Original Medicare (Fee-for-service) Appeals

Original Medicare (Fee-for-service) Appeals

What’s New

December 21, 2023 - Proposed Rule Update

Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would implement an order from the Federal district court for the District of Connecticut in Alexander v. Azar that would establish appeals processes for certain people with Original Medicare who are initially admitted to a hospital as an inpatient but subsequently reclassified by the hospital as an outpatient receiving observation services during their hospital stay and meet other eligibility criteria.  

Detailed information is available in this link to Medicare Appeal Rights for Certain Changes in Patient Status Proposed Rule Fact Sheet

The proposed rule can be viewed or downloaded from the Federal Register at: https://www.federalregister.gov/documents/2023/12/27/2023-28152/medicare-program-appeal-rights-for-certain-changes-in-patient-status 

July 28, 2022 – Updated Notice Regarding Court Decision Concerning Certain Appeal Rights for Medicare Beneficiaries

A federal district court issued a Memorandum of Decision dated March 24, 2020 (Alexander v. Azar, Case No. 3:11-cv-1703-MPS, -- F. Supp. 3d --, 2020 WL 1430089 (D. Conn. Mar. 24, 2020)), and entered a Judgment dated March 26, 2020 in a class action seeking certain appeal rights for Medicare beneficiaries who receive observation services as outpatients. Additional information on this decision is available in the Downloads section below. On January 25, 2022, the United States Court of Appeals for the Second Circuit affirmed the judgment of the district court and its grant of injunctive relief.  The district court’s decision is now final.

The appeal process for this new type of beneficiary appeal is still under development and is not currently available. More information will be posted here when it is available. Information for Medicare beneficiaries regarding the court’s decision and appeal process has been posted to Medicare.gov here, under the Appeals in Original Medicare tab. 

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 (PDF), 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 Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices. For information on hospital discharge appeal rights, refer to /Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices. 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.

Page Last Modified:
05/21/2024 01:55 PM