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Original Medicare (Fee-for-service) Appeals

What’s New

01/04/18 – CMS posts detailed information on the Low Volume Appeals Initiative.  For more details go to go.cms.gov/LVA

11/03/2017 -  As part of the broader Department of Health & Human Services commitment to improving the Medicare appeals process, CMS will make available an additional settlement option for providers and suppliers (appellants) with appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.

The low volume appeals settlement option (LVA) will be limited to appellants with a low volume of appeals pending at OMHA and the Council. Specifically, appellants with fewer than 500 Medicare Part A or Part B claim appeals pending at OMHA and the Council, combined, as of November 3, 2017, with a total billed amount of $9,000 or less per appeal could potentially be eligible, if certain other conditions are met. CMS will settle eligible appeals at 62% of the net allowed amount.

Separately, OMHA will be expanding the Settlement Conference Facilitation Process for certain appellants that are not eligible for the LVA option. More information will be available on the OMHA website at https://www.hhs.gov/about/agencies/omha/about/special-initiatives/settlement-conference-facilitation/index.html.

Please continue to monitor these websites for specific details about these options in the coming weeks.

11/02/2017: CMS has implemented changes to improve the processing and adjudication of Medicare Fee-For-Service (FFS) recurring (or serial) claims for capped rental items and certain Inexpensive and Routinely Purchased (IRP) items. For more information see the Medicare Learning Network article at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17010.pdf

Overview - Standard Appeals Process

Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and suppliers – or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision. For more information on who is a party, see 42 CFR 405.906.

Section 1869 of the Social Security Act and 42 CFR 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:

  1. First Level of Appeal:        Redetermination by a Medicare Administrative Contractor (MAC)
  2. Second Level of Appeal:   Reconsideration by a Qualified Independent Contractor (QIC)
  3. Third Level of Appeal:       Decision by the Office of Medicare Hearings and Appeals (OMHA)
  4. Fourth Level of Appeal:     Review by the Medicare Appeals Council
  5. Fifth Level of Appeal:        Judicial Review in Federal District Court

For detailed information about each level of appeal, use the navigation bar on 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 (flowchart) of the original Medicare (fee-for-service) standard and expedited appeals process, go to the "Downloads" section below.

Appointment of Representative

A party may appoint any individual, including an attorney, to act as his or her representative during the processing of a claim(s) and /or any claim appeals.  A representative may be appointed at any time during the appeals process.  

There are 2 ways that a party can appoint a representative:

  1. Fill out the Appointment of Representative Form (CMS-1696; a link to this form can be found in the "Related Links" section below); or
  2. Create a written notice containing all of the elements listed in 42 CFR 405.910.  

The appointment of representative is valid for one year from the date it contains the signatures of both the party and the appointed representative.  A valid appointment of representative may be used multiple times to initiate new appeals on behalf of the party, unless the party provides a written statement of revocation of the representative’s authority. The appointment remains valid for any subsequent levels of appeal on the item/service in question unless the party specifically withdraws the representative’s authority. A detailed explanation on appointing a representative can also be found in the Medicare Claims Processing Manual Publication 100-4, chapter 29, section 270.

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices caring for beneficiaries enrolled in Original Medicare 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 before they have finished providing them. Hospitals are also required to notify hospitalized inpatient Original Medicare beneficiaries of their hospital discharge appeal rights and their right to appeal a discharge decision.

For detailed information about the expedited determination appeals process, see the CMS.gov Expedited Determination Beneficiary Notices webpage sections at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices.html. For information on hospital discharge appeal rights, refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html. Applicable regulations can be found at 42 CFR 405 Subpart J—Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges.

Formal Telephone Discussion Demonstration Project for Durable Medical Equipment (DME) Suppliers

On January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) launched the Formal Telephone Discussion and Reopenings Demonstration with Durable Medical Equipment (DME) suppliers that submit Medicare Fee-For-Service claims. This demonstration gives selected suppliers that submit second level appeal requests (reconsiderations) the opportunity to participate in a formal recorded telephone discussion with the DME Qualified Independent Contractor, C2C Innovative Solutions, Inc. During these discussions, suppliers present the facts of the case and provide any additional documentation to support a favorable determination. Currently, only suppliers submitting claims to DME Medicare Administrative Contractor (DME MAC) Jurisdictions C and D are eligible for this demonstration. For additional information, visit the Formal Telephone Discussion Demonstration webpage for more information.

November 18, 2016: updated information on the demonstration is in the Related Links section below. See “QIC Formal Telephone Demonstration Revised Fact Sheet – November 18, 2016.”

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