Medicare Appeals Process Forms

Medicare Appeals Process

Medicare Law provides an appeals process for providers dissatisfied with the initial claim determination made by the carrier. Re-submitting denied claims instead of utilizing the official appeals process could be considered a fraudulent act. Appeals can only be filed under the following scenarios:

• PAR: Participating physician who automatically accepted assignment on the claim.
• NON-PAR: Non-Participating physicians who DO NOT accept assignment may appeal on behalf of a patient, but only when they have valid transfer of appeal rights from the patient.

Before Submitting a Medicare Appeal

There are three situations which should be resolved through a reopening - NOT through the formal appeals process. In the following situations, contact your local MAC carrier by either telephone or letter and request a reopening:

1. Correcting incomplete or invalid claims submission. For example, a missing provider NPI or an incorrect patient ID number.
2. A minor error or omission which caused the claim to be denied.
3. Failure to respond within 45 days to an Additional Documentation Request (ADR) has resulted in a denial. The reopening must be requested within 120 days from the initial determination to be considered.

The following time frames for a reopening are outlined in the Medicare Claims Processing Manual:

• Within 1 year from the date of the initial determination or redetermination for any reason; or
• Within 4 years from the date of the initial determination or redetermination for good cause as defined in §10.11; or
• At any time if the initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based. Third party payer error does not constitute clerical error as defined in §10.4.

If the reopening results in an unfavorable determination, then the appeals process should be initiated.

Medicare Appeals – After The Initial Determination

The Medicare appeals process, has five levels. Each level must be completed for each claim being appealed before proceeding to the next level. The entire process could take up to 100 days. The five levels are:

1. Redetermination – by the Medicare contractor
2. Reconsideration – by a Qualified Independent Contractor (QIC)
3. Hearing – by Administrative Law Judge (ALJ)
4. Review – by Medicare Appeals Council
5. Review – by Federal Court

Below are instructions for proper Medicare appeals. They are sufficient for most offices. Providers and billers will want to master all components and steps, especially when large dollar amounts are involved.

Appointment of Representative

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices with beneficiaries enrolled in the original Medicare (fee-for-service) plan are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end. For more information see Expedited-Determination-General-Info.pdf.

Transfer of Appeal Rights

The Transfer of Appeal Rights form (CMS-20031) allows you to pursue payment through the appeals process. Keep each completed form on file. The form includes a second page with patient information.

Note: When you appeal, you give up the right to bill the patient if your appeal fails.

Medicare Appeals Process At-A-Glance

• Medicare Appeals Process (PDF File)
• Medicare Appeals Process Flowchart (PDF file)

The chart below shows the levels of the appeals process. Pay close attention to timing deadlines and monetary amounts.

Redetermination and Reconsideration

Step 1. Redetermination

After the initial determination and denial, the Redetermination review process is performed by your contractor. Your request must be submitted in written form. Your contractor generally makes a decision within 60 days from the time they receive your request. This decision will be in the form of a letter, Medicare Summary Notice (MSN), or Remittance Advice (RA).

File the Medicare Redetermination Request Form (CMS-20027) with your carrier within 120 days of their initial determination. Be sure to attach all evidence if you check item #14 on the form.

Trouble Shooting by Using the EOMB

One of the most valuable tools available to a practice for the reimbursement process is the Explanation of Medicare Benefits (EOMB) or payment report. The effectiveness of the entire billing process can be monitored by carefully reading these forms. If the claims in your practice are consistently being down-coded, bundled, or denied as medically unnecessary or unreasonable, you could be on the road to an audit. Corrective action in the practice can prevent many of these types of denials.

Additionally, contact the patient and ask what reasons were given to him/her for the denial. There are different standards about what information goes to the patient and what goes to the provider. You may find out information that can help you in the appeal process.

Checklist for Submitting a Redetermination

Correspondence should include the items on the following checklist. Keep a checked copy with the Redetermination Request Form in the patient record for easy reference.

• A cover letter explaining why the Redetermination is being requested.
• A copy of the claim form (1500), a copy of the remittance notice, or a copy of the EOMB, as evidence of prior payment or denial.
• The patient’s name and Medicare number.
• The Health Insurance Claim (HIC) or claim control number for the claim in question (circle this number on the remittance number or EOMB).
• The date of service for the claim in question.
• The physician provider number (NPI), and that of the organization (if applicable).

Supporting Documentation

In addition to the above, include supporting documentation. Highlight information that you want to be considered. The goal is to support your position in reversing the original determination. You may want to enclose: patient's medical history, documentation of severity or acute onset, x-ray reports, test results, patient's treatment plan, consultation reports, referral requests and reports, or copies of communication between provider and patient. The submission of the Electronic Health Record (EHR) can assist in this process if your carrier is able to receive it. If you use handwritten notes or use your own style of shorthand or abbreviations, it is appropriate to transcribe your notes before submitting them for review. You cannot add information but can interpret the information that is there into a more readable format.

Signature Requirements

The only acceptable signatures are: written signature on hard copy or fax; electronic, digital, and/or digitized signature on CMS-approved secure web portals. Do not use "Signature on File" or a stamp signature.

Step 2. Reconsideration

Reconsiderations are processed by Qualified Independent Contractors (QICs). File the Medicare Reconsideration Request form (CMS-20033) with Medicare's QIC within 180 days of your local carrier's initial Redetermination. Use the Medicare Reconsideration Form along with a cover letter which includes all the information in the Checklist for Submitting a Redetermination in Step 1. In addition, you also need to include the name of the contractor that made the initial redetermination decision. Evidence submitted should include clear explanation of why you disagree with the redetermination, a copy of the MRN and any other useful documentation. This is the last level at which you can submit new evidence to reinforce your case.

Additional documentation submitted at this step could increase the time allotted for the QIC to make a decision.

Hearings and Reviews

If there is not satisfaction at levels one and two of your appeals, you can advance through these last three steps. Please note that these reviewers cannot review any new evidence, but only review all of your evidence which is submitted to them through the QIC (Level 2).

Step 3. Hearing by an Administrative Law Judge (ALJ)

If after Step 2, the disputed amount is at least $140 (for 2013), you may request an ALJ hearing within 60 days of receipt of the reconsideration decision. Use the Request for a Medicare Hearing by an Administrative Law Judge form. The ALJ is employed by the Social Security Administration and not CMS/Medicare. Only the documentation from the second level (Reconsideration) and the law is considered. Detailed instructions regarding this step are included in the reconsideration decision letter.

Step 4. Review by the Medicare Appeals Council (MAC)

The DAB, also known as the Medicare Appeals Council, provides the final review by the Social Security Administration. The purpose of the DAB review is to correct any errors that might be made by the ALJ in Step 3. Use the Request for Review of Administrative Law Judge (ALJ) Medicare Decision/Dismissal form to submit your request.

Step 5. Review by a Federal District Court

This Federal judicial review is the final step in the appeals process. Its mission is to correct any errors by the Social Security Administration’s hearing and review. To request a review, follow the instructions in the MAC decision letter from Step 4. The official CMS instructions regarding Medicare Appeals, as issued to your Medicare carrier, may be downloaded from http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf.

Medicare "Advantage" Part C Appeals

Medicare Advantage is the beneficiary option for a traditional fee-for-service (FFS) plan. Providers and patients who participate in these entities have the same rights as if they were in the traditional Part B plans. Accordingly, Medicare appeal rights are included in these programs too.

Late Filing Exceptions

As a general rule, providers have one year from the date of service to file a claim. However, it should be noted that there are exceptions to the rule. The Medicare Claims Processing Manual now includes a new section 240 in Chapter 29, that outlines the general procedure for establishing any unusual good cause for late filing.

Medicare Appeals Resources

Appeals Files:

• Medicare Appeals Process (PDF File)
• Medicare Appeals Process Flowchart (PDF file)
• CMS-20031 Transfer of Appeal Rights (PDF file)
• CMS-1696 Appointment of Representative (PDF File)
• CMS-1696 Appointment of Representative - Spanish (PDF File)
• CMS-20027 Medicare Redetermination Request Form (PDF File)
• CMS-20033 Medicare Reconsideration Request Form (PDF File)
• CMS-2003AB Request For Hearing By An Administrative Law Judge (PDF File)
• DAB101 Request for Review of Administrative Law Judge (ALJ) Medicare Decision/Dismissal (PDF File)

CMS.gov/Medicare Links:

• Original Medicare (Fee-for-service) Appeals
• First Level of Appeal: Redetermination by a Medicare Contractor
• Second Level of Appeal: Reconsideration by a Qualified Independent Contractor
• Third Level of Appeal: Hearing by an Administrative Law Judge
• Fourth Level of Appeal: Review by the Medicare Appeals Council
• Fifth Level of Appeal: Judicial Review in Federal District Court

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