Medicare Appeals

 

If the Care Provider Says Medicare Won't Pay for Your Care Take These Steps:

Who Makes the Decision?
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