Five Levels of Appeals
- Redetermination
- A redetermination is an examination of a claim by CGS personnel who are different from the personnel who made the initial determination
- A minimum monetary threshold is not required to request a redetermination
- Request may be filed on the CMS-20027

- A written request not on the CMS-20027 must include
- Beneficiary name
- Medicare Health Insurance Claim (HIC) number
- Specific service or item(s) for which the redetermination is being requested
- Specific date(s) of service
- Name and signature of the party or the representative of the party
- Attach any supporting documentation
- CGS will issue a decision within 60 days of receipt of the redetermination request
- Please forward appeal request to following address:
J15 — Part B Correspondence
CGS Administrators, LLC
PO Box 20018
Nashville, TN 37202
- Reconsideration
- A request for reconsideration may be filed if dissatisfied with the determination
- No minimum monetary threshold is required to request a reconsideration
- Must be filed within 180 days of receipt of the redetermination
- May be filed on Form CMS-20033
with
the Medicare Reconsideration Notice (MRN) - If the form is not used a written request must contain all of
the following
- Beneficiary name
- Medicare Health Insurance Claim (HIC) number
- Specific service or item(s) for which the redetermination is being requested
- Specific date(s) of service
- Name and signature of the party or the representative of the party
- Name of the contractor that made the redetermination
- Reconsideration notices are generally provided within 60 days of receipt of the request for reconsideration
- Administrative Law Judge (ALJ) Hearing
- At least $130.00 remains in controversy following the QICs decision
- May be requested with 60 days of the receipt of the reconsideration
- The reconsideration decision letter will provide details regarding the procedures for requesting an ALJ hearing
- 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
- The ALJ will generally issue a decision within 90 days of receipt of the hearing request
- Appeals Council Review
- If dissatisfied with the ALJ's decision, the party may request a review by the Appeals Council
- No requirements regarding the amount of money in controversy
- Must be submitted in writing within 60 days of receipt of the ALJ's decision
- Specify the issues and finding that are being contested
- ALJ decision will provide details regarding the procedure to follow when filing a request for the Appeals Council review
- Appeals Council will issue a decision within 90 days of receipt of a request for review
- Judicial Review in the U.S. District Court
- At least $1300.00 or more is still in controversy
- The request must be filed within 60 days of receipt of the Appeals Council's decision
- The Appeals Council's decision will contain information about procedures for requesting a judicial review

