Wednesday, May 22, 2024

Standard Appeals Part B / DME

Beginning Jan. 1, 2006, new rules went into effect, changing the process for appealing Medicare Part B and Durable Medical Equipment (DME) claims denied by Part B Medicare administrative contractors (MACs). One of the more significant changes is that second-level appeals are processed by newly created entities known as Qualified Independent Contractors, or QICs. Also, the second-level appeal is now known as a reconsideration. QICs began processing reconsiderations for Part A claim denials in May 2005.

 

This change in the appeals process was mandated by the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000, Section 521; and the Medicare Modernization Act (MMA), Sections 933, 939 and 940. Parties to Part B and DME redeterminations issued by Part B MACs on or after Jan. 1, 2006, have the right to appeal to a QIC. Parties to redeterminations issued before Jan. 1, 2006, have the right to appeal to a Carrier hearing officer (HO).

 

Part B/DME Appeals

This section provides specific information for Part B and Durable Medical Equipment (DME) services billed to a Part B MAC.

These services include:

  • Physicians’ services
  • Non-physician practitioners’ services
  • Clinical laboratory services
  • Durable Medical Equipment (wheelchairs, hospital beds, walkers, oxygen, etc.)