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Who May File an Appeal Eligible parties who can file an appeal with Medicare. |
Eligible Parties
Parties to the initial determination include:
- Beneficiaries who are almost always considered parties to a Medicare determination, as they are entitled to appeal any initial determination (unless the beneficiary has assigned his or her appeal rights);
- Providers who file a claim for items or services furnished to a beneficiary. A nonparticipating provider, that is, an entity eligible to enter into a provider agreement to participate in Medicare but has not entered into such an agreement, is not considered a provider or provider of service and does not have party status for an initial determination or appeal. Beneficiaries are parties to claims filed for services furnished by a non-participating provider;
- Participating suppliers and non-participating suppliers but only with respect to items or services furnished to a beneficiary that are billed on an assignment-related basis;
- An applicable plan with respect to the amount and existence of a recovery claim if Medicare is pursuing recovery directly from the applicable plan. The applicable plan is the sole party to an initial determination and any subsequent appeal.
In addition to his/her own right to appeal Medicare’s decision regarding an initial determination, a beneficiary is a party to any request for redetermination filed by a provider or supplier. The beneficiary is always a party to an appeal of services rendered on their behalf, at any level (except when the beneficiary has assigned his/her appeal rights to a provider or supplier).
Reference
Medicare Claims Processing Manual
Chapter 29 – Appeals of Claims Decisions
210 - Who May Appeal
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