If the Care Provider Says Medicare Won't Pay for Your Care Take These Steps: |
Who Makes the Decision? |
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Step 1 | Request that a claim be submitted to Medicare, and obtain an "initial determination." You must obtain this written determination to go to the next steps. |
Skilled Nursing Home Care: Fiscal Intermediary Hospital Care: Qualified Independent Contractor ("QIC") |
First Level of Appeal | Within 120 days of receiving the initial determination, request a "redetermination." | Fiscal Intermediary or Medicare Administrative Contractor |
Second Level of Appeal | Within 180 days of receiving redetermination request "reconsideration" if more than $100 in controversy | Qualified Independent Contractor ("QIC") |
Third Level of Appeal | Within 60 days of receiving reconsideration result, request administrative hearing | Medicare Administrative Law Judge |
Fourth Level of Appeal | Within 60 days of ALJ dismissal or denial, request administrative appeal | Medicare Appeals Council |
Fifth Level of Appeal | federal court lawsuit if more than $1,460 in controversy | Federal Judge |