Steps in the Appeals Process: Overview

220 - Steps in the Appeals Process: Overview (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) Regulations at 42 CFR 405.940-405.942 provide that a party to a redetermination that is dissatisfied with an initial determination may request that the contractor make a redetermination. The request for redetermination must be filed within 120 days after the date of receipt of the notice of the initial determination (the notice of initial determination is presumed to be received 5 days after the date of the notice unless there is evidence to the contrary). Contractors cannot accept an appeal for which no initial determination has been made. The parties specified in §210 who are dissatisfied with a determination on their Part A or B claim have appeal rights. The appeals process consists of five levels. The appellant must begin the appeal at the first level after receiving an initial determination. Each level, after the initial determination, has procedural steps the appellant must take before appealing to the next level. Each level is discussed in detail in subsequent sections. If the appellant meets the procedural steps at a specific level (including the amount in controversy (AIC) requirement if applicable), the appellant (and all other parties to the appeal decision) is then afforded the right to appeal any determination or decision to the next level in the process. The appellant may exercise the right to appeal any determination or decision to the next higher level, until appeal rights are exhausted. Although there are five distinct levels in the Medicare appeals process, the redetermination, level 1, is the only level in the appeals process that the contractor performs. When an appellant requests a reconsideration with a QIC (level 2), the contractor must prepare and forward the case file to the QIC. Further, the contractor may have effectuation responsibilities for decisions made by the QIC. The contractor, however, does not have responsibility for reviewing the QIC’s decision for accuracy. When an appellant requests an Administrative Law Judge (ALJ) hearing or review by an attorney adjudicator (level 3), the QIC must prepare and forward the case file to the OMHA. Further, the contractor may have effectuation responsibilities for decisions made at OMHA, Departmental Appeals Board (DAB)/Appeals Council, and Federal Court levels. In the chart below, levels 1 – 4 are part of the Administrative Appeals Process. If an appellant has completed all the first 4 steps of the administrative appeals process and is still dissatisfied, the appellant may appeal to the Federal courts, provided the appellant satisfies the requirements for obtaining judicial review. CHART 1 - The Medicare Fee-for-Service Appeals Process APPEAL LEVEL TIME LIMIT FOR FILING REQUEST MONETARY THRESHOLD TO BE MET 1. Redetermination 120 days from date of receipt of the notice initial determination None 2. Reconsideration 180 days from date of receipt of the redetermination* None 3. Administrative Law Judge (ALJ) Hearing 60 days from the date of receipt of the reconsideration Current AIC requirements can be found on CMS.gov at: http://www.cms.gov/Medicare/Ap peals-and- Grievances/OrgMedFFSAppeals/ HearingsALJ.html. See §250 for additional information. 4. Departmental Appeals Board (DAB) Review/Appeals Council 60 days from the date of receipt of the ALJ hearing decision None 5. Federal Court Review 60 days from date of receipt of the Appeals Council decision Current AIC requirement can be found on CMS.gov at: http://www.cms.gov/Medicare/Ap peals-and- Grievances/OrgMedFFSAppeals/ Review-Federal-District- Court.html. See §345 for additional information *NOTE: If a party requests QIC review of a contractor’s dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor’s dismissal notice.