Change in the Amount in Controversy Requirement for Administrative Law Judge Hearings and Federal District Court Appeals
MLN Matters articles are subject to revision. We recommend that you visit
http://www.cms.hhs.gov/MLNMattersArticles/ frequently to stay abreast of updates. This MLN Matters article relates to Change Request 5897 which is also available at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5897.pdf.Provider Types Affected Physicians, providers, and suppliers submitting claims to Medicare contractors (Carriers, DME Medicare Administrative Contractors (DME MACs), Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Impact on Providers This article is based on Change Request (CR) 5897 which notifies Medicare contractors of an increase in the Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal District Court appeal rights beginning January 1, 2008.
The amount remaining in controversy requirement for ALJ hearing requests made before January 1, 2008 is $110. The amount remaining in controversy requirement for requests made on or after January 1, 2008 is $120. For Federal District Court review, the amount remaining in controversy goes from $1,130 for requests prior to January 1, 2008 to $1,180 for requests on or after that date. Background The Medicare claims appeal process was amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). In addition, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for annual reevaluation (beginning in 2005) of the dollar amount in controversy required for an Administrative Lay Judge (ALJ) hearing and Federal District Court review.
Change Request (CR) 5897 revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 29, Section 330.1 and Section 345.1) to update the Amount In Controversy (AIC) required for an ALJ hearing or Federal District Court review. As of January 1, 2008, the amount remaining in controversy must be at least $120 for an ALJ hearing or at least $1,180 for a Federal District Court review requested on or after January 1, 2008.
Additional Information The official instruction, CR 5897, issued to your carrier, FI, RHHI, A/B MAC, and DME MAC regarding this change may be viewed at
http://www.cms.hhs.gov/Transmittals/downloads/R1437CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
If you have any questions, please call your Provider Contact Center (PCC) at 1-877-567-9249 (for North Carolina and South Carolina Part A providers) or 1-866-801-5301 (for home health and hospice providers).