The 5 Levels of a Medicare Appeal - dummies

The 5 Levels of a Medicare Appeal

By Patricia Barry

Copyright © 2015 AARP

You have up to five opportunities to argue your case through the Medicare appeals process. Just because all these levels exist doesn’t mean you necessarily have to go the full distance, though. At each level, you have a chance of winning. If you don’t win, the denial triggers the opportunity to take your case to the next level if you want to do so.

Just what those levels are and who presides over them depends on whether you’re challenging a decision concerning your coverage in traditional Medicare, a Medicare Advantage plan, or a Part D drug plan. As you can see from the table, the first level has a different review panel for each type of coverage, whereas in level 2, Medicare Advantage plans and Part D plans share the same panel. For levels 3, 4, and 5, all three programs use just one type of judgment per level.

The Five Levels of Appealing a Medicare Decision
Level of Appeal Who Reviews Your Case
1 Traditional Medicare: Medicare Administrative Contractor
Medicare Advantage: Your MA plan
Part D: Your Part D plan
2 Traditional Medicare: Qualified Independent Contractor
MA and Part D: Independent Review Entity
3 Administrative law judge
4 Medicare Appeals Council
5 Federal court

Source: U.S. Department of Health and Human Services

In each case, if you receive a denial, you’ll also receive a full set of instructions on how to go about taking your case to the next level.

Level 1: Redetermination by Medicare or your plan

Redetermination, the first level of appeal, gives you the opportunity to challenge a denial of coverage or of an initial coverage determination request if you don’t agree with the decision. You’re asking the Medicare contractor (in the case of traditional Medicare) or your plan (in the case of Medicare Advantage or Part D) to reconsider its first decision. In effect, you’re signaling your intent not to take no for an answer.

You (or anyone acting on your behalf) must make this appeal within a certain time frame of the denial determination, according to which program or plan you’re challenging: 120 days (traditional Medicare) or 60 days (Medicare Advantage or Part D plan). If you have good reason for delay (such as sickness), you can ask for more time. Make sure you have supporting paperwork to back up your appeal. If you have documents (such as a doctor’s statement) you used in the original coverage determination request or new evidence that wasn’t submitted before, be sure to send in all this information now.

Form CMS-20027 (“Medicare Redetermination Request Form”) provides a useful template for making this level 1 request in the traditional Medicare program.

How long you have to wait for a reconsideration decision again depends on which program or plan you’re challenging:

  • Traditional Medicare: Within 60 days, but if you submit new information after your original request, the decision can be delayed for a further 14 days.

  • Medicare Advantage plan: Within 30 days for a standard request, or within 72 hours if you submit an expedited request that needs a fast turnaround because delay could jeopardize your life or health.

  • Part D plan: Within 7 days for a standard request, or within 72 hours for an expedited request.

If you disagree with the decision made in level 1, you can take your appeal to the next level. In traditional Medicare, you must do this within 180 days of receiving the Medicare Administrative Contractor’s reconsideration decision. In a Medicare Advantage plan, your case is automatically referred to the second level of appeal if the level 1 decision goes against you. In a Part D plan, you can request a level 2 reconsideration within 60 days of the date of the plan’s decision.

Level 2: Reconsideration by an independent panel

In level 2, you leave behind the organizations that decided against you (or didn’t decide at all) in the first round of appeal, and your claim is investigated by an independent panel with no connection to the Medicare contractor or your plan. This panel is either the Qualified Independent Contractor (QIC) if the issue concerns traditional Medicare services or the Independent Review Entity (IRE) in the case of a Medicare Advantage or Part D drug plan.

By requesting a reconsideration, you’re asking one of these panels to reevaluate the outcome of your level 1 appeal by taking a fresh look at your claim. The panel considers Medicare regulations, information in your case file (submitted by your plan or a hospital, for example), and any information that you provide. You have the right to ask the QIC or IRE for a copy of every document in your case file, though you may be charged a copying fee. If English isn’t your first language, you’re entitled to ask that the QIC or IRE send letters to you in the language you understand best.

The process is somewhat different depending on the circumstances:

  • If you’re appealing a service in traditional Medicare, the QIC should send you a written response about 60 days after receiving your request for a reconsideration. If you disagree with its decision, you have 60 days to request a hearing with an administrative law judge (level 3). But if you don’t receive a timely decision, you can ask the QIC to move your case directly to level 3.

  • If a Medicare Advantage plan decides against you in level 1, it must automatically send your case to the IRE. You’ll receive a letter from the plan telling you the specific reason for the denial. If you want to send further information to the IRE, you should do so quickly. The IRE must receive your letter within 10 days of the date of the denial from your plan. The IRE should send its decision within 30 days for a standard request (or 60 days if the issue involves payment), or within 72 hours if you’ve asked for an expedited (fast) decision on the basis that delay would put your life or health at risk. If you disagree with the decision, you have 60 days to request a hearing at level 3 of the appeals process.

  • If your Part D drug plan decides against you in level 1, it should send you not only a denial but also a form that you can use to request a reconsideration (level 2). If you don’t receive this form, call your plan and ask for one. Send your request to the IRE at the address or fax number included on the form. After reviewing your case, the panel must make a decision within 7 days or within 72 hours if you request an expedited response. If you disagree with the IRE’s decision, you have up to 60 days to request a hearing at level 3.

Level 3: Hearing with an administrative law judge

An administrative law judge (ALJ) is a lawyer authorized to conduct hearings on disputes between a government agency and anyone affected by the agency’s actions.

The ALJ level introduces a new requirement that doesn’t exist at lower levels of appeal. This requirement is the amount in dispute (sometimes called the amount in controversy) — a specified dollar minimum that represents the cost to you of having your appeal denied. In 2015, this amount is $150, but it goes up slightly each year. If your likely cost is less than this amount, you can’t appeal to an ALJ. But if you file more than one claim, you may be able to combine them to meet the minimum amount.

You or your representative must request an ALJ hearing within 60 days of receiving the level 2 denial. Make this request on the form sent to you with the denial and send it to the given address with supporting documents or statements that you want considered. You can ask for a translator or interpreter in your own language (including sign language) if you need to.

At the ALJ level of appeal, your best bet may be to get professional help from one of the sources listed later in this chapter. Someone who’s experienced in such appeals can guide you through the process and may act on your behalf in making the appeal in some circumstances.

You can ask the ALJ to conduct a hearing just on the written evidence, without your taking part, but it’s usually best to participate. In that case, the hearing is held on the telephone, via video conference, or (more rarely) in person in a hearing room before the judge. Somebody representing the other side (Medicare or your plan) is also likely to participate. You and other witnesses are asked questions under oath, but ALJ hearings are more informal than a civil court case. Judges are usually understanding and easy to talk to, and they often rule in the beneficiary’s favor.

ALJ decisions are usually made within 90 days, but some cases are settled more quickly and some take longer. If the decision goes against you, you have the right to appeal to the Medicare Appeals Council within 60 days.

Level 4: Review by Medicare Appeals Council

The Medicare Appeals Council (MAC) is a section of the U.S. Department of Health and Human Services. If you want to take your case to this stage — the fourth level of appeal — I recommend that you have an advocate or lawyer with experience of the process to represent you. The MAC review often focuses on a question of law (such as whether the ALJ interpreted Medicare law correctly), a question of fairness (such as whether the ALJ considered all the evidence), a question of fact (such as whether the evidence supports the decision), or a question of policy (such as when there’s a dispute about how Medicare interprets the law). Most people are way out of their depth here without an advocate helping their case.

At this level of appeal, the MAC decides a case simply by reviewing the written evidence. No hearing is required, and the amount in dispute doesn’t matter. If the MAC denies your request for a review or rules against you, you can file for a federal court hearing.

Level 5: Hearing in federal court

If you go to this final stage of appeal, which typically involves issues of law, you really want to be represented by a licensed attorney. At this level, the amount in dispute is again a factor, but the minimum dollar claim is much higher than at the ALJ level: $1,460 in 2015. To request this review, you must file within 60 days of the MAC’s decision, following the instructions given in the Appeal Council’s denial letter, and a federal court judge reviews your case. If the case goes to court, the judge determines whether the decision of the MAC (in reversing or modifying the ALJ’s ruling or allowing it to stand) is supported by substantial evidence.