Corporate

Level of Appeals

Physicians, suppliers, and beneficiaries have the right to appeal claim determinations made by MACs. The purpose of the appeals process is to ensure the correct adjudication of claims. Appeals activities conducted by MACs are governed by the Centers for Medicare & Medicaid Services (CMS).  Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims Decisions and the Original Medicare (Fee-for-service) AppealsExternal Website Web page for additional information.

There are five levels of appeal. As a MAC, CGS handles the first level of appeal, redetermination requests.

Level

Time Limit for Filing Request

Monetary Threshold to be Met

Redetermination

120 days from the date of receipt of the notice of initial determination

None

Reconsideration

180 days from the date of receipt of the redetermination. NOTE: If a party requests QIC review of a contractor's dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor's dismissal notice.

None

Administrative Law Judge (ALJ) Hearing

60 days from the date of receipt of the reconsideration

Current Amount in Controversy (AIC) requirements can be found on the CMS websiteExternal Website. See §250 for additional information.

Departmental Appeals Board (DAB) Review/Appeals Council

60 days from the date of receipt of the ALJ hearing decision

None

Federal Court Review

60 days from date of receipt of the Appeals Council decision

Current AIC requirement can be found on the CMS websiteExternal Website. See §345 for additional information.

The beneficiary or their representative may request an appeal on any service processed for them. Provider and Suppliers may appeal services for which assignment was accepted. For unassigned claims, providers/suppliers may act as the beneficiary's representative if the beneficiary signs an authorization statement (such as form CMS-1696External PDF). In addition, provider/suppliers may request a redetermination on an unassigned claim if Medicare B denied the service as not reasonable and necessary or the provider/supplier billed in excess of the Limiting Charge and the provider/supplier is required to refund any fees collected from the beneficiary.

Updated: 10.28.19

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