Medical Billing: How to Appeal to the Medicare Appeals Council (MAC)

By Karen Smiley from Medical Billing and Coding For Dummies

As a medical billing professional, you may find yourself facing a stalemate in the Medicare Appeals Process. The Medicare Appeals Council (MAC) is part of the Departmental Appeals Board of the Department of Health & Human Services (HHS). It is independent of the other appeal boards.

To submit a request, you use form DAB-101, which you can download from the Health & Human Services website. You can either submit the appeal online (doing so requires that you register with the Departmental Appeals Board electronic filing system on the HHS website), or you can submit a request in writing.

Make sure the written request includes the following:

Beneficiary (patient) name and Medicare number.
The specific service(s) or item(s) for which the reconsideration is being requested, along with the date of service.
The date of the ALJ decision and a copy of the decision.
The name and signature of the provider. As the representative of the provider, you use your name and sign the form.

After you complete the form, you can fax it to (202) 565-0227 or mail it to the following address:

Department of Health & Human Services
Departmental Appeals Board
Medicare Appeals Council, MS 6127
Cohen Building Room G-644
330 Independence Ave., S.W.
Washington, D.C. 20201

You must file the appeal within 60 days after receiving the ALJ’s decision. The MAC assumes that you received the decision five days after the date on decision itself. Therefore, timeliness is a huge factor, and if your appeal is late, you need good cause.

The MAC may dismiss, deny, or grant your request. It also has the option of returning the issue back to the ALJ for reconsideration. Most providers opt not to pursue the Medicare Appeals Council level.

If the reimbursement amount in question is above the current minimum requirement, then the next level of appeal is by Judicial Review in a Federal District Court. The notice received from the MAC provides information needed to file a civil action, which represents the final level of appeal. At this level, the provider will benefit by using an attorney, and the legal costs will likely outweigh any perceived wrongs.