The purpose of the first level appeal decision letter is to notify the provider of the decision on their Medicare appeal. The decision can be:
- Partially Unfavorable
If the provider disagrees with the first level appeal decision, the letter instructs the provider to:
- Appeal to the Qualified Independent Contractor (QIC),
- Submit the appeal in writing
- Appeal within 180 days of the date the first level appeal decision letter was received
Note: If the provider agrees with the decision, no action will need to be taken.
The letter is broken into sections of information for the provider concerning their first level appeal.
Summary of Facts:
- Provider name
- Dates of service
- Type of service
- Date the request for redetermination was received
- Lists of the documents sent with the request
Decision: A brief statement of the appeal decision.
Explanation of the Decision: Explanation of what policy (Local Coverage Determination (LCD), National Coverage Determination (NCD)), regulations and/or laws were used to make the determination.
Who is Responsible for the Bill: Information concerning the limitation of liability, waiver of recovery and physician/supplier refund requirements are included, as applicable.
What to Include in Your Request for an Independent Appeal: If the denial was based on insufficient documentation or if specific types of documentation are required to issue a favorable decision, the list of what documentation would be necessary to pay the claim is listed here.
- Note: Providers do not need to resubmit documentation that was submitted as part of the first level Appeal. This will be forwarded by the contractor to the QIC.
Important Information about Your Appeal Rights:
- Your right to appeal this decision
- How to appeal
- Who may file an appeal
- Other important information
Resources for Medicare Enrollees:
- The State Health Insurance Assistance Program (SHIP) can answer questions about payment denials and appeals
- The number for the SHIP can be found in the Medicare & You handbook
- 1-800-MEDICARE can be contacted for answers to general questions about Medicare
Reconsideration Request Form: The form providers should use if they wish to appeal the first level appeal decision to the QIC.