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Legal Services of North Dakota |
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Part A Appeals After the provider submits a claim for payment, you will receive a notice. The notice "Explanation of Medicare Benefits" tells you what Medicare paid. The notice tells you how to appeal, where to appeal, and the date by which you must appeal. Each appeal must be in writing and filed within 60 days from the date on each notice. File the appeal with either Medicare or Social Security. If you disagree with the initial decision, you can request a Reconsideration. This is a paper review. Medicare will review the claim and issue a second decision. If you disagree with the second decision, you can ask for a Hearing. You can request a Hearing, if the amount in controversy is $100 or more. The hearing will be before an Administrative Law Judge of the Social Security Administration. This can be a paper review or an in-person hearing. If you disagree with the Judge's decision, you can request a Departmental Appeals Board (DAB) review. This is a paper review. If you disagree with the DAB decision, you can file an action in Court. You can file the Court action, if the amount in controversy is $1,000 or more. You must file the action within 60 days of the DAB decision. Part A Appeals on Decisions Made by a PRO A Peer Review Organization (PRO) decides some initial claims. These are medical decisions. The PRO decides whether services furnished or proposed are not reasonable, necessary, or delivered in the most appropriate setting. File a PRO appeal with either the PRO or Social Security. Each appeal must be in writing and filed within 60 days from the date on each notice. You have the same appeal rights as under the other PART A Appeal section (Reconsideration, Hearing, DAB and Court Review). However, you can request an Expedited Reconsideration on any pre-admission denial. If you want the Expedited Reconsideration you must make the request within 3 days after the initial decision and it must be filed with the PRO. Although you have 60 days to request a Reconsideration the sooner you appeal, the sooner you will receive a decision. The PRO has time frames to decide the claim. These start when they receive your appeal. If you disagree with the PRO Reconsideration, you can request a Hearing. You can request a hearing, if the amount in controversy is $200 or more. A hearing will be before an Administrative Law Judge of the Social Security Administration. This can be a paper review or an in-person hearing. If you disagree with the Judge's decision, you can request a Departmental Appeals Board (DAB) review. This is a paper review. If you disagree with the DAB decision, you can file an action in Court. You can file the action, if the amount in controversy is $2,000 or more. You must file the action within 60 days of the DAB notice. Part B Appeals After the provider submits a claim, you will receive a notice. The notice "Explanation of Medicare Benefits" tells you what Medicare paid. It tells you how to appeal, where to appeal, and how many days you have to appeal. INITIAL DECISION - A Medicare Carrier initially decides the claim. If you disagree with the decision, you can request the Carrier to review the determination. CARRIER REVIEW - The review request must be in writing and made within 6 months from the date on the initial notice. File the request with either the Carrier, Medicare or Social Security. The Carrier will make another decision. This is a paper review. If you disagree with the reviewed decision, you can request a Carrier Hearing. CARRIER HEARING - You can request a Carrier Hearing, if the amount in controversy is $100 or more. The Carrier Hearing request must be in writing and made within 6 months from the date on the review notice. File the request with either the Carrier, Medicare, or Social Security. The Carrier will make a third decision. This can be a paper review, a telephone or in-person hearing. If you disagree with the decision, you can request a hearing before an Administrative Law Judge (ALJ). ALJ HEARING - You can request the ALJ Hearing, if the amount in controversy is $500 or more. The ALJ hearing request must be in writing and made within 60 days from the date on the Carrier Hearing notice. File the request with either the Carrier or Social Security. The hearing will be before an Administrative Law Judge of the Social Security Administration. This can be a paper review or an in-person hearing. If you disagree with the ALJ decision, you can request a Departmental Appeal Board (DAB) review. DAB REVIEW - This is a paper review. The DAB review request must be in writing and made within 60 days from the date on the ALJ notice. File the request with Social Security. If you disagree with the DAB decision, you can file an action in Court. COURT ACTION - You can file a Court action if the amount in controversy is $1,000 or more. You must file the Court action within 60 days of the DAB notice. Please Note: At all APPEAL levels, you have the right to submit new evidence to support your case. In addition, at all HEARING levels, you have the right to be at the hearing and to be represented. Reopening a Case Medicare can review and 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 good reason could be a serious illness which prevented you from appealing, not understanding the requirements, or not receiving the notice. 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. |
