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  • Writer's pictureMichael Breslin

The Medicare Appeals process

The appeals process remains the same regardless of the contractor who is conducting the audit.

There are four to five levels of appeals. We say four to five because there are two entry points to the process. The ADR level and the Redetermination level. ADR’s are pre-payment appeals where the contractor is asking for proof the claim meets the LCD and PIM requirements prior to paying or denying the claim. Redeterminations are the starting point for denied claims.

Medical Review Additional Development Request: ADR’s

· Pre-Payment & Pre-Denial

· Request for Medical Records prior to rendering a decision: SHOW ME STATE

· You have 45 days from the letter date or date of the EOB to respond

· If you do not respond the claim will be denied

· Any claim submitted for payment to Medicare is eligible for a Medical Review

· ADR’s will occur when elements of the claim match parameters of the pre-payment edit system. The types of edits are:

o Automated Edits

§ System generated edits based on pre-programed parameters

o New Provider/New Benefit Edits

§ Contractors may monitor billing patterns of new providers to ensure compliance. New edits may be utilized until coverage, coding and billing are appropriately utilized

o Provider Specific Probe Edits

§ These are used when problematic billing patterns and/or complaints received by Medicare occur. The provider will receive notification of a probe that typically reviews 20-40 claims.

o Referral Edits

§ Referral edits are based on a referral from other entities, for example the state surveyor after identifying potential unusual billing patterns or practices. Providers are notified by letter when they have been placed on a referral edit. The source of the referral is not disclosed.

o Provider Specific Edits

§ TR edits may focus on an issue found in data and reviewed in the provider specific probe edit or may simply pull a percentage of any claims billed by that provider. At the end of each quarter, the effectiveness of all TR edits will be evaluated, and individual provider error rates will be calculated. Based on the error rate of claims reviewed during the previous quarter, a provider may be placed on TR. Providers remain on TR for a three-month period. The percentage of claims selected for medical review is dependent upon the provider's percentage of denials and the length of time the provider has been on TR.

§ At the end of each quarter, the provider's error rate will be re-evaluated to determine if continued review is appropriate. If the provider's denial rate meets acceptable parameters in accordance with the Progressive Corrective Action Memorandum, they will be removed from TR.

§ If a provider remains on TR for more than three quarters, or does not improve their denial rate, the provider may be referred to the Zone Program Integrity Contractor (ZPIC).

o Widespread Edits

§ CGS will review claims with the greatest risk of inappropriate program payment, this includes areas that have been identified through data analysis. The following list provides examples of widespread edits but is not all inclusive.

· Length of stay or number of visits

· Revenue and/or HCPCS

· Diagnosis and may include ICD-10 codes in relation to revenue codes


The first true level of appeal as the provider/supplier has received an actual claim denial.

· Notice can be in the form of a demand letter or an EOB (explanation of benefits)

· You have 120 days from the date of the denial to respond

o Where the appeal is during a post-payment appeal, MAC’s “could” begin recoupment request within 30 -days so it is critical that your appeal is filed prior to this

· Redetermination appeals are handled by the MAC


When providers/suppliers do not agree with a redetermination denial they can take the appeal to the second level: Reconsideration.

· Reconsiderations are handled by the Qualified Independent Contractor (QIC)

· You have 180 days to file your appeal

· Post-Payment appeal recoupments could begin within 60 days of the redetermination denial

· Typically, you are not allowed to add additional documentation or evidence without “good cause” if it is not submitted at the Reconsideration.

o Incredibly critical that you have all your evidence/proof submitted so that you are not precluded from submitting it a ALJ in case you receive an unfavorable decision at Reconsideration. This includes documentation, defense rationale’s, etc.

Administrative Law Judge (ALJ) Hearing

· The third level of appeal is the ALJ Hearing.

· To preserve this right, the supplier/provider must submit their request for an ALJ hearing within 60 days of the date of the Reconsideration findings.

· Hearings are typically conducted via a telephone conference

· There is a minimum dollar amount the claim must be in order to ask for an ALJ. Currently it is $160, however, if you have multiple claims at the ALJ level for the same beneficiary you can pool them together to meet the criteria

Medicare Appeals Council

The fourth level of appeal is the Medicare Appeals Council (MAC) review.

· Must file a written request within 60 days of receiving the ALJ decision

· Your request for MAC review MUST identify which part of the decision you disagree with and explain your reasons for disagreement.

· The MAC may also choose to review the ALJ decision on its own motion

· For CMS or a contractor to file a motion for MAC review, their motion must include that they feel there was an error of law that was material to the outcome of the case or must present a broad policy issue that may affect the public interest.

· The review does not include a hearing, rather they review the motions/briefs and render decisions based on such submitted information.

· The MAC can direct the ALJ to:

o change its decision consistent with the MACs order

o Hold another hearing

o Uphold the ALJ decision

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