Wednesday, May 22, 2024

Standard Appeals


There is now a new level of the appeals process for Medicare Part A and Part B claims submitted to Medicare administrative contractors (MACs). This second level of the appeal process is called a reconsideration (not to be confused with the previous first level of appeal for Part A claims). These new reconsiderations are processed by Qualified Independent Contractors (QICs).

This change in the appeals process was governed by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 Section 521 and the Medicare Modernization Act Sections 933. 939, 940. Parties to Part A and Part B redeterminations issued by FIs on or after May 1, 2005 will have the right to appeal to a QIC. All redeterminations issued before May 1, 2005 will have appeal rights to the Administrative Law Judge (ALJ) for Part A claims and to the hearing officer (HO) for Part B claims.

In addition to the new level of appeal, there are a number of other changes that will affect the process providers and Part A MACs use for appeals of claim decisions made by Part A MACs.


For more information: CMS Change Request (CR) 3530 (Transmittal R146OTN)