Original Medicare (Fee-for-service) Appeals
Standard Appeals Process
Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions.
Section 1869 of the Social Security Act and 42 C.F.R. part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B).
There are five levels in the Medicare Part A and Part B appeals process. The levels are:
- First Level of Appeal: Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).
- Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
- Third Level of Appeal: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
- Fourth Level of Appeal: Review by the Medicare Appeals Council
- Fifth Level of Appeal: Judicial Review in Federal District Court
Appointment of Representative
A party may appoint any individual, including an attorney, to act as his or her representative to help the party during the processing of a claim or claims and /or any appeals of claims. A representative may be appointed at any time during the appeals process. The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696; a link to this form can be found in the "Related Links" section below) or use a conforming written instrument. If the form CMS-1696 is not used, the written request must contain all of the elements listed in 42 CFR 405.910 (a link to this section of the regulation can be found in "Related Links" below). The appointment of representative is valid for one year from the date it is signed by both the party and the appointed representative. A detailed explanation of appointment of a representative can also be found in the CMS Internet Only Manual (IOM) 100-4, Chapter 29, section 270 (see below in "Related Links").
Expedited Determination Appeals Process (Some Part A claims only)
Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices with beneficiaries enrolled in the original Medicare (fee-for-service) plan are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end.
For more detailed information about the Expedited Determination Appeals Process, go to the "Related Links" section below.
For more detailed information about each level of appeal, go to the left side of this page. A downloadable brochure from the Medicare Learning Network (MLN) designed as a quick reference to the claims appeals process for providers, physicians and other suppliers can be found in the "Related Links" section below. To see a diagram of the original Medicare (fee-for-service) standard and expedited appeals process, go to the "Downloads" section below.
****NEW****Formal Telephone Discussion Demonstration Project for Durable Medical Equipment (DME) Suppliers
On January 01, 2016, CMS launched a new Demonstration with DME Suppliers that submit Medicare Fee-For-Service (FFS) claims, called the Formal Telephone Discussion Demonstration. The Demonstration will provide selected suppliers that have submitted second level appeal requests, called reconsiderations, the opportunity to participate in a formal recorded telephone discussion with the DME Qualified Independent Contractor (QIC), C2C Innovative Solutions, Inc. For more information on this demonstration, see the link to “Formal Telephone Demonstration Fact Sheet 2016” in the Related Links section below.
- Appointment of Representative Form CMS-1696
- 42 CFR 405.910 Appointment of Representative - Opens in a new window
- IOM 100-4 Chapter 29 Appeals of Claims Decisions - Opens in a new window
- Expedited Review General Information [PDF, 22KB]
- Medicare Appeals Brochure Providers Physicians and Other Suppliers - Opens in a new window
- Formal Telephone Demonstration Fact Sheet 2016 [PDF, 17KB]
- Page last Modified: 03/02/2016 11:21 AM
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