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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Appeals

Denials by Medicare are on the rise.  Congress and the Office of Inspector General have both called for increased scrutiny over Part A and B Medicare claims.  Reduced payments to Medicare Advantage Plans have caused the plans to take a more hardline approach to claims approvals and denials.  Providers’ main tool to combat these denials is the appeals process.   If you are thinking about filing an appeal and need assistance, please contact us at zedgar@med-comply.com.

Levels of Appeals and Time Limits for Filing

  • Redetermination
  • QIC Reconsideration
  • ALJ Hearing
  • Appeals Council Review
  • Judicial Review
  • Weekends and Holidays

Good Cause for Late Filing

  • Good Cause for Late Filing by Beneficiaries
  • Good Cause for Late Filing by Providers

Decisions Subject to Appeal

    • Initial Determinations that may be Appealed
    • Decisions that may not be Appealed

Who may File an Appeal

Representatives

Appointing the Representative 

Level 1: Redetermination

Level 2: Reconsideration

Level 3: Administrative Law Judge (ALJ) Hearing

Level 4: Appeals Council Review

Level 5: Judicial Review

Medicare Advantage Appeals


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