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The 5 Levels of the Appeals Process

There are 5 levels of appeals available to you:

Level 1 is a Redetermination, which is conducted by the DME MAC. A Redetermination is a completely new, critical re-examination of a disputed claim or charge. You should not request a Redetermination if you have identified a minor error or omission when you first filed your claim. In that case, you should request a "Reopening". Information on clerical reopenings is available under the "Reopening a Claim to Correct and Error" section of this website. CGS has 60 days to complete a redetermination. If additional documentation is required, the processing time is 74 days from the date of the initial receipt.

Level 2 is a Reconsideration. This appeal is conducted by the Quality Independent Contractor (QIC). You may only file a Reconsideration after you have submitted a Redetermination and received a response. All Reconsideration requests must be submitted in writing to the QIC within 180 days of receiving the redetermination letter. The QIC has 60 days to render a reconsideration decision.

Level 3 is filing an appeal with the Administrative Law Judge (ALJ). ALJs hold hearings and issue decisions related to Medicare coverage determination that reach Level 3 of the Medicare claims appeal process.

Level 4 is the Department Appeals Board (DAB) Review. The DAB provides impartial, independent review of disputed decisions in a wide range of Department programs under more than 60 statutory provisions.

Level 5 is the Federal Court (Judicial) Review.

The easiest, fastest and most efficient way to submit a redetermination request is to utilize the myCGS Web Portal. You can find the redeterminations and reopenings feature using the Reprocessing tab.

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