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Printed Date: 9/22/2015
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 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):
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)
*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.
Third Level of Appeal – Administrative Law Judge (ALJ)
*The QIC decision letter will provide the HHS OMHA office to which an ALJ request is mailed.
Fourth Level of Appeal – Departmental Appeals Board Review (DAB) / Appeals Council
Fifth Level of Appeal – Federal District Court Review
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Last Updated: 03/02/2020