December 26, 2018
Level of Appeals
CGS handles the first level of appeal, Redeterminations. Recently, we have noticed an increase in the number of initial appeal requests sent as a Reconsideration before a Redetermination has been requested. When appealing our claim decisions, please keep in mind that you must go through the appeal levels in order, starting with a Redetermination.
After we process your claims, physicians, suppliers, and people with Medicare have the right to appeal our claim determinations. Appeals activities conducted by us are governed by the Centers for Medicare & Medicaid Services (CMS).
There are five levels of appeal. They are as follows:
Level | Type of Appeal | Time Limit for Filing Request | Monetary Threshold to be Met |
---|---|---|---|
1 | Redetermination | 120 days from the date of receipt of the notice of initial determination | None |
2 | 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 |
3 | 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 website. See §250 for additional information. |
4 | Departmental Appeals Board (DAB) Review/Appeals Council | 60 days from the date of receipt of the ALJ hearing decision | None |
5 | Federal Court Review | 60 days from date of receipt of the Appeals Council decision | Current AIC requirement can be found on the CMS website. See §345 for additional information. |
Please refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims Decisions and the Original Medicare (Fee-for-service) Appeals Web page for additional information.