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Key Changes to the Medicare Appeals Process

February 4, 2010

On January 8, 2010, the Centers for Medicare and Medicare Services instituted revisions in the appeal process for all Medicare fee-for-service claims.

On January 8, 2010, the Centers for Medicare and Medicare Services instituted revisions in the appeal process for all Medicare fee-for-service claims. The final rule modified the original appeals process that was enacted as part of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

The appeals process was revised to establish a uniform procedure guideline for managing both Medicare Part A and Part B appeals. Revisions were made to the time frames for filing requests for appeals, imposing a time limit for "redetermination" decisions made by contractors. It also created a time limit for issuing decisions at the Administrative Law Judge and Medicare Appeals Council levels. CMS also established a new section in the Code of Federal Regulations. The addition of subpart I placed the requirements for fee-for-service appeals by carriers and administrative contractors in one central location.

The final rule altered the appeals threshold if a provider decides to take any appeal to a higher level. The threshold minimum is $130 for ALJ hearings, $130 for MAC hearings and $1,260 for the federal district court. Please note that requests for contractor determination and appeals to a Qualified Independent Contractor are not required to meet a minimum dollar amount.

Below are the key changes for Medicare Part A and B appeals process:

  • The term contractor is defined to ensure that the term is used consistently throughout the Medicare Appeals Process. Contractor means any entity that contract with the Federal government to review and/or adjudicate claims, determinations and/or decisions.
  • Deadlines for appeals are counted in calendar days as opposed to business days. Note that where the regulations provide for a time frame and that day falls on a legal holiday or any other Federal non-work day, Medicare will move any action(s) to be done on the first day after such days.
  • Certain terms have been clarified (e.g., “final”, “final action”, “final and binding”) to ensure that parties understand when administrative assistance has been exhausted.
  • When a request for an in-person hearing with an Administrative Law Judge is granted, the ALJ must issue a decision within the adjudication timeframe (90 days) unless the requesting party agrees to waive such timeframe.
  • If the ALJ or MAC does not meet the 90-day timeframe, the appellant can escalate the case to the next level of appeal.
  • A provision was added to clarify that a Qualified Independent Contractor’s dismissal of a request for reconsideration of a contractor’s dismissal action is binding and not subject to any further review.
  • A beneficiary or provider has 120 calendar days from receipt of an initial determination in which to request a redetermination.
  • The ALJ function was moved from the Commissioner of the Social Security Administration to the Secretary of the Department of Health and Human Services

Appealing a claim denial is a team effort and physician practices should be familiar with the entire process to maintain proper reimbursement. As always, rheumatology practices should have staff in place to handle denials as soon as they come in the office to meet the required time line. Once a biller or coder identifies a denial, he or she should communicate with other staff members involved to determine whether the documentation supports a case against the contractor’s decision. If so, these staff members should be prepared to compile the documentation and information needed to request a redetermination.

The amendments to the Medicare appeals process can be found at http://edocket.access.gpo.gov/2009/pdf/E9-28707.pdf “Changes to the Medicare Claims Appeal Procedures,” 74 Fed. Reg. 65,296 (Dec. 9, 2009) (to be codified at 42 C.F.R. pt. 405). Published by the Centers for Medicare and Medicaid Services (CMS). For additional questions on the appeals process or practice management and coding information, contact the ACR health policy department at (404) 633-3777.

Original Medicare Appeals Process

Revised Medicare Appeals Process
  • Redetermination by the Medicare processor – FI, carrier or MAC
    • An individual must file an appeal within 120 days
    • The FI, carrier or MAC must issue a decision within 60 days

No minimum threshold of dollar amount to meet
  • Redetermination by Contractor
    • An individual must file an appeal within 120 days
    • The contractor has to make a decision within 60 days

No minimum threshold of dollar amount to meet
  • Reconsideration by a Qualified Independent Contractor
    • An individual must file an appeal within 180 days
    • The QIC must issue a decision within 60 days

No minimum threshold of dollar amount to meet
  • Reconsideration by a Qualified Independent Contractor
    • An individual has 60 calendar days to request a reconsideration of a contractors determination dismissal action
    • An individual must file an appeal within 180 days
    • The QIC must issue a decision within 60 days

No minimum threshold of dollar amount to meet

  • Hearing by an Administrative Law Judge
    • An individual must file an appeal within 60 days of the QIC’s reconsideration – case must be at $120 in dispute
    • The ALJ must issue a decision within 90 days

  • Hearing by an Administrative Law Judge
    • An individual must file an appeal within 60 days – case must be at $130 in dispute
    • The ALJ must issue a decision within 90 days

  • Review by the Medicare Appeals Council within the Departmental Appeals Board
    • An individual must file an appeal within 60 days of the ALJ’s decision
    • The Medicare Appeals Council must issue a decision within 90 days

  • Review by Medicare Appeals Council
    • An individual must file an appeal within 60 days – case must be at $130 in dispute
    • The Medicare Appeals Council must issue a decision within 90 days

  • Judicial Review in U.S. District Court
    • An individual has 60 days to file for judicial review, provided that at least $1,180 remain in dispute

  • Judicial Review in U.S. District Court
    • An individual has 60 days to file for judicial review provided that at least $1,260 remain in dispute
    • No time limit for decision making

For additional information, or if you have questions about coding and billing, contact the Socioeconomic staff at (404) 633-3777.

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