's case; and
d) The right of the beneficiary to obtain copies of records that the provider sends to the QIO in completing its review.

2. Financial Protection: The provider may not bill the beneficiary for any services until the appeals process is complete. Medicare continues to cover services provided until the date indicated on the Notice of Medicare Provider Non-Coverage. If the QIO disagrees with the provider’s proposed termination of services and determines that services should continue, Medicare coverage continues as well.

3. QIO Determination: Within 72 hours of the request for determination, the QIO must issue a determination of coverage. In reaching its decision, the QIO reviews the medical records and evidence submitted by the provider and by the beneficiary. The QIO solicits the views of the provider and beneficiary, and if necessary, ascertains whether the beneficiary’s physician has certified the continued need for the services. Although the beneficiary is encouraged to present evidence and an argument as to why services should continue, the burden of proving that termination of services is correct rests on the provider.

See 42 CFR §§ 405.1200 - 405.1202.

Step Three: Expedited Reconsideration

Who: The beneficiary or his/her representative may request an expedited reconsideration.
When: The request must be submitted to the Qualified Independent Contractor (QIC) indicated in the QIO’s notice of determination. It must be received by noon of the day following the day in which the beneficiary is notified (either by phone or in writing) of the QIO’s determination. If the QIC is not available (i.e., closed for the weekend), the request must be submitted by noon of the next day that the QIC is available. The QIC will accept and process an untimely request, but financial beneficiary protections and the 72-hour time frame for QIC review (as discussed below) will not apply.
What: The request must be made in writing or by telephone. It should indicate the basis for seeking continued services or treatment. The beneficiary may submit evidence for the QIC to consider in making its reconsideration. See HAP’s How to Help on a Medicare Appeal for suggestions on deciding what evidence to include in the request for expedited reconsideration.
What Happens Next: Unless the beneficiary requests an extension of the time for reconsideration, the QIC must complete its review and issue a notice of its findings within 72 hours of receiving the request for reconsideration. If the QIC does not issue a decision within 72 hours, the QIC must notify the beneficiary of his or her right to have the case escalated to the Administrative Law Judge hearing level if the amount remaining in controversy after the QIO determination is $120 (2008) or more.

If the QIC determines that Medicare coverage should continue, provider services will continue, and Medicare will pay for the cost. Should the QIC determine that continued services are not covered by Medicare, it must explain how the enrollee can further appeal this denial of coverage. The beneficiary will be liable for any costs that arise for continued provider services unless the QIC's decision is reversed on further appeal.

See 42 CFR §405.1204.

Step Four: Administrative Law Judge (ALJ) Hearing

See “Step Three: Administrative Law Judge Hearing” under Part II, Coverage and Payment Appeals, above.

Step Five: Medicare Appeals Council (MAC) Review

See “Step Four: Medicare Appeals Council (MAC) Review” under Part II, Coverage and Payment Appeals, above.

Step Six: Judicial Review

See “Step Five: Judicial Review” under Part II, Coverage and Payment Appeals, above.

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Original Medicare: The Appeals Process

Original Medicare:
The Appeals Process