If your Part A or Part B Medicare claim is denied - for people in Original fee-for-service Medicare
About appeals
You have the right to appeal any decision about your Medicare services. If Medicare does not pay for an item or service, or if you are not provided an item or service you think you should receive, you can appeal.
Ask your doctor or provider for a letter to support your appeal, or for medical records related to the bill that might help your case. Your appeal rights are described on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) form.
Note: An appeal is a special kind of procedure you follow if you disagree with a decision about your health care. It is a way to deal with a complaint about a treatment decision or service not covered. A grievance, however, is different. A grievance is a complaint about the way your Medicare health plan is providing care.
For example, you may file a grievance if you have problems with:
- cleanliness of the facility;
- reaching the plan’s customer service department;
- staff behavior; and/or
- operating hours.
If a Part A or Part B claim is denied or not handled in the way you think it should be, you can challenge the decision. It pays to ask for a formal Redetermination or Reconsideration of the initial decision. Very few people do this, but when they do - more than half the claims challenged result in paid claims or higher payments.
Initial determination
When a claim for Medicare coverage or payment has been processed by the Medicare carrier or intermediary, you are sent a Medicare Summary Notice (MSN). This notice tells you whether or not Medicare will pay for the services and how much you must pay. If Medicare will not pay for the services, the MSN should provide the reason why coverage is denied. If you are not satisfied with Medicare's determination, you may file an appeal. There are potentially five levels of appeal:
Step 1. Redetermination
If you want to appeal an initial determination, you must submit a written, signed request for redetermination within 120 days (approximately four months) of the initial determination. The MSN will direct you where and how to file the request. (Requests can no longer be filed at a local Social Security office.) The contractor you appeal to must issue a decision within 60 days.
Step 2. Reconsideration by Qualified Independent Contractor (QIC)
If the redetermination is decided against you and you want to continue the appeals process, you can file a request for reconsideration with the QIC, who will conduct an external review. The QIC contactor for California is First Coast Service Options (FCSOs). You have 180 days to request redetermination. The QIC must issue its decision within 60 days of receiving your request. You can request an extension of 14 days. Also, a 14-day extension is added each time additional evidence is submitted to the QIC. If the QIC does not issue a timely decision, you can request that the appeal be "escalated" to the next level (an ALJ review). Once a request for escalation is made, the QIC has five days to either issue a decision or send a request to the ALJ level. The ALJ normally has 90 days to issue a decision; however, if an appeal is escalated without a QIC decision, the ALJ time period is extended to 180 days.
Step 3. Administrative Law Judge (ALJ) Review
If your claim is denied by the QIC review, you have the right to a fair hearing before an administrative law judge (ALJ) if the amount in dispute is at least $120 (in 2008). You have 60 days from the date of the QIC decision to file a request for an ALJ hearing. The ALJ has 90 days to issue a decision, but the timeframe can be extended for various reasons, such as submission of new evidence or if you request an in-person hearing. ALJ hearings take place within the federal Department of Health and Human Services (DHHS), which has only four offices nationwide that house ALJs. So ALJ hearings will be held by:
- Video teleconference;
- Telephone; or
- In-person (at the ALJ's discretion, if you can show "good cause" as to why the hearing should be in person).
Step 4. Medicare Appeals Council (MAC)
If the ALJ decides against you and you want to continue the appeals process, you have 60 days to request a MAC review. Most MAC reviews will not be in person. Instead, the MAC will review the relevant documents and issue a decision. The MAC has 90 days to issue a decision, but this time period can be delayed for several reasons.
Step 5. Federal Court
If the MAC rules against you and the amount in dispute is at least $1,180 (in 2008), you can file a lawsuit in federal district court within 60 days. You will probably need legal assistance, and the process will likely be time-consuming.
Note: You should consider seeking legal advice before appealing to an administrative law judge, the Medicare Appeals Council, or federal court.
Expedited appeals
If you face a termination of services from a hospital, skilled nursing facility (SNF), home health agency (HHA), or hospice and comprehensive outpatient rehabilitation facility (CORF), you may request an expedited, independent determination.
The steps in an expedited appeals process are as follows:
Step 1
You receive notice of termination/discharge. The provider must give you notice no later than two visits or two days before the proposed end of services. You may appeal if you disagree with the termination and, if the services are from an HHA or CORF, a doctor certifies that failure to continue the service may place your health at significant risk.
Step 2
You appeal the decision to the Quality Improvement Organization (QIO), which in California is Lumetra. You must request the appeal by noon of the day prior to termination of services (this can be done by phone or in writing). You may contact California's Quality Improvement Organization, Lumetra at 1-800-841-1602, or 1-800-881-5980 (TDD for the hearing impaired). The provider must send you a detailed notice explaining why the services are either no longer reasonable and necessary or no longer covered. The provider must continue services until two days after the provider gave you the first notice or until the service termination date, whichever is later.
Step 3
Lumetra has 72 hours from receipt of your request for an expedited appeal to issue a decision. The initial notice of their decision must be by telephone and written notice must follow. The written decision must include:
- A detailed explanation of the decision;
- A statement explaining when you are liable for payment for the services; and
- Information about your appeal rights, including how to request a reconsideration.
Step 4
You have the right to request reconsideration by the Qualified Independent Contractor (QIC), which is Maximus CHDR. Your request must be in writing or by telephone, submitted no later than noon of the calendar day following the initial notification from Lumetra about their decision (whether by telephone or in writing). The QIC must issue a decision within 72 hours after your request for expedited reconsideration is received. (This period may be extended up to 14 days by you if more time is needed to collect medical records.) The QIC decision may be by telephone, followed by a written notice that includes the same information as required above by Lumetra. If you wish to pursue the appeal further, your next request would be for an Administrative Law Judge (ALJ) hearing.
Quality of health care complaints
"Quality of health care complaints" refer to hospitals discharging a Medicare patient too early from the hospital or other issues related to the quality of care or treatment. When you are admitted into the hospital, you will be asked to read and sign a form entitled “An Important Message from Medicare (PDF).” This document is available in English and Spanish. The message describes your rights, including the right to appeal a notice of discharge. If you feel that you are being discharged too soon, ask for the hospital discharge notice in writing. For Medicare Part A or Part B quality of health care complaints, including hospital discharge notices, contact California's Quality Improvement Organization, Lumetra, at 1-800-841-1602, or 1-800-881-5980 (TDD for the hearing impaired).
Page updated June 12, 2008