If you are dissatisfied with an initial claim determination, you have the right to request an appeal. There are several appeal levels. You much begin the Appeals process with the first level before progressing to the second level. Each level must be processed before proceeding to the next level. The information below includes specific details on each level of appeal, the amount in controversy thresholds, if applicable, and the time limits for filing the appeal.

It is critical that you submit requests for redetermination within the time limits established by the Centers for Medicare & Medicaid Services. These time limits can only be extended in certain circumstances.

First Level of Appeal – Redetermination (initial appeal)

  • A redetermination is conducted by a Medicare Administrative Contractor (MAC)
  • Timely filing limit: 120 days from the date of the initial claim determination notice
  • Minimum Amount in Controversy: None

*A Redetermination Request must be filed prior to filing a Reconsideration Request with the QIC.

Redetermination requests must be submitted within 120 calendar days from the date of receipt of the initial determination notice. The initial determination notice is the Electronic Remittance Advice (ERA) or Standard Provider Remittance Notice (SPR):

  • From the first submission of that service
  • Does not include any service rejected as a billing error (remark code MA130)
  • If the date shown on the ERA or SPR is more than 120 days from the current calendar date, the time frame for requesting a redetermination has ended. An exception can be made if good cause exists (see below for more information regarding good cause).

Example:

Date of Initial Determination (From the ERA or SPR)
Current Calendar Date
Elapsed Days
Redetermination must be received by
5/15/2019
10/15/2019
153
9/17/2019
8/15/2019
10/15/2019
61
12/18/2019

Note: CMS allows a grace period of an additional five days beyond the time limit of 120 days from the date of the initial notice. This allows for a 5-day period for mail delivery. We may allow for additional time if documentation can be provided showing that mail delivery took longer than five days.

Extension of Time Limit for Filing a Request for Redetermination
If an appeal request is filed late, the time period may be extended for filing a redetermination if good cause can be shown. These extensions are not routinely granted, so it is important to provide detailed supporting documentation if requesting an extension of this time limit.

Remember: Claims rejected as unprocessable (billing errors, indicated with remark code MA130) have no appeal rights and cannot be submitted as Redetermination requests. The best way to handle these is to correct any errors or omissions and resubmit the claim.

Reference: CMS Publication 100-04 (PDF, 790 KB), Chapter 29, § 240.

Second Level of Appeal – Reconsideration – Qualified Independent Contractor (QIC)

  • A reconsideration is conducted by a Qualified Independent Contractor (QIC)
  • Timely filing limit: 180 days from receipt of the redetermination
  • Minimum Amount in Controversy: None
  • If no Redetermination has been conducted, you should not file a Reconsideration

*Reconsideration requests should be mailed directly to the QIC. The address for the QIC is included in the redetermination letter. A copy of the redetermination decision letter should be included with the reconsideration request.

Example:

Date of Determination
Current Calendar Date
Elapsed Days
Appeal must be received by
3/15/2019
10/15/2019
214
09/11/2019
5/15/2019
10/15/2019
153
11/11/2019

Third Level of Appeal – Administrative Law Judge (ALJ)

  • Conducted by the Office of Medicare Hearings and Appeals in the Department of Health and Human Services
  • Timely filing limit: 60 days from receipt of the QIC (Reconsideration) decision
  • Minimum Amount in Controversy:
    • $160 for requests filed on or after January 1, 2019
    • $170 for requests filed on or after January 1, 2020

*The QIC decision letter will provide the HHS OMHA office to which an ALJ request is mailed.

Example:

Date of Determination
Current Calendar Date
Elapsed Days
Appeal must be received by
7/15/2019
10/15/2019
92
9/13/2019
9/15/2019
10/15/2019
30
11/14/2019

Fourth Level of Appeal – Departmental Appeals Board Review (DAB) / Appeals Council

  • Completed by the Appeals Council within the Departmental Appeals Board in the Department of Health and Human Services
  • Timely filing limit: 60 days from the date of the ALJ decision or dismissal
  • Minimum Amount in Controversy: None

Example:

Date of Determination
Current Calendar Date
Elapsed Days
Appeal must be received by
7/15/2019
10/15/2019
92
9/13/2019
9/15/2019
10/15/2019
30
11/14/2019

Fifth Level of Appeal – Federal District Court Review

  • The Federal District Court performs a judicial review
  • Timely filing limit: 60 days from the date of the Appeals Council decision
  • Minimum Amount in Controversy:
    • $1,630 for requests filed on or after January 1, 2019
    • $1,670 for requests filed on or after January 1, 2020

Example:

Date of Determination
Current Calendar Date
Elapsed Days
Appeal must be received by
7/15/2019
10/15/2019
92
9/13/2019
9/15/2019
10/15/2019
30
11/14/2019

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


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