Complete Topic List

     

Original Medicare Plan Part A And Part B Appeals

Original Part A and B Appeals

  • For a denial of a Part A or Part B service in Medicare there are five standard steps in the appeal process. The beneficiary will receive the service and an initial determination will be processed  by Medicare contracting carriers and intermediaries. The beneficiary will be informed of the denial on the Medicare Summary notice which provides information on why the claim was denied and informs the beneficiary of their appeal rights.
     
  • If you disagree with the initial decision, you can request a Redetermination to the Medicare Administrative Contractor (MAC) within 120 days of the date on the notice.  This is a paper review.  The MAC must issue a decision in 60 days.
     
  • If you disagree with the redetermination decision you can file a reconsideration. You need to request this within 180 days. The reconsiderations are processed by Medicare qualified Independent Contractors (QICs) which conduct an external, independent review of the redetermination. The QIC has 60 days to render a decision.
     
  • If you want to appeal a reconsideration decision you can ask for a Hearing in front of an Administrative Law Judge. (ALJ)  You can request a Hearing, if the amount in controversy is $160 or more. The hearing request has to be within 60 days of the redetermination action decisions. In most cases the hearings are conducted over the telephone or video teleconference. In-person hearings are rare and are only granted if you can show “good cause”. ALJ generally has 90 days to decide, although this can sometimes be extended.
     

If you disagree with the ALJ’s decision, you can request a review of the decision by the Medicare Appeal’s Council (MAC). You have 60 days to request this review. The MAC has 90 days to make a decision, but this can be extended.

If you disagree with the MAC decision, you can file an action in Federal District Court.  You can file the Court action, if the amount in controversy is $1,600 or more.  You must file the action within 60 days of the MAC decision.

Expedited Appeals in Certain Circumstances
 

Hospital Discharges

  • A Medicare beneficiary must be provided with notice of discharge rights twice during the course of the hospital stay, once within two days after admission and again two days to four hours before discharge; if the stay is three days or less, once is sufficient. If the beneficiary feels they are not ready to medically leave the hospital they have the right to appeal the decision by requesting an expedited review through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
     
  • The patient may remain in the hospital at least until noon of the day after the BFCC-QIO decision. If the doctor agreed the patient should be released the patient has the right to appeal the decision by following the same process.
     
  • If the BFCC-QUI issues a favorable decision, Medicare will continue to pay for the care. If the decision is unfavorable to patient, the hospital may charge the patient for any costs incurred starting at noon the day after the decision was received. The patient has the right to then request a reconsideration by the QIC no later than noon of the calendar day following the decision rendered by the BFCC-QIO, and the QIC has 72 hours to decide. The hospital may NOT bill the patient until the QIC makes a decision. If the QIC is unfavorable, the patient will be responsible for all costs including costs incurred during the 72 hours.

Skilled nursing facility, home health, hospice

  • An expedited appeal process is also available when services are terminated for skilled nursing home facility, home health, hospice or comprehensive outpatient rehabilitation facility.
     
  • Some of the details and time frames differ from hospital discharges.
     
  • The provider must provide written notice to the patient at least two days or two visits before the services are to be terminated. The patient must request an expedited determination by the BFCC-QIO by noon of the day prior to the day the services are termination. The provider must provide a second notice which includes the reasons the termination is being made. Services are required to be continued until two days after the first notice was given or until the service termination date (whichever is later).
     
  • Once the request for the expedited appeal is made, the BFCC-QIO has 72 hours to make a determination along with an explanation, the patient’s liability for services, and information on the patient’s appeal rights. If the decision is unfavorable, the patient has the right to appeal by requesting an expedited reconsideration by the QIC. The QIC must make a decision within 72 hours.

Reopening a Case

  • The beneficiary or a contractor can request  review and Medicare can revise a decision within 12 months from the date on the notice.
     
  • If you missed the deadline to appeal, you must state, in writing, the reasons.  If you have a good reason, Medicare may allow the appeal.  A serious illness which prevented you from appealing or not understanding the requirements could be good reasons.
     
  • After the 12 month period, but within 4 years from the date on the initial determination, Medicare can review and revise the decision for Good Cause.  You can show Good Cause exists if you have new and material evidence to submit, or if the evidence used to decide the claim clearly shows that an error was made.

Medicare can review and revise a decision, at any time, for clerical errors or fraud.

Representation

You can have representation with the appeals.  If you want help, you can have a friend, lawyer or someone help you.

 

Disclaimer: This information is not legal advice. If you have a legal problem, you should talk to a lawyer and ask for advice about your options

May 2019
Published by Legal Services of North Dakota in conjunction with Aging Services Title III