Skip to Main Content

Print | Bookmark | Font Size: + |

Five Levels of Appeals

  1. Redetermination
    1. A redetermination is an examination of a claim by CGS personnel who are different from the personnel who made the initial determination
    2. A minimum monetary threshold is not required to request a redetermination
    3. Request may be filed on the CMS-20027External PDF
    4. A written request not on the CMS-20027 must include
      1. Beneficiary name
      2. Medicare Health Insurance Claim (HIC) number
      3. Specific service or item(s) for which the redetermination is being requested
      4. Specific date(s) of service
      5. Name and signature of the party or the representative of the party
    5. Attach any supporting documentation
    6. CGS will issue a decision within 60 days of receipt of the redetermination request
    7. Please forward appeal request to following address:

      J15 — Part B Correspondence
      CGS Administrators, LLC
      PO Box 20018
      Nashville, TN 37202

  2. Reconsideration
    1. A request for reconsideration may be filed if dissatisfied with the determination
    2. No minimum monetary threshold is required to request a reconsideration
    3. Must be filed within 180 days of receipt of the redetermination
    4. May be filed on Form CMS-20033External PDFwith the Medicare Reconsideration Notice (MRN)
    5. If the form is not used a written request must contain all of the following
      1. Beneficiary name
      2. Medicare Health Insurance Claim (HIC) number
      3. Specific service or item(s) for which the redetermination is being requested
      4. Specific date(s) of service
      5. Name and signature of the party or the representative of the party
      6. Name of the contractor that made the redetermination
    6. Reconsideration notices are generally provided within 60 days of receipt of the request for reconsideration
  3. Administrative Law Judge (ALJ) Hearing
    1. At least $130.00 remains in controversy following the QICs decision
    2. May be requested with 60 days of the receipt of the reconsideration
    3. The reconsideration decision letter will provide details regarding the procedures for requesting an ALJ hearing
    4. Appellants must also send notice of ALJ hearing request to all parties to the QIC reconsideration and verify this on the hearing request form or in the written request
    5. The ALJ will generally issue a decision within 90 days of receipt of the hearing request
  4. Appeals Council Review
    1. If dissatisfied with the ALJ's decision, the party may request a review by the Appeals Council
    2. No requirements regarding the amount of money in controversy
    3. Must be submitted in writing within 60 days of receipt of the ALJ's decision
    4. Specify the issues and finding that are being contested
    5. ALJ decision will provide details regarding the procedure to follow when filing a request for the Appeals Council review
    6. Appeals Council will issue a decision within 90 days of receipt of a request for review
  5. Judicial Review in the U.S. District Court
    1. At least $1300.00 or more is still in controversy
    2. The request must be filed within 60 days of receipt of the Appeals Council's decision
    3. The Appeals Council's decision will contain information about procedures for requesting a judicial review

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved