Appeals
- Appeals Overview
- What is a Redetermination?
- What is a Reopening?
- Levels of the Appeals Process
- TIPS to Filing an Acceptable Appeal Request
- Appeals Time Limit Calculator
- Where to File Your Appeal
- Who Can Request an Appeal
- Redetermination Forms
- Appealing Overpayments
- Important Appeals Links
Overview
The Medicare program offers suppliers and beneficiaries the right to appeal claim determinations made by the carrier. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by Medicare carriers are governed by the Centers for Medicare & Medicaid Services.
What is a Redetermination?
The first step in the appeals process is a Redetermination, which is conducted by the carrier. A redetermination is a completely new, critical reexamination of a disputed claim or charge. The Redetermination Specialist considers all evidence submitted by the appellant and applies all applicable statutory and regulatory provisions including(CMS)rulings, Medicare manual instructions, Change Request, National Coverage Determinations (NCDs), Regional medical review policies (RMRP), local Coverage Determinations (LCDs), and Policy Articles.
TopWhat is a Reopening for Minor Errors or Omissions?
Where the supplier has made a minor error or omission in filing the claim, which in turn causes the claim to be denied, the supplier should not request a redetermination. In the case where a minor error or omission is involved, the supplier can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. Suppliers can request a reopening for minor error or omissions either by telephone or in writing. Suppliers have one year to request a reopening from the date on the remittance notice.
Additional information can be found in our Reopenings section.
Levels of the Appeals Process
| Appeal Level | Time Limit for Filing Request | Monetary Threshold |
|---|---|---|
| Redetermination | 120 days from the date of issuance of the initial determination or overpayment demand letter | None |
| Reconsideration | 180 days from the date of receipt of the Redetermination notice | None |
| Administrative Law Judge (ALJ) | 60 days from the date of receipt of the Reconsideration notice | For requests filed on or after January 1, 2010, at least $130 remains in controversy |
| Departmental Appeals Board (DAB) Review | 60 days from the date of receipt of the ALJ decision/dismissal | None |
| Federal Court (Judicial) Review | 60 days from the date of receipt of the DAB decision or declination of review by DAB | For requests filed on or after January 1, 2012, at least $1,350 remains in controversy |
These time limits may be extended if good cause for late filing is shown. When an appeal request appears to be filed late, the contractor makes a finding of good cause using the guidelines established in the Internet Only Manual (IOM), Publication 100-04, Chapter 29, Section 240 before taking any other action on the appeal.
Tips to Filing an Acceptable Appeal Request
Preventing Your Appeal Request From Being Dismissed
All Redetermination requests must contain the following information:
- The printed name (including the last name) and signature of the person filing the request
- The beneficiary's name
- The Medicare health insurance claim number of the beneficiary
- The specific service(s) and/or item(s) for which the redetermination is being requested; and
- The specific date(s) of service
It is important that any documentation or remittance advices submitted with the redetermination request match the information listed on the request. In order to perform a complete and accurate review of your case we must be confident that we are addressing the issues you intended to submit. Therefore, when there are attachments that contain information that do not match the information on the form the request will either be dismissed or returned for clarification.
Common examples of conflicting attachment information:
- The date of service listed on the form is January 10, 2010 for a wheelchair and the remittance advice and/or other information is for a different date of service or item.
- A date of service and a claim control number (CCN) are provided on the request form. The CCN does not match what we have on file for that date of service. In this case the redetermination will be conducted based on the date of service only.
Incomplete requests will be dismissed with an explanation of the missing information. You will be instructed to resubmit the request with all of the missing information. Incomplete requests that are resubmitted for appeal must be submitted within the 120 day timely filing limit. Incomplete requests that are resubmitted past the 120 day timely filing limit will be dismissed.
Appeals Time Limit Calculator
Simply enter the initial determination date that appears on your Medicare Remittance Notice, Medicare Summary Notice, or Demand Letter. The tool will then calculate the date that your Redetermination Request must be submitted by in order to meet the timeliness requirement.
I would like to submit my Redetermination Request today. Will it meet the 120 day timeliness requirement? (opens in new window)
Where to File Your Appeal
| Level | Where to File |
|---|---|
| Redetermination | CGS DME MAC Jurisdiction C P. O. Box 20009 Nashville, TN 37202 OR FAX: 615-782-4630 |
| Reconsideration | C2C Solutions, Inc. ATTN: DME QIC P.O. Box 44013 Jacksonville, Florida 32231-4013 Website: www.C2Cinc.com |
| ALJ Hearing | (ADQIC) HHS Office of Medicare Hearings and Appeals (OMHA) field office |
| DAB Review | DAB or ALJ Hearing Office |
Who Can Request an Appeal
- Medicare beneficiaries or their authorized representatives, or Medicaid state agencies or parties authorized to act on behalf of Medicaid state agencies for the beneficiaries.
- Medicare providers, practitioners, or suppliers participating with the Medicare program and accepting assignment on all services performed.
- Medicare providers, practitioners, or suppliers not participating in the Medicare program and not accepting assignment but are held liable for indemnification under §1842(I)(1)(A).
Appealing Overpayments
When appealing an overpayment there are some key elements that should be submitted with your overpayment appeal request. Submitting these key elements will allow us to properly address all the issues in your request and will expedite the processing of your appeal.
Please provide the following elements when sending in an overpayment appeal request:
- A copy of the audit results letter. (For example, a notification letter from the contractor who audited your claims such as the ZPIC's, RAC, PSC or Medical Review.)
- A copy of the overpayment demand letter. (This letter is the official demand letter that is issued by CGS or the RAC. It contains the total amount of the overpayment, information on where to send payment and appeal rights.)
- Clearly state the Beneficiary's name, Date of Service and HCPCS Code of the item(s) that you wish to appeal.
Note: If you wish to appeal every claim or the entire amount of the overpayment demand letter you must specify this in your request.
Example: On the redetermination request form you can write: I would like to appeal the entire overpayment amount. See attached overpayment demand letter.
Note: You can also send in an overpayment spreadsheet or list containing all of the items identified in bullet three above.
Note: CGS has 60 days from the date of receipt to process your claim. If we have to call and request additional documentation the processing time limit is 74 days from the date of receipt.
Important Appeals Links
- Code of Federal Regulations (CFR)
- Social Security Act
- CMS Internet-Only Manuals
- Local Coverage Determinations (LCDs)
- Supplier Manual
- DME MAC Insider
Forms
Claims forms, including the Redetermination Request Form and the Reopening Request Form can be found on our Forms page.
